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Are Safe Pregnancies In Rural India A Luxury?

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By Nupur Sonar:

Having a baby in a remote village of eastern Bihar, India means being pregnant with anxiety and a sense of helplessness. Without access to health infrastructure to monitor pregnancies and provisions for emergency care, it is a life threatening situation for both the mother and the unborn child. In cases of abortions, women who approach state-run health facilities are turned away due to lack of infrastructure and are forced to approach private practitioners. Most of them, cannot afford their services.

Image Credit: Wikimedia Commons
Image Credit: Wikimedia Commons

Last year, 24-year old Masuhsun Khatun from Fulvari village of Bihar’s Kishanganj district was expecting her fifth baby. She was five months pregnant in June 2014, when she tripped and fell in the front yard of her house.

Later that night, Masuhun woke up writhing in pain and bleeding profusely. Her husband tried calling a government ambulance but to no avail. He then hired a private vehicle to get Masuhun to the nearest government hospital. They found no doctors there and Masuhun was taken to a private practitioner, who informed her that she needed to undergo an abortion.

Two weeks after the abortion at a private health facility, Masuhun started bleeding again. This time she was taken to a state-run hospital, where she was told she had foetal remains in her womb. Masuhun was forced to undergo a remedial procedure at her home, under the supervision of an auxiliary nurse midwife (ANM), because the hospital lacked adequate medical facilities. Although, ANMs are not qualified to perform surgical procedures. Her condition worsened over the next five days before she passed away.

For three weeks, Masuhsun shuttled between private practitioners and state-run medical facilities. Her husband, a daily wage labourer, spent nearly Rs 40,000 on her pregnancy and the subsequent termination, including Rs 17,600 on eight bottles of blood required for transfusion.

Community Correspondent Navita Devi’s report reveals that due to lack of proper abortion facilities, trained medical personnel and access to public health facilities, several other women in Fulvari village of Kishanganj district in Bihar suffered the same fate as Masuhun’s. The ones who survived, live with financial burdens and a trauma that never leaves them.

This, however, isn’t just the story of the women of Fulvari.

India Has The Highest Number Of Maternal Deaths

56,000 women succumb to pregnancy related complications in India every year — the highest across the world. Rajasthan, followed by Assam, Uttar Pradesh and Uttarakhand, has the highest maternal mortality rates—the number of women aged 15-49 dying due to pregnancy related complications per 100,000 live births—in India, according to a report by the Registrar General of India.

Madhya Pradesh, Chhattisgarh, Odisha, Bihar and Jharkhand are other states with critical numbers. Infections due to non use of a sterile kit during delivery, home births without trained providers, eclampsia, postpartum haemorrhage, early pregnancies, anaemia and unsafe abortions are the leading causes of maternal deaths. However, these deaths are entirely preventable. According to government data, although India’s maternal mortality rate has come down considerably in the last two decades, urban-rural disparities continue to exist.

In 2005, the Ministry of Health and Family Welfare launched the Janani Suraksha Yojana (JSY), a cash transfer programme, that incentivised institutional deliveries, in order to reduce maternal deaths in India. Women are awarded Rs 1,400 in rural areas and Rs 1,000 in urban areas to give birth in public health facilities, under the scheme. It also makes provisions to reduce out-of-pocket expenditure, providing free antenatal check-ups, IFA tablets, medicines, nutrition in health institutions, provision for blood transfusion, and transport from health centres and back. The scheme, however, makes no provisions for medical intervention in cases of accidents, and women like Masuhusn are left to fend for themselves.

While the scheme’s focus remains on reducing maternal and neonatal deaths, by providing free institutional care, ground reports by Video Volunteers’ (VV) Community correspondents reveal that access to prenatal and postnatal care, nutrition and timely medical intervention remain dismal in several parts of the country.

These reports are first in a series of VV’s project on Community Monitoring of Maternal Health in India. Through its network of over 180 community journalists from marginalised communities, VV seeks to report violations, produce stories, take action and devise solutions to improve the state of maternal healthcare in India.

Poor Infrastructure

Women continue to give birth in deplorable conditions at unhygienic and ill-equipped health facilities. While Bharti Kumari reports on how dangerous it is to deliver at the Telmocho sub-health centre in Dhanbad district of Jharkhand, Meri Nisha Hansda’s report reveals how pregnant women wait for hours to receive medical attention and are charged not just for medicines but also for using the toilet at the Primary Health centre in Godda. According to the health ministry guidelines a Primary Health Centre is supposed to have two doctors. However, no doctor was present at the time when Paku Tudu was brought in to the hospital. Her delivery was conducted by an ANM.

Missing Infrastructure And Health Workers

While India’s public health system grapples with a dearth of health facilities, shortage of human resources is one of the biggest impediments to the functioning of existing public health facilities in India. The absence of a health centre nearby also means that pregnant women have to travel long distances to avail medical services.

