Traditional and modern maternal child health services in tribal areas: a case study of Dhar district.1. Introduction
Maternal and child health is an important dimension of community health nursing. Health service especially meant for mothers and children is more commonly known as "Maternal and Child Health Services". The mission of maternal and child health is to improve the availability of and access to high quality preventive and primary health care for all women (who belong to reproductive age group i.e. 15 to 45 year) and children regardless of their ability to pay. To accomplish this mission welfare state assumed special responsibility with respect to the weaker sections of society. As such, the tribals living in inaccessible areas and with very poor economic background, deserve special treatment. A lot of work has been done on health planning as an integrated part of overall social and economic planning.
The health services organization in the country has extended from the national level to the sub-centre level in the remote rural areas. Broadly, four levels of health organization may be distinguished--national, state, district and local. The health care system operates in urban areas through a number of hospitals and family welfare centres and in rural areas through a network of Primary Health Centres (PHCs), sub-centres and Anganwaries. Though a vast network of health services infrastructure has been built up to the grass root level, tribals are still in a primitive stage and follow their traditional practices even in term of maternal and child health care, curing themselves by superstitious methods. This unawareness keeps them under unhygienic conditions because of which maternal and child mortality may be higher among them. According to National Family Health Survey -2 India (1998-99)1, children of women belonging to scheduled castes and scheduled tribes have higher rates of infant and child mortality than children of women belonging to other backward classes or to women not belonging to scheduled caste or scheduled tribe. According to National Family Health Servey-2 (Madhya Pradesh) (1998-99)2 Madhya Pradesh has the highest neonatal, child and under five mortality rates than any other state in India and even the infant mortality and post neonatal mortality rates are highest in the country. The basic question therefore emerges that in spite of the network provided by the state, why the access and affectivity is so poor at the grass root level. To find out the answer to this question this study was undertaken. The objectives of the study are given below:
(1) To study the status of the traditional and modern maternal and child health services at the family level,
(2) To analyze the perceptions of people about traditional and modern maternal and child health care techniques and facilities,
To achieve these objectives, Dhar District was selected for the study. The study was focused on tribes, so only those blocks of Dhar District were selected in the study where the tribal population was more than 70 per cent. According to census of 2001, there were six blocks in the district where tribal population was more than 70 per cent. These were Bagh, Umarban, Dhai, Gandhwani, Kukshi and Tirla.
In the above six blocks the total number of villages, as per census of 2001, were 615. Out of 615 villages, only medium sized villages with a population of 500 to 2000 were included in the sampling frame. Thus, in the sample, 295 villages were included. The actual selection of 5 per cent villages, i.e., 15 villages was made randomly from the population range of 500 to 1000 and 1000 to 2000 in proportion to the number of villages in each category from 6 designated blocks.
From the selected 15 villages all those available women who were pregnant and had children up to five years were included in the study. The number of such women actually available in the village during the survey was 250; all of them were included in the survey. For quantitative data collection, interview schedules were used as the tool. The schedules were finalized after pre- testing. To have a deeper and qualitative insight of the problem, observation and directional group discussions were held.
Both the primary and secondary data have been collected for the analysis of the problem.
Secondary data was collected through various published material like published books, census report, five year plans, including state five year plans, statistical abstracts, government publications, annual report of the ministry of health and welfare, National Family Health Survey-India, National Family Health Survey -Madhya Pradesh, research reports, Journals and periodicals, letter-magazines, news papers etc.
With the help of interview schedules primary data were collected through personal interviews with the respondents. Observations and group discussions were conducted in the villages and Government hospital (SC/PHC/CHC/FRU). Interviews and discussions were also held with the functionaries of the health department and WCD department.
The information collected through the schedules was properly codified using the code book and entered on the master chart in the excel framework by the help of computer. The data was then tabulated and analyzed.
2. Profile of the Sample Population
The socio-economic condition of the sample households has been depicted in Table 1.
Being a tribal dominated region the sample reflects the dominance (84.8per cent) of scheduled tribes in the surveyed households. Among the tribals the majority were Bhil followed by Bhilala and Patlya. Rest of the 15.2 per cent surveyed population belonged to scheduled castes.
The age structure of the respondents reflects the younger population. This is so because in the survey only pregnant women were included. Out of these 38.4 per cent were expectant mothers belonging to the age group of 26 to 30.
Bhils prefer to live in nuclear families, and therefore, in the surveyed household nearly 60 per cent families were found to be nuclear.
The table clearly reflects that small family is still a far removed concept among the rural areas in the tribal region. In the surveyed population the average size of family was 7 and nearly half of the respondents were having 2 to 5 children and a perceptibly higher percentage of 30 was of those who were having 6 to 8 children. Nearly 9 per cent of the respondents were having even more than 8 children.
In spite of the legislative provision regarding the age of marriage, nearly 61 per cent respondents were married below the age of 18 and 17.6 per cent of the pregnant mothers were 12 to 15 years old at the time of marriage.
Despite intensive state efforts to propagate education among women, 85 per cent of the surveyed respondents were illiterate and only 3.2 per cent had education above primary level.
