Three years ago, UNICEF India commissioned me to do two book-length reports on newborn and maternal deaths in the country. India has a miserable record on both fronts. The idea was to find out why newborns and pregnant women died in such huge numbers in India and some simple, practical ways in which such deaths could be averted. I was lucky to have a boss who was passionate, energetic, and smitten by the need to incorporate insights from the field into policy and colleagues who didnot mind that I was not a MBBS doctor. I spent several months , travelling to remote villages, small towns across India including tsunami-ravaged Andaman and Nicobar Islands. I saw first hand how motivated frontline workers were making change possible. One of the most inspiring visits was to Rajasthan where one saw an example of what writer Anand Giridhardas calls India’s “fatalistic creativity” . In this rugged terrain where ‘dacoits’ still lurked, I saw the “jugaadu” genius of India at work. The much-in-news ‘jugaad’ being used not only as transport to get from point A to point B but to save lives.
I share this excerpt from my report for UNICEF. It focuses on an intervention aimed at gauging some of the socio-cultural reasons behind maternal deaths in India and empowering communities to come up with their own solutions. (commissioned by UNICEF. Those who are interested in the subject can read it online as well http://www.unicef.org/india/MAPEDIR-Maternal_and_Perinatal_Death_Inquiry_and_Response-India.pdf)
Behind Rajasthan’s image as an exotic tourist destination, lies a grim reality. The state’s maternal mortality ratio (MMR) has declined from 508 in 1997-’98 to 445 in 2001-2003 but it is still significantly higher than the country average of 301.11 Women die during pregnancy, child birth, and soon after, due to medical causes that are well-documented. But the silent tragedy persists in the countryside because the underlying causes of unsafe motherhood are often not adequately addressed.
Saving mothers in Rajasthan entails battling nature and prejudice.More than 60% of the state’s total area is desert. Villages are sparsely populated and scattered. Road connectivity is poor. Parts of the terrain are difficult to navigate, posing enormous challenges for health workers. In recent years, the failure of the monsoon has caused a severe drought exacerbating the economic situation of many rural families in the state. Poverty combined with deeply entrenched biases against females potentially affect women’s access to health services.
A maternal death is one extreme consequence of the widespread neglect of women in the state, but there are other telling indicators of male-female differentials and the low status accorded to most women. Many districts in Rajasthan have an adverse sex ratio for females pointing to widespread and illegal female foeticide. Rajasthan recorded the highest growth in literacy rate in India, in 1991-2001, moving from 38.6 % to 61.03 %. But literacy levels, especially for girls, remain among the lowest in the country.
A common thread runs through the stories of maternal deaths in rural Rajasthan: the women who died had little control over their lives, minimal access to basic services, and little exposure to the outside world. The deceased were victims of gross neglect either by their families or their community or the health system — sometimes, all three. The circumstances that led to their death are not unique to Rajasthan. But they are exacerbated by the state’s poor infrastructure, weak health system, scattered populations and deeply entrenched social and cultural practices that continue to discriminate against girls and women. In 2007, maternal survival remains one of the most pressing challenges confronting the desert state as it seeks to carve a new image for itself, and better its record in human development.
Dholpur is one among the 3 districts in Rajasthan currently implementing MAPEDIR. Here, with support from UNICEF and the district health system, Mangalam Seva Samiti, a local NGO, has taken the lead in carrying out the community-based social audit of maternal deaths.
Dholpur district is bounded in the south by the Chambal River. Large tracts of land along the river bank have been transformed into ravines due to river erosion. These ravines, traditionally, provided a safe refuge for outlaws in the Chambal valley. At below 900, the district also has one of the worst sex ratios in the country. More than 40% of the district’s population is made up of scheduled castes and tribes, according to the 2004 District Level Household Survey (DLHS) conducted under the aegis of the Government’s RCH Programme.
MAPEDIR was initiated as a modest initiative in one block of Dholpur district in 2005 (Basedi) and extended to another block (Badi) in 2006. The first Training of the Trainer session took place in July 2005. The first batch of MAPEDIR interviewers were trained around October in the same year. Mangalam Seva Samiti, a local NGO with experience in community health, piloted the tool in Dholpur district with support from UNICEF Rajasthan and the district health system.
A community takes charge
This was no Bollywood blockbuster. But a film so stirred Surendra Singh Chauhan, a resident of Dhanukapura village in Dholpur district that he spontaneously volunteered the use of his ‘jugaad’ for obstetric emergencies. Chauhan’s jugaad (a diesel operated vehicle made locally by modifying irrigation pump sets) is normally used to transport cattle and grains to the market.
“When I saw the film some five months ago, I was convinced that I could help to prevent mothers from dying…” says Chauhan. He charges a nominal two hundred fifty rupees for each trip to the Bari Community Health Centre. ” In the last 4 months, I have rushed 4 expectant mothers to the CHC,” he adds. Dhanukapura, a village of 2000 inhabitants was one of several sites in Rajasthan where a UNICEF-supported video film was screened to raise awareness about maternal deaths. “Wherever the film was shot, villagers were keen to know more about maternal deaths and the services/facilities they could tap into to prevent such tragedies,” says O P Singh, UNICEF consultant .Dhanukapura has not had a maternal death in recent years but the film galvanised the villagers into action. The community worked out a strategy for referral transport in case of obstetric emergencies. The changes happened due to pains-taking work at the grassroots. Field workers of Mangalam and UNICEF mapped the number and type of vehicles in each village in Dholpur where they were working. .Transport owner/operators were contacted. There were people like Chauhan who were convinced about the work being done to save mothers in their area and wanted to help out. For the grassroots activists, the next step was to find out the rates and availability of vehicles at the block level. Then, rates were fixed to avoid bickering and bargaining. The NGO workers also inform the police, requesting them not to stop or harass vehicles transporting women requiring emergency obstetric care to hospitals. Today, the collective efforts have paid off. For example, Dhanukapura has a list of 3 motor vehicles, 2 tractors and 1 jugaad in case an expectant mother needs to be rushed to a health facility. Much of the awareness about maternal health that one notices among the women in Dhanukapura is also due to the work done by the local ASHA Sahyogini. “For the past two years, I have been visiting 10 houses every day. Wherever there was a pregnant woman, I drummed the message of the need for regular antenatal checkups, and the need to be aware of potential complications. A lot of my time went making families aware of the danger signs that can potentially put a woman at risk during pregnancy, child birth or soon afterwards. I also stressed the need for adequate nutrition because anaemia is widely prevalent. Families are poor so you have to tell them about vegetables and fruits they can afford. Many pregnant women have to work in the fields and I reminded them to take care of their diet and to take enough rest,” says Rekha Devi, the village ASHA.Dhanukapura showcases the powerful, catalytic role MAPEDIR could play but there is still much to be done. “There are families where no one is literate. And awareness levels about maternal and child health are very low. Some families would not even let an infant be weighed because they believe it would attract evil spirits!” as Rekha Devi points out.