In interviews to Reena Ramteke, several women from Khatti village in Chhattisgarh say that ANMs hardly ever visit the village, and that the sub-health centre in the village always remains locked. A sub-health centre is a state-run first care provider staffed by an ANM who is responsible for administering antenatal care to pregnant women.

One Frontline Health Worker For 14 Centers

Frontline health workers are often blamed for dismal healthcare in rural India. However, they are spread too thin and are forced to work under inhuman conditions. According to the ministry guidelines, one ANM is supposed to look after eight sub-health centres. However, in Jharkhand’s Dhanbad district, two ANMs look after 23 centres in Baghmara block. Ahilya Devi looks after 14 of the 23 centres. “There is no water and provisions for emergency light in cases of power failure. In such a case we have no choice but to use a flashlight, lantern or candle. How do we put stitches in such a case?” she asks. She admits that because of the workload, she often can’t make it to some sub-health centres.

Out-Of-Pocket Expenditure

Gyanti Kumari reports from Bihar’s Siwan district on the shortage of medicines at the Rajapur Primary-health centre and instances where women were forced to spend money on medical facilities they are entitled to under the JSY. “The ANM charged Rs 50 per injection and Rs 500 to cut my daughter’s umbilical cord,” says Muni Devi’s mother.

No Cash Incentives

Instances of women not receiving cash incentives promised under JSY are endemic across rural India. Satyanarayan Banchor, reports on one such instance from Bankheda village of Bolangir district in Odisha. “Why should we deliver at public health institutions when we neither get quality care nor incentives that we are entitled to?,” they ask.

Why Do Women Opt Out Of Government’s Scheme?

In testimonies to VV’s community correspondents, women say that the lack of infrastructure, support from healthcare providers and high out of pocket expenditure discourages them from seeking care at state-run facilities. Unavailability of or delay in the arrival of an ambulance is another deterrent.

In August this year, the health ministry plans to send voice messages delivering advice to pregnant women to increase health awareness amongst them. The government plans to make use of India’s network of 950 million mobile connections to combat maternal and infant mortality. This might prove to be a cost-effective way of spreading awareness but what about safety of women who choose to deliver at public health institutions? How far will awareness campaigns take us at a time when the public health system is in complete disarray?

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An ambassador and trained facilitator under Eco Femme (a social enterprise working towards menstrual health in south India), Sanjina is also an active member of the MHM Collective- India and Menstrual Health Alliance- India. She has conducted Menstrual Health sessions in multiple government schools adopted by Rotary District 3240 as part of their WinS project in rural Bengal. She has also delivered training of trainers on SRHR, gender, sexuality and Menstruation for Tomorrow’s Foundation, Vikramshila Education Resource Society, Nirdhan trust and Micro Finance, Tollygunj Women In Need, Paint It Red in Kolkata.

Now as an MH Fellow with YKA, she’s expanding her impressive scope of work further by launching a campaign to facilitate the process of ensuring better menstrual health and SRH services for women residing in correctional homes in West Bengal. The campaign will entail an independent study to take stalk of the present conditions of MHM in correctional homes across the state and use its findings to build public support and political will to take the necessary action.

Saurabh has been associated with YKA as a user and has consistently been writing on the issue MHM and its intersectionality with other issues in the society. Now as an MHM Fellow with YKA, he’s launched the Right to Period campaign, which aims to ensure proper execution of MHM guidelines in Delhi’s schools.

The long-term aim of the campaign is to develop an open culture where menstruation is not treated as a taboo. The campaign also seeks to hold the schools accountable for their responsibilities as an important component in the implementation of MHM policies by making adequate sanitation infrastructure and knowledge of MHM available in school premises.

Read more about his campaign.

Harshita is a psychologist and works to support people with mental health issues, particularly adolescents who are survivors of violence. Associated with the Azadi Foundation in UP, Harshita became an MHM Fellow with YKA, with the aim of promoting better menstrual health.

Her campaign #MeriMarzi aims to promote menstrual health and wellness, hygiene and facilities for female sex workers in UP. She says, “Knowledge about natural body processes is a very basic human right. And for individuals whose occupation is providing sexual services, it becomes even more important.”

Meri Marzi aims to ensure sensitised, non-discriminatory health workers for the needs of female sex workers in the Suraksha Clinics under the UPSACS (Uttar Pradesh State AIDS Control Society) program by creating more dialogues and garnering public support for the cause of sex workers’ menstrual rights. The campaign will also ensure interventions with sex workers to clear misconceptions around overall hygiene management to ensure that results flow both ways.

Read more about her campaign.

MH Fellow Sabna comes with significant experience working with a range of development issues. A co-founder of Project Sakhi Saheli, which aims to combat period poverty and break menstrual taboos, Sabna has, in the past, worked on the issue of menstruation in urban slums of Delhi with women and adolescent girls. She and her team also released MenstraBook, with menstrastories and organised Menstra Tlk in the Delhi School of Social Work to create more conversations on menstruation.

With YKA MHM Fellow Vineet, Sabna launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society. As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

Read more about her campaign. 

