Koti (Himachal Pradesh): "I was compelled to walk for four kilometres with my new-born, in knee-deep snow, just days after childbirth…while most women would even find it difficult to stand for long," Kaushalya Chauhan told IndiaSpend, as she recalled the birth of her younger daughter in January 2020.

It had merely been four days since the premature birth of Chauhan's daughter Arushi, when the staff at Shimla's Kamla Nehru Hospital asked her to vacate the hospital bed for the waiting patients. The ordeal that followed turned what was supposed to be Chauhan's most cherishable moments into a misadventure--as her still recouping body weathered a storm, literally, on her way back to her village.

India accounted for 12% of the world's total maternal deaths in 2017, second only to Nigeria (23%), according to a WHO report. India's maternal mortality ratio was 103 deaths per 100,000 live births for the period 2017-19, as per the government's bulletin released in March 2022. Meanwhile, the third United Nations Sustainable Development Goal aims at reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030.

Even two years after the incident, Koti's Community Health Centre in Shimla district remains unequipped to handle deliveries such as Chauhan's; it has insufficient staff, beds and equipment, failing to provide even the most basic medical facilities to the people in the vicinity.

Himachal Pradesh's community health centres in rural areas had just five of 80 obstetricians and gynaecologists required, four of 85 paediatricians and five of 80 physicians needed at the healthcare centres, as per the 2019-20 rural health statistics.

Shimla district, which is also home to the capital city of the hilly state, has about 2.5 doctors per 10,000 persons, according to a study based on the 2011 District Statistical Abstract of Himachal Pradesh. The ratio is in stark contrast to the World Health Organization (WHO) norm of 10 doctors per 10,000 persons.

Inaccessibility of emergency medical transport

In the absence of an ambulance service or convenient public transport, Chauhan's husband Keshav Ram, a daily wage labourer, hired a private taxi for Rs 4,000 to their home at Koti village--30 km from Shimla city. "I was in excruciating pain, but as heavy snow blocked the roads, I had to walk several kilometres with my new born girl to reach home. We even had to push the car several times on the way," 34-year-old Chauhan recalled.

"We didn't have much money and could not afford to rent a room near [the hospital]. Hence, we had decided to return to Koti. Not that it was a cheaper option but we chose this to steer clear of other expenses," added Chauhan, who contributes to the household income by working as a tailor. Kaushalya and her husband also cultivate vegetables on their three bigha land (0.60 acres) and manage to earn about Rs 20,000 when they get regular work--of which Rs 2,500 is spent on house rent, excluding the expenses of water and electricity.


Kaushalya Chauhan stitches a salwar for a client, outside her house, as her daughter Arushi (2) looks on, at Koti village in Shimla district, Himachal Pradesh, March 26, 2022.
Photo credit: Kumar Divyanshu

It was with great difficulty that Chauhan had first reached Shimla to secure a hospital bed for her delivery, amid heavy snowfall.

Chauhan recalled that as she reeled with unanticipated labour pain in the eighth month of her pregnancy, her husband had to plead with their neighbour, a private taxi driver, to rush her to Deendayal Upadhyay Zonal Hospital in Shimla, the nearest government hospital, about 30 km away.

Unprepared to deal with emergency delivery, despite being fully-equipped, the government zonal hospital referred her to Kamla Nehru State Hospital. "I was in severe labour pain and was praying to get admitted, but the hospital refused when they got to know that it was only my eighth month of pregnancy. I was referred to Kamla Nehru Hospital, which was a few more kilometres away, and there was no ambulance available," said Chauhan.

Three months back, the zonal hospital asked 28-year-old Anuradha Devi, another resident of Koti, to go to a private hospital on the day of her delivery, as she was anaemic.

"We do have certain limitations when it comes to premature deliveries. We do not have a neonatal intensive care unit," said Shivika Mittal, a gynaecologist at the zonal hospital. Hospital authorities declined to comment further.

The infrequent and expensive transport facilities in the region means that a lot of women opt for non-institutional delivery. "Not everyone can afford Rs 4,000-5,000 to go to Shimla from Koti. In fact, when it snows, rates are hiked to almost twice the usual price," said Reena Devi, an Accredited Social Health Activist (ASHA) at Koti village. "Meanwhile, ambulances take a very long time to arrive. This is the main challenge people face here."

At least 204 ambulances function in Himachal Pradesh apart from the ones operating under the National Health Mission (NHM).

Missing healthcare workers

Chauhan would not have had to face such hardships if the medical facilities at her village were at par with the far-flung district hospitals. As per government requirements, a CHC must be a 30-bedded hospital with specialised services, such as an operation theatre, X-ray machine, a labour room and a laboratory. It is also required to be manned by at least one surgeon, physician, gynaecologist and paediatrician, along with other staff.

But Koti's community health centre has a labour room but is bereft of even beds and other basic facilities, and there are no nurses or gynaecologists, which has ensured that not a single delivery has been undertaken here.

"We wish we had an active PHC [primary health centre] or CHC in or around the village to ensure that every woman can give safe, institutional birth," said Reena. "The closest to us is CHC Koti. However, poor infrastructure and unavailability of staff at our village CHC compels many pregnant women to seek healthcare at district hospitals, which requires considerable road travel. This becomes a challenge in adverse weather conditions."

"Even for routine check-ups during pregnancy, I had to visit hospitals in Shimla. If we had adequate maternal healthcare facilities at our CHC, I wouldn't have to suffer this much with an infant, in spine-chilling cold," said Chauhan.


A fact sheet displayed at the CHC at Koti states that it caters to 2,383 people of 36 villages, at Koti village in Shimla district, Himachal Pradesh, March 26.
Photo Credit: Kumar Divyanshu

"I am aware of the situation at CHC Koti. The labour room is not in a working condition and I have also spoken to the concerned medical officer…but we cannot do much without the staff availability," Surekha Chopda, the chief medical officer of Shimla, told IndiaSpend.

She added: "Even if the labour room is active, we would need a gynaecologist and class 4 staff so that the labour room remains in a working state. Many times, people get posted here but they do not join the CHC. This situation is not unique to Shimla, but this is the state of affairs in other districts as well; in fact, in other states too."

Availability of health infrastructure, access to affordable and quality maternal health care, especially in districts with high fertility, low education, that are economically poor, are key pathways to reduce maternal mortality in India, as per a 2021 preprint.

Little has changed over the years in rural Himachal Pradesh, from when Kaushalya gave birth to her elder daughter, Kamini, at a hospital in Shimla in January 2014. The weather conditions were similar, and so was the state of healthcare infrastructure.

"The health facility in rural Himachal Pradesh is in an alarming condition, especially when we talk about maternal health. If infrastructure is available in a district, there is lack of staff to undertake the duty. In fact, a lot of seats are vacant in the healthcare centres and hospitals," said Kuldeep Singh Tanwar, a social activist working on public health, who is also the president of the Himachal Kisan Sabha and a retired Indian Forest Service officer.

He added that medical infrastructure was already poor in Shimla district, but the Covid-19 situation has worsened it further. "Moreover, during lockdowns, the unavailability of public transport and sky-high rates of private vehicles have forced people of the villages, who have limited funds, to avoid visiting hospitals."

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