Roshni village (Madhya Pradesh): She came in an ambulance but went back home in a bullock cart.

Ladki Korku had given birth to her first two children on the mud floor of her hut, assisted by her mother-in-law who carried out the procedure with a used blade like many traditional midwives do across villages in the country.

This practice of birthing babies with crude tools has the state government worried. So, for Kokru’s third delivery, it sent a van over to the young wage worker’s house on the edge of a hilly forest, whisking her away to the nearest health outpost several miles away.

View a slideshow on how the introduction of the ‘Janani Express’ and the ‘Janani Suraksha Yojana’ by the Madhya Pradesh government has helped lower morbidity rates in the state


State health officials say hospital births have soared since the round-the-clock free ambulance service called Janani Express was introduced four years ago. Some 600 of these mobile vans now criss cross the state. As a result, the proportion of babies born in hospitals rather than at home has soared from 20% in 2005 to 81% in 2010.

And in July last year, the state government set up a call centre in Khandwa district here to request for an ambulance by dialling a helpline number.

The lack of proper medical facilities is one reason why India has an intolerably high level of maternal deaths. For every 100,000 women who give birth to babies, 254 do not come out of labour alive, one of the highest ratios in the world and one that puts India at the same level as countries such as Pakistan and Afghanistan. While the maternal mortality ratio has fallen in the last three decades, progress is tardy and far from meeting the United Nation’s Millennium Development Goal of reducing it to 109 for every 100,000 births by 2015.

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Dr Nomita Chandhiok, a maternal health expert and scientist at the Indian Council of Medical Research, warns about the social and economic factors that will continue to challenge the health of women.

Three kinds of delays are responsible for high maternal mortality: Families take a long time to decide to take a pregnant woman to hospital, too few doctors man rural health clinics and the lack of transport leads to a higher proportion of home deliveries where women in trouble can’t get timely help.

Increasing access: Ladki Korku arrived in an ambulance to give birth at a hospital in Roshni village. Ten hours later, she prepares to go back home with her husband Munna and the newborn in a bullock cart.

The transport service is one of a series of steps Madhya Pradesh, which reports one of the country’s highest numbers of maternal deaths (335 deaths per 100,000 births), is looking at. Efforts are on to set up at least one “model maternity wing" in each of the state’s 50 districts in the next five years at a cost of Rs75 crore. More than a dozen state-of-the-art sick newborn units have already been set up with technical help from the United Nations Children’s Fund. It has also initiated a maternal audit to analyse the reasons for childbirth deaths in various regions in the state.

At the Khandwa district hospital, an hour away, the phone trills incessantly at Varsha Kaithwas’ desk. “Do you have a BPL (below the poverty line) card?" she queries, as she taps away the information on a computer. “Where exactly is your village located?" Calls from remote parts are routed to a small room inside the hospital complex, and the young operator keeps tabs of ambulances leaving and returning to the premises. “We treat every call as an emergency," says Kaithwas, who along with four other colleagues mans the 24-hour control room.

For decades, India has invested in training traditional birth attendants known as dais, arming them with free kits of scissors, soaps and a week’s training . This strategy did not help to improve morbidity rates. So, the government decided to dismantle the old order and lure women with cash to come to hospital to seek professional care. Under the National Rural Health Mission, the government pays Rs1,400 (Rs1,000 in urban areas) in return for hospital delivery under a scheme called Janani Suraksha Yojana.

The state-of-the-art centre for newborns at Khandwa district hospital.

To implement the scheme, several states have now introduced new elements to increase maternity enrolment. Apart from cash and transport, Tamil Nadu has introduced the concept of “birth companion" where a relative or a friend can enter a labour room to give moral support. Rajasthan, on the other hand, has hired a sea of “Yashodhas", women assistants who teach mothers how to breastfeed and keep babies warm. And in far-flung villages of Orissa where no healthcare infrastructure exist, women are urged to go to specially set-up “delivery huts".

