Only 18, Bijol Mahato is expecting her first child. She listens keenly as Chhobi Mahato, an accredited social health activist (ASHA) with Dakhinsole sub-centre, explains that though counselling about early pregnancy has helped in some cases, there is still pressure from in-laws to deliver the first child quickly in villages.

Like the young would-be mother, Nilima Mahato also listens quietly as Chhobi patiently explains the techniques of breastfeeding.
Like Bijol and Nilima, Chhobi, who recently completed a year working as an ASHA, takes her health-related help to nearly 170 households across three villages.

On a balmy January afternoon, as Chhobi comes visiting expecting mothers in her village, Nandaria, Governance Now catches up with her to gather the life and times of a field-level health worker. And cutting across a maze of mess and misconception prevalent among residents, it’s hardly an easy job.
“Once the first child is born, a mother-in-law usually relaxes,” Chhobi says, referring to her advises to young Bijol. “The second child usually is born after three to five years but they (locals; more specifically, in-laws) don’t seem to understand that it affects a woman’s health.”

Corroborating, Bijol’s sister-in-law Mallika says she experienced complexities when she delivered her first child at 18. “Doctors told us that either the mother or the child can stay healthy,” she says. Her first child is now five years old, and Mallika suffers from high blood pressure — a result of the complications encountered at the time of delivery.

It is very important, for instance, for an expecting mother to take regular doses of iron pills to ensure development of the unborn child. “I have given iron pills to high school girls to treat anaemia, and I have had meetings with mothers of girls, explaining to them why iron is essential,” says Chhobi.
Sometimes she enlists the help of the school headmaster to reach out to the parents, through their children.

Fighting unfounded fears
Reluctance to use contraception is another challenge health activists like her face in the villages, Chhobi says. And her observation is validated by the likes of Shefali Mahato, who just had her second child. “I have never used any kind of contraception. My husband had said that we will take care,” Shefali says.
Another villager, Papia Ray, says she became pregnant immediately after marriage — an unplanned pregnancy, though she had “never even thought of” taking pills or using contraception.

The deep-seated misconception about contraception is evident from people like Seema Mahato, who says that both she and her husband are afraid of using contraceptives. “What if we die?” she asks, alarmed.

Chhobi says she has been trying to convince people to wear intrauterine device (IUD), telling them that it is safe and hassle-free. “Pills dry up breast milk, while condoms are unreliable,” she says. All a woman needs to do is go to the health sub-centre and ask for an IUD — the ANM, she says, will do the needful.

But Shantana Mahato demonstrates the fallacies associated with IUD in particular and, often, contraception in general. “I don’t want to wear an IUD,” Shantana says. “What if something happens to me? My children are too young...” she reasons, equally alarmed, when asked why she did not try IUD.
Fighting frustration, irregular payments

Besides addressing the ground-level challenges, Chhobi says ASHAs also have to deal with irregular, in fact a paltry, pay, among other issues. “We do not have a fixed income. We earn only when a woman gets pregnant, or a child is born,” she says. “Our work is hectic but we will work with more enthusiasm if we get our payments regularly.”

Anima Piri, an ASHA with Kashijora sub-centre, says: “Our dues have not been cleared since October 2012. Though maternal and infant deaths have reduced significantly due to our services, we are not even entitled to something as basic as pension.”
Frustrated, many ASHAs had recently stormed the district magistrate’s office to voice their grievances, Papia Adhikari, district secretary of the ASHA workers’ union, affiliated to the All India United Trade Union Centre (AIUTUC), says.

She says ASHAs were initially paid '800 per month. But the earlier format was scrapped and a new one implemented in October 2011, through which ASHAs receive remuneration based on their work. But Adhikari says that’s not enough: “We want a fixed salary, gratuity, and pension. Our payments are delayed by eight months. We have to nearly revolt every time to get our money.

“We don’t have a stable income. If there is no expecting mother or newborn in my area, I am not entitled to any payment.”

Each ASHA gets '200 on successful delivery in a hospital, and an additional '100 for staying the night at the hospital. “Where will we stay (otherwise)?” Adhikari asks. “There is no accommodation facility; besides, who will guarantee our safety?”

Pointing out the case of neighbouring Sikkim, AIUTUC’s district coordinator Narayan Adhikari says, “The Sikkim government pays ASHA workers '3,000 per month, besides their entitlement as per the central government’s format. But we have got no response from the state government till date.”
Highlighting another issue, he says, “There is no gynaecologist at the Pingla block hospital, so women (expectant mothers) from the area come to Medinipur hospital. As a result, ASHAs working there (in Pingla) are not getting money.”

ASHA workers, he stresses, are “harassed” in many such ways.
Popped the question, Dr Trideep Das, deputy chief medical officer (CMO)-1, West Medinipur, says: “Pingla is a block primary health centre. But the gynaecologist posted there was detailed to Ghatal in view of the (prevailing) law and order situation.”
But conceding that public demand is for a specialist at Pingla as well, Dr Das says, “We will depute a gynaecologist as soon as manpower is available.”

Plight of link person
Monideepa Chakraborty, ANM of Kashijora sub-centre, highlights the plight of link persons as well: “ASHAs have been working for the last four years but link persons helped us before that. They are our link in places where there is no ASHA. They inform people about upcoming immunisation and vaccinations.”
But for all that work, they take home a paltry '100 per month, Chakraborty says, adding, “There has been no hike in their salary.”

Shikha Singh, a link person at Kashijora sub-centre, says she is holding on to this job despite the meagre and irregular pay only with the hope that things will change for the better. Singh says she hasn’t received remuneration for the past eight months.

The CMO’s office refused to comment on the issue.

While sources in the CMO office label most such grievances as “politically motivated”, AIUTUC’s Narayan Adhikari says, “We are planning to launch a central (nationwide) movement soon to voice our complaints.”.