In the central Indian state of Madhya Pradesh, a modest concrete house stands along a dirt path in a remote village called Nanora. Inside the house, Savitri Jatav tends to her family.
“My sons were all born here,” she says. “They were delivered in this very room — all three sons.”
Women have always delivered at home around here, says Jatav, who is in her forties. In the past, it was only women who had trouble during childbirth who went to the nearest hospital. “They would go by bullock cart,” she says. Some would go by tractor. The hospital is only six miles away, but that is a long distance where roads are bad and transportation options few. “It would take a long time,” she adds.
Many women, especially in more distant villages, could not get to the hospital at all. “The majority of women never made it to the hospital,” says Dr. Govind Singh, a senior administrator at the big government hospital in the region, in the district of Shivpuri.
Giving birth at home, it was all too common for women to die during childbirth. “Maternal mortality in this region used to be about 400,” says Singh. “That means for every 100,000 women who gave birth, 400 sacrificed their lives.” He says they often died of preventable causes, like excessive bleeding, infections, or obstructed labor.
But in 2007, the government of Madhya Pradesh, with the help of UNICEF, started a free ambulance service just for pregnant women. Called Janani Express (“janani” means “mother” in Hindi), the service transports pregnant women and new mothers from their villages to health facilities and back.
Receiving a call, sending help
The ambulances are located across the region and are dispatched by a call center based at the Shivpuri hospital. The center is just a small, square room staffed by one person at any given time. The dispatcher takes a call and then finds the ambulance closest to the caller through an online tracking system. He then contacts the driver of the vehicle.
On a recent day, that driver was Suresh Karan. He was at a hospital in a little town called Pohri when he got the call and was told to go pick up a woman in labor.
Karan wasted no time. He switched on his ambulance siren and made his way through the narrow streets of Pohri toward the tiny village of Nanora, where Jatav — the woman who gave birth to her three sons at home — lives. It was her daughter-in-law who was in labor, waiting for the ambulance.
The ambulance wound along paved streets, then made a sharp left turn onto a bumpy mud road, passing farms of golden wheat and green legumes. Soon, the road ended in a cluster of mud and concrete houses. Karan parked in the village square and sent word through some villagers to the Jatavs.
A few minutes later, a group of women approached. Among them was Laali Jatav, 21, a slight woman, hardly five feet tall. Her pregnant belly protruded through the pleats of her sari, and her face was contorted in pain.
Laali climbed into the back of the ambulance and lay down on one of the seats. Her husband, an aunt, and a village health worker filed in after her to accompany her.
The drive to the hospital was far from comfortable. The ride was bumpy due to the rutted roads, and the back of the ambulance was outfitted sparingly, with two long seats on either side and with no sophisticated medical equipment — just a first aid kit under one of the seats for deliveries that might happen in transit.
Laali sat up. Her aunt put an arm around her, reminding her to breathe and reassuring her that she was going to be fine.
Twenty minutes later, Laali reached the hospital and was led to the delivery room. In a couple of hours, she gave birth to a healthy daughter.
Signs of success
When Janani Express started seven years ago, it consisted of just 35 ambulances.
“Now we have this transport network across the entire state, with nearly 1,000 ambulances providing 24-7 services,” says Dr. Gagan Gupta, a health specialist with UNICEF India who helped launch the service.
He says in 2013 alone, one million pregnant women benefited from the service.
“Half of these were from marginalized groups in the country,” says Gupta. “And half of these women used the service between sunset and sunrise, [when] the community and villages suffer the most in terms of transport.”
The service doesn’t just transport women who are in labor. It also brings in women for regular health checkups throughout their pregnancy, so that high-risk patients can be identified early on. It transports new mothers and their infants back home after the delivery. And it brings them to the hospital throughout the following year, to make sure the mother and baby get postnatal care.
The advent of Janani Express has led to a dramatic rise in the number of institutional deliveries, says Gupta.
“Previously, three out of 10 women were delivering in hospitals,” he says. “Now nearly nine out of 10 women are delivering in the hospitals, and there has been a sharp decline in the maternal mortality.”
In the two districts where the service was first started (Guna and Shivpuri), as recently as 2007, 262 women died for every 100,000 who gave birth. By 2011, that number had fallen to 181, he says.
The success of Janani Express has led other states to start similar services, all funded by the Indian government. It is part of a broad effort to improve maternal health around the country.
The ambulance service alone is no silver bullet, admits Gupta, but he says it has made a difference.
And people in villages agree.
Back in Nanora, two days after giving birth, Laali was at home, lying on a cot, holding her baby. Her mother-in-law ran around, doing chores while stopping by Laali’s bed now and then to beam at her new granddaughter.
“Times have changed for our daughters-in-law,” Savitri Jatav said, thinking back on the times she gave birth to her sons at home. “It’s a lot more convenient now.”