As more patients arrive, the medical establishment is grappling with a familiar problem: acute shortage of doctors skilled in reproductive care. For example, here at Roshni’s primary health centre, there’s no gynaecologist, or an anaesthetist. Nor were there any blood transfusion facility in Khalwa, a few miles away. “We’ve the infrastructure, but we don’t have doctors," says Ram Chand Panika, civil surgeon at Khandwa district hospital where many of the cases are referred. An average of 30 deliveries take place every day, which works out to a daily disbursal of Rs42,000 under Janani Suraksha.

In the maternity ward, Anju Korku lies back on a dark rexin mattress, her baby slung low in a soft cloth near her. She had gone to a local primary health centre near her village, but they sent her to Khandwa on an ambulance when her condition became critical during labour.

To meet supply gap, several states such as Gujarat and Madhya Pradesh are striking partnerships with private clinics. The government has now roped in Federation of Obstetric and Gynaecological Societies of India (FOGSI) to set up training programmes for MMBS doctors to handle emergency obstetric care.

With demand for ambulances rising, births sometimes take place in a moving van. Ravi Dasore, an ambulance driver, claims four births have taken place in the back of his vehicle. On a recent morning, Dasore sped across wheat fields, weaving through trucks and bullock carts to attend a call. He arrived at the village of Pandhana 45 minutes later to pick up Sunita More. Expecting her first child, she had high blood pressure and the local clinic wanted her to be transported to Khandwa.

The government banks on accredited social volunteers called Asha, who are the government’s first contact point in villages, to bring the women to hospitals. Under the state’s maternal health policy, they get paid Rs50 for reporting every childbirth death at home. They get paid another Rs350 for bringing a pregnant woman to a government clinic under Janani Suraksha.

“Half the battle is won if you can convince a woman to come," Basanti Panchori, an Asha worker accompanying Sunita, says. “We tell her don’t deliver at home, it is messy. Let’s go to the hospital."

Sunita More also travelled with a village midwife. With poor health facilities, families still turn to dais for help, although now a vanishing profession since the cash incentive programme started. Outside the labour room in Khandwa hospital, a melee of Asha workers, auxiliary nurses in their trademark blue saris and midwives throng the entrance with family members. Among them is Mulkha Bai, a pleasant graying lady. A midwife for several decades, she says she has given birth “to an entire village". She’s here at the hospital with her family as her grand-daughter goes into labour. “The world has changed," says Mulkha Bai. “We must keep up with the times."

With a serial cash offers, Janani Suraksha has met the first challenge of bringing mothers to the hospital, says Dr Nomita Chandhiok, a maternal health expert and scientist at the Indian Council of Medical Research. But she cautions that social and economic factors like low nutrition, lack of priority to women’s education and health will continue to challenge women’s health. “Families today are still reluctant to pay for a woman’s diagnosis. Such social changes take a long time to percolate," she says.

According to a 2009 United Nations Population Fund’s (UNFPA) report assessing Janani Suraksha, India needs to improve its post-delivery practices, where majority of the deaths occur. Due to overcrowding, most hospitals cannot keep patients for long and observe the 48-hour observation protocol. A majority leave in less than a day after giving birth. Many still don’t receive the promised incentive on time and a few don’t get at all, it said.

News of deaths though keep trickling in—if not of the mother, it’s the child. In the district of Barwani, 25 women died during childbirth last year. Government investigations showed that the deceased were acutely anaemic.

India spends 4.2% of its national income on health. To bring about universal healthcare, it has miles to go before it can reach interior villages like Piplia Bhaolia.

In November last year, Phulboti Korku delivered a boy here in the middle of a wheat field. The illiterate mother of two girls sought no medical help for herself or her child after he was born, who died a fortnight later, adding another grim number in the registry books, and leaving the grieving parents with no explanation why it happened.

“God willing, I’ll take my wife to a hospital next time," Asharam, Phulboti’s husband, promises.

This is part of a six-part series that examines key challenges faced by women throughout India and attempts to overcome them, drawing on experiences in Madhya Pradesh, which has among the worst indicators in the country as far as women are concerned.

Photos by Priyanka Parashar/Mint