Bhubaneswar (Women’s Feature Service) – In her ninth month of pregnancy, Laxmi Bhatra from Orissa’s Anchala village in the tribal dominated Kosagumuda block of Nawrangpur district, suddenly felt unwell. On seeing his wife’s condition, Kamlochan, a landless worker, got on to his bicycle, tied a hapless Laxmi loosely to him, and peddled 15 kilometres along a hilly pathway to a six-bed health facility. When he got there, instead of admitting the visibly suffering woman, the local doctor gave her some medication and sent her home. Laxmi delivered a stillborn male child soon after, and died a week later.
Laxmi’s story is so common in a state with one of the highest levels of infant mortality in India that it hardly figures as the tragedy that it is. But it is a reminder that if India is to come closer to achieving the Millennium Development Goal (MDG) of reducing its under-five mortality rate by two-thirds by the year 2015, it must focus urgently on child mortality.
In September, heads of state will gather at the United Nations to review progress on the MDGs – the set of promises they made in the year 2000 to eradicate extreme poverty and its root causes by 2015. As UN Secretary General Ban Ki-moon recently observed, “We must not fail the billions who look to the international community to fulfill the promise of the Millennium Declaration for a better world.” He was speaking about people like Laxmi, in regions like Orissa. More babies die in this state than almost anywhere in the country. The state has an Infant Mortality Rate of 71 deaths per 1,000 live births — as compared to the national figure of 55, with neonatal deaths (those that occur in the first four weeks of life) accounting for 69 per cent of these deaths, according to the 2008 Sample Registration Survey 2008. Most babies, especially those born into tribal communities, have a very low birth weight (less than 2,500 grams), indicating widespread malnutrition and the high anaemia levels of their mothers.
Poverty and malnutrition make a deadly combination. Majhibani Sikaka, 50, a panchayat ward member from Sargipayu village, Rayagada district, says “malnourished pregnant women continue to work right till the day of delivery, sometimes bearing heavy loads on their heads.” Sikaka estimates that at least three out of ten newborns die in her Dongria Kondh community. Mini Majhi, a Trained Birth Attendant, adds that “families in tribal regions are so poor they cannot afford to miss a day’s earnings to visit health centres for regular check ups. They also have no money to spend on childbirth.” Majhi should know. She has been working for 10 years in the interiors of Kandhamal, another predominantly tribal district.
Making the situation more complex is the general illiteracy. Pregnancy complications are generally treated by the local ‘bejuni’ or witch doctor. He dispenses herbal potions and chants magic words to chase away the evil eye believed to have caused the problem. But this dependence on the ‘bejuni’ is in itself a comment on the poor health delivery system.
In fact, improving mother and child survival in poverty-stricken regions was a central objective of the National Rural Health Mission (NRHM) when it was set up in 2005. Its key human resource is the trained female community health activist, called the Accredited Social Health Activist (ASHA). ASHAs are recruited from the villages they serve and are expected to visit expectant mothers, explain the benefits of giving birth in a health institution, and impart advice on immunisation, sanitation and nutrition. Financial incentives are also meant to play a part. After delivery, a mother is supposed to receive Rs 1,400 (US $31) to compensate for lost wages and general expenses.
But even the best plans go awry when faced with administrative failure. Health facilities in rural Orissa are poorly equipped and understaffed, with even the health workers on the rolls choosing to live in nearby towns rather than at their supposed place of work. Sushanta Garada of the Nawrangpur Democratic Action, a member group of the community-based monitoring of health services under NRHM, says “if there is some risk, doctors at the first referral at block levels will not even touch these patients. They are referred to the district hospital.”
Garada cites the example of a primary health centre in his area where a notice on the wall reads that the doctor will be available for three hours, two days per week. “Childbirth does not wait for a doctor’s availability,” comments Garada.
As in Laxmi’s case, topography also contributes to this familiar tragedy. Nawrangpur is hilly and has only fair weather roads or footpaths. These too turn risky during the monsoons, and can be navigated only by foot or at best by bicycles. Garada explains, “In Nawrangpur, which has one of the highest IMR levels in Orissa, women nearing their delivery date, even if they have complications, have to sometimes travel 70 kilometres to the district hospital through terrain that can be crossed only on foot and could even entail crossing rivers. There exists no other mode of transport.”
In such a situation, the role of the ASHA can make all the difference between life and death. According to Pramila Swain, president of the Bhubaneswar based National Alliance of Women, ASHAs have contributed to bringing down the number of neo-natal deaths, but the system needs improvement. There are problems in the selection of these women. The village panchayats that take these decisions are often influenced by vested interests. The recruits are sometimes too young, with little knowledge about child bearing. They also find it difficult to travel long distances to isolated hamlets in order to accompany patients at night to health facilities. Petty corruption is a problem, too. In the Daringibadi block of Kandhamal, for instance, cases of women having their deliveries at home but getting their names into hospital registers in order to get the Rs 1,400 given for institutional deliveries have surfaced. Doctors and health workers also sometimes connive to cheat bona fide patients of their dues.
In Orissa’s capital city, Bhubhaneswar, Dr P.K. Senapati, State Maternal Health Programme Manager, believes things are improving despite the odds. For instance, institutional childbirths have risen in Orissa from 23 to 39 per cent between 1999 and 2006. Says Dr. Senapati, “While institutional childbirths are rising, we realise that a poor state like Orissa has to also focus on home delivery and strengthening home-based care by training grassroots health workers.” According to Dr. Senapati, health workers are also being instructed to keep track of pregnancies – from inception to delivery – for the timely detection of complications.
Such efforts are paying off. The Infant Mortality Rate dropped 20 points between 2001 and 2008, according to reliable data. The pace of change, however, needs to be urgently hastened. The Government of India estimates that, at the present rate of change, the country is likely to fall short by 28 percentage points on its MDG commitment to reduce child mortality.
In fact, South Asia is one of the worst performing regions in the world when it comes to child mortality and maternal mortality, according to the ‘Millennium Development Goals Report, 2009. In September, when the international community reviews progress on the MDGs, the concern of babies dying because of poverty and lack of medical care will once again come on the global radar.
This is why Laxmi’s story – and the lessons learnt from it – are so important.