As far as the occupational status was concerned the data reveals that only 17.6 per cent households were depending on agriculture alone while 78 per cent were either labourers or working on others' fields as labourers, besides cultivating their own fields. The presence of tertiary sector was found to be less than 5 per cent.
With an average of 7 members in a family, annual income of an average household was less than Rs. 10000. Thus, a majority of surveyed households were below poverty level.
With regard to socio-economic condition the overall picture which emerged was that the surveyed households were mostly tribal, with more number of children, mostly illiterate, and belonging to predominantly labour category with low income.
3. Analysis of the Reasons for not going to Government Hospital
The respondents were asked the reason for not going to government hospital which has been tabulated under Table 2:
Table 2 Reasons for not Going to Government Hospital Sr. Responses Given by Respondent Per cent of No. Responses 1 First go to government hospital but in absence 15.2 of relief to private hospital. 2 Do not trust government hospital for want 16.9 of relief 3 Prefer private services because government 20.1 hospitals also charge treatment cost. 4 Government hospital is far off. 23.6 5 Do not feel necessity because they prefer 24.0 services of Badva, Dai, Gunia, Ojha locally.
The above table shows the responses regarding the reasons for not going to government hospital. Out of all the responses, 15 per cent respondents first go to government hospital, because government hospital treatment is cheaper but when they do not get relief there, they go to private hospital. About 17 per cent responses show that they do not get good treatment, good medicine, correct diagnosis, sufficient care and attention at government hospital. Proper check-up is also not done here before giving medicine. That is why they do not trust government hospitals and go to the private one. According to 20 per cent responses, government hospital (CHC) also charges for treatment, medicine and check-up in addition to demands of health staff like nurse, compounder, and dresser extra in PHC. So these people, thus finding no difference between government and private hospital, do not go to the former. According to 24 per cent responses, government hospital (CHC) is far off, because they have to visit CHC as no doctor is available at PHC. The day they go to CHC, they are unable to do routine works. To visit government hospital (CHC) they have to spend on transport due to lack of transport facility. Thus, they lose both time and money and do not prefer government hospital but go to untrained and unqualified medical practitioners or private doctor available in the village itself. According to 24 per cent responses, they had no health problem serious enough for them to go to government hospital and ordinary health complaints could be dealt with the help of local man/women such as gunia, badva, dai, who treat the patient with old mendicant or bandage and cure them. Sometimes the local man (Badva) performs spiritual rites and tie thread to give them relief. In time of pregnancy related problem dai and badva could be consulted who could handle that problem a step that saves them from visiting a government hospital.
The above table shows the responses regarding problems faced by the respondents in govt. hospital. As per the table 12 per cent of the complaints are lack of attention, improper care and a general feeling of neglect. Even at the time of emergency, doctor did not care to attend them. They were not directed about the places and process of check-up in the government hospital. According to 15 per cent responses, government hospital also charged them for treatment. Doctors were also not available in PHC. Even other health staff, like ANM, compounder dresser etc. did not attend the patient in the hospital (PHC) and did their check-up at their residence with fees. According to 17 per cent responses, the doctors do not administer medicine at all, provide insufficient quantity or prescribe it to be purchased from outside which the patient could not afford.
According to 18 per cent respondents, government hospital is overcrowded and the patient has to wait indefinitely in queue. Many a time, he has to wait for the doctors or nurses to turn up, who most often leave hospital without any apparent cause and come back very late. The patient has to again go through the same ordeal at the medicine counter also, i.e., waiting endlessly in queues, absence of counter clerk, his leaving the window now and then at leisure, obviously for taking tea, gossiping with colleagues or just for no particular reason; this is all a trying experience for the patient visiting a government hospital.
As per 19 per cent responses, the doctors supposed to attend their duties on appointed days, do not follow the schedule at PHC. Even if they do, they do not care to observe the appointed time table and leave the place any time without intimation and it takes 5 to 6 days for the patient to get check-up done from that doctor. Under such circumstances, the patient has to approach private hospital or CHC service during the time of crises. Only 19 per cent respondents expressed not to have any problems with government hospitals because they could get free medicine and considered the problems to be routine and could be taken for granted.
4. Perception of the People about Modern and Traditional Health System
Most of the respondents believed in their traditional health culture because they neither felt any necessity of the modern facility, nor they had any awareness about it. Whenever they faced any health problem at first they go to their local man or women such as ojha, Gunia, dai, who treat them with traditional methods or medicines. Because the medicine man/woman resides somewhere nearby in the same locality, it becomes easier for the villagers to approach them; this saves them of the travel cost. The medicine man/woman prepares a variety of mixtures, oils or ointments out of various forest plants or their roots collected from the neighbouring forest which are used for treatment of pregnant women and other diseases. At the time of child delivery also, the same oil is used for massaging the women. Medicinal herbs are also used for the purpose of abortion. The villagers have more faith in these medical measures than the modern medical care simply because they have been depending upon the local medicine, the man and his traditional system of treatment over the ages.
