Kharpariya village, about 50 km from the headquarters town of Madhya Pradesh’s Mandla district, is like many villages in the region, home to the Baiga, deemed a particularly vulnerable tribal group (PVTG) for whom permanent contraception methods are banned to prevent extinction. However, care for pregnant women, which can equally help to increase the Baiga population, is not gaining the momentum it should. Sunita Bairagi, the accredited social health activist (ASHA) of the village, does not deny that, despite the 10 years she has spent working in the village, she has hardly been able to connect with the Baiga women and persuade them to have deliveries under medical supervision. Last year, she says, she was able to persuade only one of five pregnant women to have her baby in hospital. And this year, none of the three pregnant women preferred institutional delivery. “They don’t listen,” she says. “Families prefer to take pregnant women to an ojha first. Only if there are complications, they decide to go to hospital.”

 

Visits to ojhas, or traditional healers, can prove dangerous because of some of the methods they use – or they may delay patients from reaching the hospital, causing fatalities. Manauti, a 21-year-old, lost a baby because her family was reluctant to visit a hospital, and her mother-in-law Titiliya is full of remorse now. “Manauti was full-term pregnant when her condition deteriorated,” she says. “She was shivering, which is not a good sign in our tradition.”

Bairagi had asked the family to rush Manauti to the district hospital in Mandla, and even alerted doctors there to the condition of the patient so that they could remain prepared. “But the medical team kept waiting at the hospital, while the family took her first to Khatola village to visit an ojha. The doctor knew the health worker in Khatola, so he called him up and asked him to visit the ojha’s place and convince them to go to the hospital,” says Bairagi. “By that time, the case was at its worst. Manauti was brought to Mandla hospital, but had to be referred to Jabalpur Medical College. Her baby died in the womb and Manauti had to be kept in hospital for three days.”

 

It’s not unusual for pregnant women to develop complications, one reason being that many women here are severely anaemic. Some of the practices of traditional midwives are unhygienic and cause infection. In emergencies, traditional midwives and ojhas use methods that are downright crude, leading to the death of mother and child. Despite all this, people are reluctant to take their women to health centres or hospitals. Reluctance to change from familiar old ways, fear of doctors and modern medicine and the unaffordability of transportation and medicines are the chief reasons.

 

Mangalwati, mother to a two-year-old boy, hasn’t yet made up her mind if her delivery, due in a month, will be at a hospital or at home, with the assistance of a dai, or midwife. She has never been to school, is illiterate, and ignorant about maternal health practices. “If the first was delivered properly at home, why can’t the second?” she asks, countering Bairagi’s attempts to persuade her to choose a hospital delivery. Bairagi gently reminds her that her condition has been so bad that she has already had to take three blood transfusions. All three times, the procedure was carried out at a private hospital. Rajesh, her husband, a labourer, agrees to take her to hospital. But Bairagi knows she can never be sure if that will happen.

 

Health personnel like Bairagi say such stories abound in the region; even after a miscarriage, or a complicated delivery, families are reluctant to take their women to hospital the next time they are pregnant. The deaths resulting from lack of medical care are blamed on destiny.

 

Nationwide, there has been an exponential growth in institutional deliveries over the last decade – especially in rural areas. Encouraging institutional delivery makes good sense, for it reduces maternal and infant mortality and helps improve national productivity. But places like Mandla district have proved extremely resistant: only one or two institutional deliveries take place in a year. Data accessed from the district hospitals reveal that there were only two institutional deliveries out of four reported pregnancies in Bhanpur Kheda, two out of six in Gadiya, and only one out of five in Kharpariya.

 

Mandla is in the Satpura mountain range, bounded on the north by Jabalpur and on the south by Balaghat district. It is home to tribals, who still live in mud houses with barrel-tiled or tin roofs. Some tribals have brick houses, but these are most basic. Agriculture is the main source of livelihood, and women supply much of the labour. According to a 2013 survey on the statistical profile of scheduled tribes in India, 51 percent Baiga women are agricultural workers. They spend maximum time in the fields; the second share of their time is taken by firewood collection. Young women are under such pressure to attend to their fields and household chores that they go back to work within a week of delivery.

 

In fact, women here say they don’t want to stay in hospital even for a day. Getting admitted to hospital means losing three days. Premwati, of Bhanpur Kheda, says she got back to the fields on the fifth day after her home delivery. “We don’t wait for too long,” she says. “We just tie the kid on our back and get to work. Who else will do our work?”

 

Money for hospitals is another problem. Villagers in Bhanpur Kheda complain of poor frequency of Janani Express, an ambulance service run by the government. Calling a private ambulance means shelling out Rs 200-300. Male members say they cannot afford the amount if there is a sudden emergency. Mangawati’s husband Rajesh says he’d prefer to take her to a local doctor nearby. “The government hospital is far away. To take her to hospital [which is 15-20 km away from the Baiga villages] means booking a private van. We cannot afford that,” he says. One has to walk at least six km to get the ambulance or other vehicle, and Rajesh says neither can his wife walk so far nor can he take her on his bicycle.

