The World Health Organisation says no region in the world can justify more than 10-15 Caesarean deliveries per 100 births. Over nine months in Madhya Pradesh,a government scheme for expecting mothers has seen nearly one in two had C-sections when they enrolled in accredited private clinics which,incidentally,got four times more money for a Caesarean surgery. Forty hospitals accredited with the government under the Janani Sahyogi Yojana performed 265 C-section deliveries against 307 normal deliveries between April 2009 and December 2009,damning figures which confirm the alarm sounded by the National Institute of Health and Family Welfare (NIHFW) two years ago when it did a sample study of six districts in the state. Janani Sahyogi is a component of a scheme that pays BPL beneficiaries Rs 1,400 and health volunteers an honorarium to motivate women to avoid home deliveries and go in for institutional deliveries. Part of the National Rural Health Mission,the schemes popularity forced the government to engage private clinics because government hospitals could not cope with the rush. Figures accessed by The Indian Express indicate that some of these hospitals had a 500 per cent rate in lower-segment Caesarean section (LSCS or C-section) operations. These are governments own figures compiled from details provided by the private clinics. The figures are a blot for the scheme that has been a success in the state,which is notorious for its high maternal and infant mortalities. Till the norms were revised recently,a C-section operation under the scheme earned a private clinic Rs 5,500 while a normal delivery fetched only Rs 1,200. In case of a blood transfusion,the clinics got extra money. Dr D K Pal of Jabalpur Medical College,who was a member of the NIFHW study in 2007 to assess the schemes implementation,said the number of C-section deliveries was unusually high even then. This had prompted the institute to recommend a separate study and an inbuilt mechanism to discourage the practice. However,the situation seems to have got worse. Defending the ratio,hospitals claim the reason the numbers are skewed is that only complicated cases come to them. Dr Amit Nagar of Siddharth Hospital in Ashta,which reported 45 LSCS to 24 normal deliveries in nine months after April 2009,says: We have kept records. Every case was either late,complicated or botched up by midwives. Commissioner,Health,Manohar Agnani admitted that the rate of C-sections was high but said the scheme could not be discontinued because lives were at stake. We are struggling between extremes. Agnani has a point. The scheme was halted for a few months last year when a private,20-bed hospital in Bhopal sent a bill of more than Rs 75 lakh in a month,claming that most cases were LSCSs. However,the schemes temporary closure flooded the government hospitals with patients. Sultania Hospital in Bhopal,for example,got 230 patients against its capacity of 90. Six women died within 48 hours in June. The scheme was finally resumed,obviously with no changes seen on the ground. On the other hand,the government is under pressure to offer more incentives as the number of private clinics under the scheme has drastically come down since the payment norms were revised. Copying the Gujarat scheme of block payment,Madhya Pradesh decided to start paying clinics Rs 1.85 lakh for 100 deliveries,irrespective of the number of LSCS. As per the revised norms,the clinics get their payment even if the number of LSCS is less than 8 per cent,which the government says is the normal rate. So,while the government paid Rs 3.82 crore in 2007-2008 and Rs 7.17 crore in 2008-2009 under the scheme,in the nine months preceding December 2009,it paid only Rs 16.38 lakh to private clinics. True to the nature of such government schemes,clinics have found another easy way out. Once the threshold of 8 LSCS is reached,they start turning complicated cases away. An officer admitted on condition of anonymity: We may have to go back to the old system of payment to encourage private participation. Agani said the government was planning to seek the help of the Indian Medical Association to identify clinics that are genuine.