These people also have faith in occult sciences. The traditional healer, who practices the skill to drive away the evil spirits, is called Badva. When a person, irrespective of age or sex, starts behaving abnormally or showing symptoms of a disease, mysterious enough for the villagers to comprehend, it is generally believed that he or she is possessed (more precisely by an evil spirit). In such cases as also in cases of complicated pregnancies, the local exorcist is consulted who by way of magical rites, tying hands of the patient by threads and performing all sorts of weird rituals, is supposed to have cured the problem.
During the survey it was found that villagers try to attend to child delivery cases themselves or call Traditional Birth Attendant (TBA) who is more trustworthy than Auxiliary Nurse Midwife (ANM) because T.B.A. belongs to their own culture and lives amidst them. They believe that TBA or an experienced aged woman can easily perform the duty in case of delivery and she can take care at the time of any crisis. TBA does not take any fixed charge for her services. The villagers pay her according to their capacity and convenience or pay nothing at all if they do not have any money and giving away food grains, oil etc.; this supplements the fee in kind. This is another reason because of which TBA is preferred by the villagers as against modern health facilities which are considered expensive and time consuming. Many a time, the tricks of local medicine men prove to be effective but sometimes the patients face risk as their illness is not diagnosed correctly. Often it is too late for them to approach any doctor outside their area still they believe that doctor's treatment is time consuming. Most often deliveries take place while on their way to the hospital or the patient succumbs to the disease en route. Thus, there is a general tendency of reluctance against modern health measures on the part of villagers.
Normally the villagers are reluctant to use modern health services unless there is an emergency and when such emergencies actually occur, they fail to avail government health services and the available infrastructure there. Government had provided centres (subcentre/primary health centre / community health centre) at every level. In spite of such a massive health system, there was not a single ideal health centre or delivery centre in a village which could be contacted during the emergency. When the patients had visited or gone to the sub centre, they found them closed all the times. The doctors were also not available at PHCs, because there was no arrangement for patients in PHC/ SC, so the patients had to come to CHCs. Though it was far off and not easily accessible by any regular services of transport yet when they opt for treatment at CHC, most of the CHCs take charge for services at the time of normal delivery also. Although doctors did not charge fee in case of normal delivery but other staff of the centre, like nurse, ayah etc had charged fee compulsorily from the patients. At the time of night if any emergency case comes, their fee increases. Doctors also charge fees in case of other health related problems except normal deliveries. If the patient has no money to pay, the staff does not treat them properly and insist on payment of fee. The provision of free treatment is confined to papers or records only, not in real practice.
5. Conclusions and Findings
Government had provided centres (SC/PHC/CHC) at every level. In spite of such massive health system, the situation is far from satisfactory. There was not a single ideal health centre or delivery centre in village which could be contacted during the emergency. So the patients had to come to CHCs. But most of CHCs demand charge for services. The provision of free treatment is confined to papers or records only, not in real practice. When they face any health problem at first they go to their local men or women such as an Ojha, Gunia, Dai, Vadya, Badva who treat them with traditional methods. It is easier for the villagers to approach them because they reside with them in the same habitation. They have to spend little money to access the local medicine man/ woman.
In sum, the perception of the people is that modern health facilities are more expensive and time consuming than the traditional treatment. Normally the villagers are reluctant to use modern health service unless there is an emergency. They try to help themselves at the time of delivery or call T.B.A., who is more trustworthy than an A.N.M. They believe that T.B.A. or an experienced aged woman can easily perform the duty in respect of delivery and she can also take care at the time of any crisis.
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Table 1 Analysis of Socio-Economic Profile of the Respondents Personal & Demographic Categories Frequency Percentage Characteristics Caste Scheduled Tribes 212 84.8 Scheduled Caste 38 15.2 Present Age 18-20 22 8.8 21-25 80 32.0 26-30 96 38.4 31-35 40 16.0 36-40 12 4.8 Type of Family Nuclear 148 59.2 Joint 94 37.6 Broken 08 3.2 Number of Children 1 to 2 40 16.0 2 to 5 113 45.2 6 to 8 75 30.0 8 to 10 22 8.8 Education Illiterate 213 85.2 Literate 17 6.8 Primary 12 4.8 Middle 08 3.2 Age at time of 12 to 15 year 44 17.6 Marriage 15 to 18 year 109 43.6 Above 18 year 97 38.8 Occupation Agriculture + Labourer 104 41.6 Only Labourer 91 36.4 Agriculture 44 17.6 Business 08 3.2 Government Services 03 1.2 Annual Family 5,000 63 25.2 Income 5001 to 10,000 111 44.4 10,001 to 15,000 38 15.2 15001 to 20,000 16 6.4 20,001 to 25,000 12 4.8 Above 25000 10 4.0 Table 3 Problems Faced by Respondents in Government Hospitals Sr. Responses Given by Respondent Per cent of No. Responses 1 Nobody pays attention at Government hospitals 12 2 Government hospital staff charge for the services 15 3 Doctors prescribes medicine from outside 17 4 It is time consuming 18 5 Doctors are not available there 19 6 No problem with Government hospitals 19