 

The government has mandated three antenatal check-ups, two dosages of tetanus toxoid injection and regular intake of iron and folic acid tablets for pregnant women. According to the reproductive and child health guidelines, the first antenatal check-up is to be done within 12 weeks, the second between 14 and 26 weeks, the third between 28 and 34 weeks, and the fourth between 36 and 40 weeks. The details are to be noted in the antenatal register by an ASHA and submitted to the nearest community health centre. Records are kept of the pregnant woman’s weight, iron levels and blood pressure. The ASHA is also meant to counsel the woman about family planning and urge them to go for institutional delivery.

 

The ground reality, however, is very different. Sukalaya Bai, 24, of Bhanpur Kheda, is the mother of a two-year-old boy. But she never had the check-ups done, nor did she take injections or tablets. She says she never went to the anganwadi, where the ASHA is usually stationed. Sukarati and Premwati, two women Governance Now met, had also had home deliveries and did not undergo check-ups. A WHO guideline recommends that a pregnant woman visit a doctor at least eight times. Evidence suggests that the quality of contact established by frontline workers is of prime importance in ensuring that pregnant women in rural areas get proper medical attention. But in these villages, only a couple of women said they took iron and folic acid tablets. And the antenatal records registers were incomplete. The condition is the worst in Gadiya village. Madhulata Yadav, an ASHA, was clueless about the number of pregnant women in the village. The anganwadi worker says Yadav visits the village once in ten days, because she is from a nearby village. In fact, ASHAs are meant to be from the same village they serve.

 

For the last three years, scientists at the National Institute for Research in Tribal Health (NIRTH), Jabalpur, are trying to study the social and behavioural changes in maternal healthcare services through interventions. The study was done in Baiga community of Dindori district of Madhya Pradesh. The findings show that the tribe has underutilised maternal and child health care services on offer from the government. Out of 24 targeted villages, information, education and communication (IEC) interventions were made in 12. Meanwhile, 12 were kept in the control group. Information related to ANCs and institutional delivery was communicated at mass level through discussions. 

 

It was found that antenatal checkups were significantly higher among women in intervention group as compared to villages where there were no camps. Institutional delivery improved by 10 percent and postnatal checkup improved by 12 percent in intervention areas. An overall improvement of 42 percent was noticed in awareness related to maternal and child health (MCH) services.

 

Dr Dinesh Kumar, who conducted the study, told Governance Now that these results can be replicated only if frontline workers are ready to participate. “The problem is that frontline workers don’t talk to people. There is, therefore, no awareness. IEC is compulsory but it is not part of the routine. An effective intervention strategy has to be initiated to see the changes.” Clearly, ASHAs have no zeal and they try to find a cover-up for their ineffectiveness, citing customs and traditions of the tribe.

 

One of the ways to improve women’s access to healthcare is through direct cash transfers. The Janani Suraksha Yojana (JSY) was one such scheme, now merged with the maternity benefits programme announced by prime minister Narendra Modi in December last year. 

 

It was on May 19, the ministry of women and child development released a letter on the pan-India implementation of the maternity benefit programme (MBP). The scheme is to be implemented through the integrated child development services (ICDS). The first installment of Rs 1,000 will be given to the women on the early registration of pregnancy.  The second installment of Rs 2,000 will be given after at least one antenatal check-up, and the remaining Rs 2,000 after the childbirth is registered and the child has received the first cycle of BCG, OPV, DPT and hepatitis B vaccinations. 

Earlier, JSY provided direct benefit of Rs 1,000 for institutional deliveries. Though there hasn’t been any official announcement of the merger of the two schemes, the letter says: “The eligible beneficiaries would receive the remaining cash incentives as per approved norms towards maternity benefit under existing scheme after institutional delivery so that on an average a woman gets Rs 6,000.”

 

Since the integrated scheme hasn’t been initiated, there is no information on its coverage area. But Asha Parte, an ASHA of Dae village, complains, “Under JSY, money reaches the account after eight months. ASHAs get the money within three months but pregnant women don’t get it early. Only those who are able to run from pillar to post are able to get the money. Therefore, villagers have no interest in the scheme.”

 

An idea that has been under consideration is that, since many rural women prefer home deliveries, why not train dais, or midwives, in the hygiene that needs to be maintained during the procedure. Also, in the signs and symptoms of emergencies that call for medical intervention by trained gynaecologists. After all, home deliveries have been the norm for centuries.

 

But this would require a lot of intervention. For some of the methods dais use are crude. “If the mother bleeds extensively during delivery, I press the vagina with my heel,” says Radha Dhurve, a dai. She says that if there is some difficulty in delivery, she inserts her fingers and hooks them in the armpit of the foetus to pull it out.

 

“Nothing wrong has ever happened when I go for a delivery,” says Dhurve confidently. She says she doesn’t hesitate to make a slight cut to ease the baby out if it is stuck. “It’s after all God who delivers children.”  

 

Most dais keep reusing the blade they use to cut umbilical cords till they are blunted. Rs 100 or so is what they get per delivery.

 

Intervention by the government is definitely called for. Cultural resistance and ignorance need to be dispelled. Equally, outreach by medical social workers needs to be strengthened to educate the endangered Baigas to ensure that the births that take place remain viable, improving their population. n