Emergency Obstetric Care Insurance
By Jillian Waid | Jillian Waid is a research associate at the CMF. She is currently based in Ahmedabad and Udaipur and managing health insurance related projects.

Background

Complications during pregnancy and childbirth are a significant cause of mortality and morbidity among women in the developing world. A vast majority of these conditions is preventable. Of all deaths annually caused by pregnancy or childbirth, less than 1 per cent occurs in high-income countries, though these nations experience 11 per cent of worldwide births. India alone, with 26 million births annually, accounts for over one quarter of maternal deaths worldwide (WHO, 2005). The Centre for Micro Finance (CMF) has been working with Seva Mandir, an NGO in Udaipur district, Rajasthan, to develop an obstetric care insurance product to confront the major cause of these deaths: improper and delayed medical care, particularly in cases of medical emergencies. In Rajasthan, only 43 per cent of births are attended to by a skilled health professional (MoHFW, 2006). In rural areas, such as the zone in which Seva Mandir is active, the figure is considerably lower. Recent surveys undertaken by Seva Mandir indicate that the incidence of institutional deliveries within its precinct is approximately 22 per cent. There are many reasons why vital medical care is not received or is delayed until it is too late to save the life or health of the woman. As pregnancy is a normal part of the life cycle, it is not commonly viewed as a condition that requires medical care. Even though, Seva Mandir has been working on reproductive and health issues for over 20 years in Rajasthan, local workers still confront an extremely low demand for maternal health care. Though there is some indication that this may be changing among the younger generations, complications are often identified only after they have become critical, when there is not enough time to reach a competent medical service provider. There is a shortage of well-equipped maternity hospitals in both the public and private sectors in Rajasthan. In tribal areas, this shortage is acute. The government is only able to fill 30 per cent of required posts for obstetricians & gynaecologists at the community hospital level in such regions (MoHFW, 2005). In addition to social and infrastructural impediments, costs for proper care and treatment during pregnancy and childbirth are far out of reach for the rural poor. Travel to a well-equipped hospital alone can be equal to the monthly salary of a primary income earner of a family in such an area. A prevailing Government of Rajasthan programme offers monetary incentives to those who avail of institutional delivery services at government health facilities. However this programme appears to be sadly under utilized. Due to the lack of availability of physicians at the local community health center (CHC) and primary health center (PHC) levels, individuals who wish to utilize this scheme generally choose district hospitals for deliveries. Unfortunately, the amount received does not totally offset the cost of transportation and care in a district facility, and, once an emergency presents itself, these facilities are often too distant.

Seva Mandir's Obstetric Insurance Scheme This year, as a pilot project, Seva Mandir launched an obstetric care insurance scheme in nine remote villages on the Gujarat–Rajasthan border. Under this programme, women can avail of care in three full-service, private maternity hospitals in Gujarat in response to any complication during pregnancy or delivery. The hospitals were chosen based on stated preferences of the women who live in the pilot area. For a premium of Rs.350, women have access to a dai (traditional midwife) trained by Seva Mandir on safe delivery and pre-natal care. The dai will provide basic antenatal and postnatal care including tetanus toxoid (TT) vaccinations and iron and calcium tablets. If no complications are experienced during the pregnancy and delivery, this dai will also be able to provide in-house services for a normal delivery. In the case of any complication, the dai will provide support in visiting a hospital and even accompany the woman to the institution. In-hospital care is offered for both prenatal and delivery care, in the case of an emergency or a complication. For prenatal care, women cover their own cost of transportation to the clinic but Seva Mandir will cover the entire cost of care, including the cost of one ultrasound per pregnancy, if required. Antenatal care (ANC) visits are limited to two per pregnancy and medicines are limited to curative care. In the case of delivery care, Seva Mandir will bear 75 per cent of hospital costs in addition to Rs.800 to help cover the cost of transportation. In addition to documenting the process, this intervention can be expected to contribute to our understanding of how much emergency obstetric care can do to reduce the mortality burden in Rajasthan, and the effect insurance may have on care seeking behaviour. It is estimated that 20 percent of maternal deaths are attributable to indirect causes such as anaemia (WHO, 2005); incidence of anaemia among married women in Rajasthan is 53 per cent; among pregnant women this figure rises to 60 per cent (MoHFW, 2006).

Initial Results Efforts to combat these complicating conditions during the pilot study have met with mixed results. Women, often under pressure from their in-laws, do indeed utilize the insurance to visit the hospital for an ANC check-up in response to a pregnancy complication, but they often fail to change their behaviour or take the medication in compliance with the doctor's recommendation. This has been found to be the case regardless of whether the nutritional supplements or medicines were paid for by the women's families or covered by insurance. In such instances, the benefits of professional prenatal care are small, and further non-finance interventions are certainly called for to reduce the incidence of pregnancy related complications caused by preventable conditions. These initial results and observations will be taken into account in suitably modifying the insurance product before it is re-launched in the pilot area in October 2007. Initial scale-up of this product to at least eighty villages is currently slated for mid-year 2008.

References

1.Ministry of Health and Family Welfare. (2005). State-wise Position of Obstetricians and Gynaecologists at Community Health Centres in Tribal Areas of India. MoHFW, Government of India. Retrieved from http://www.indiastat.com/india/ShowData.asp?secid=402412&ptid=29095&level=4.

2.Ministry of Health and Family Welfare. (2006). National Health and Family Survey – 3. Fact Sheet: Rajasthan. International Institute of Population Sciences, Mumbai for the MoHFW, Government of India. 3.World Health Organization. (2005). The World Health Report: 2005: Make Every Mother and Child Count. WHO: Geneva.