A student from Delhi School of Social work, Vineet is a part of Project Sakhi Saheli, an initiative by the students of Delhi school of Social Work to create awareness on Menstrual Health and combat Period Poverty. Along with MHM Action Fellow Sabna, Vineet launched Menstratalk, a campaign that aims to put an end to period poverty and smash menstrual taboos in society.

As a start, the campaign aims to begin conversations on menstrual health with five hundred adolescents and youth in Delhi through offline platforms, and through this community mobilise support to create Period Friendly Institutions out of educational institutes in the city.

Find out more about the campaign here.

A native of Bhagalpur district – Bihar, Shalini Jha believes in equal rights for all genders and wants to work for a gender-equal and just society. In the past she’s had a year-long association as a community leader with Haiyya: Organise for Action’s Health Over Stigma campaign. She’s pursuing a Master’s in Literature with Ambedkar University, Delhi and as an MHM Fellow with YKA, recently launched ‘Project अल्हड़ (Alharh)’.

She says, “Bihar is ranked the lowest in India’s SDG Index 2019 for India. Hygienic and comfortable menstruation is a basic human right and sustainable development cannot be ensured if menstruators are deprived of their basic rights.” Project अल्हड़ (Alharh) aims to create a robust sensitised community in Bhagalpur to collectively spread awareness, break the taboo, debunk myths and initiate fearless conversations around menstruation. The campaign aims to reach at least 6000 adolescent girls from government and private schools in Baghalpur district in 2020.

Read more about the campaign here.

A psychologist and co-founder of a mental health NGO called Customize Cognition, Ritika forayed into the space of menstrual health and hygiene, sexual and reproductive healthcare and rights and gender equality as an MHM Fellow with YKA. She says, “The experience of working on MHM/SRHR and gender equality has been an enriching and eye-opening experience. I have learned what’s beneath the surface of the issue, be it awareness, lack of resources or disregard for trans men, who also menstruate.”

The Transmen-ses campaign aims to tackle the issue of silence and disregard for trans men’s menstruation needs, by mobilising gender sensitive health professionals and gender neutral restrooms in Lucknow.

Read more about the campaign here.

A Computer Science engineer by education, Nitisha started her career in the corporate sector, before realising she wanted to work in the development and social justice space. Since then, she has worked with Teach For India and Care India and is from the founding batch of Indian School of Development Management (ISDM), a one of its kind organisation creating leaders for the development sector through its experiential learning post graduate program.

As a Youth Ki Awaaz Menstrual Health Fellow, Nitisha has started Let’s Talk Period, a campaign to mobilise young people to switch to sustainable period products. She says, “80 lakh women in Delhi use non-biodegradable sanitary products, generate 3000 tonnes of menstrual waste, that takes 500-800 years to decompose; which in turn contributes to the health issues of all menstruators, increased burden of waste management on the city and harmful living environment for all citizens.

Let’s Talk Period aims to change this by

Find out more about her campaign here.

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A former Assistant Secretary with the Ministry of Women and Child Development in West Bengal for three months, Lakshmi Bhavya has been championing the cause of menstrual hygiene in her district. By associating herself with the Lalana Campaign, a holistic menstrual hygiene awareness campaign which is conducted by the Anahat NGO, Lakshmi has been slowly breaking taboos when it comes to periods and menstrual hygiene.

A Gender Rights Activist working with the tribal and marginalized communities in india, Srilekha is a PhD scholar working on understanding body and sexuality among tribal girls, to fill the gaps in research around indigenous women and their stories. Srilekha has worked extensively at the grassroots level with community based organisations, through several advocacy initiatives around Gender, Mental Health, Menstrual Hygiene and Sexual and Reproductive Health Rights (SRHR) for the indigenous in Jharkhand, over the last 6 years.

Srilekha has also contributed to sustainable livelihood projects and legal aid programs for survivors of sex trafficking. She has been conducting research based programs on maternal health, mental health, gender based violence, sex and sexuality. Her interest lies in conducting workshops for young people on life skills, feminism, gender and sexuality, trauma, resilience and interpersonal relationships.

A Guwahati-based college student pursuing her Masters in Tata Institute of Social Sciences, Bidisha started the #BleedwithDignity campaign on the technology platform Change.org, demanding that the Government of Assam install
biodegradable sanitary pad vending machines in all government schools across the state. Her petition on Change.org has already gathered support from over 90000 people and continues to grow.

Bidisha was selected in Change.org’s flagship program ‘She Creates Change’ having run successful online advocacy
campaigns, which were widely recognised. Through the #BleedwithDignity campaign; she organised and celebrated World Menstrual Hygiene Day, 2019 in Guwahati, Assam by hosting a wall mural by collaborating with local organisations. The initiative was widely covered by national and local media, and the mural was later inaugurated by the event’s chief guest Commissioner of Guwahati Municipal Corporation (GMC) Debeswar Malakar, IAS.

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