In her ninth month of pregnancy, Laxmi Bhatra from Orissa’s Anchala village in Kosagumuda block of Nawrangpur district, suddenly felt very uneasy. On seeing his wife’s condition, Kamlochan, a landless worker, got on to his bicycle, tied a hapless Laxmi loosely to him and paddled 15 kilometres along a hilly pathway to a six-bed health facility in the block. When he got there, the local doctor – instead of admitting the visibly suffering woman – gave her some medication and sent her back 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 the country that it hardly figures as the tragedy it is. Yet, it helps one understand Orissa’s baby blues – the state has an Infant Mortality Rate (IMR) of 71 deaths per 1000 live births as compared to the national figure of 55. Laxmi’s story also needs to be understood if India has to come closer to achieving its Millennium Development Goal (MDG) of reducing by two-thirds, between 1990 and 2015, its under-five mortality rate.
Neonatal deaths (those that occur in the first four weeks of life) account for 69 per cent of infant deaths (Sample Registration Survey 2008) in Orissa. Most of the babies that die have very low birth weight (less than 2,500 grams), indicating widespread malnutrition. In rural Orissa, 71.3 per cent of pregnant women (19-45 years) suffer from anaemia (NFHS III – 2005-2006).
Laxmi came from precisely such an impoverished, tribal background. In fact, more than 22 per cent of Orissa’s population is tribal. Says Mini Majhi, a TBA (Trained Birth Attendant), “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 have no money to spend on childbirth.” Majhi has been working for 10 years in the interiors of Kandhamal, another predominantly tribal district that has the highest IMR levels in Orissa.
Adds Majhibani Sikaka, 50, a panchayat ward member from Sargipayu village in Munnikhol Gram Panchayat, Munniguda block, Rayagada district, yet another tribal pocket in southern Orissa, “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 10 newborns die in her Dongria Kondh community – and if there is a choice between saving the child or the mother, the mother wins, as she is an earning member.
Making the situation more complex is the general illiteracy and blind belief in traditions that are sometimes harmful. 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 abysmal lack of health delivery.
In fact, 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 to address the concern is the trained female community health activist – the Accredited Social Health Activist (ASHA). ASHAs are recruited from the villages they serve and they 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$1=Rs 44.60) to cover lost wages and general expenses.
But the basic infrastructure to achieve these goals is just not there. 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.
Says Sushanta Garada of the Nawrangpur Democratic Action, a member group of the community-based monitoring of health services under NRHM, “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 says that the doctor will be available for three hours, two days a week. “Childbirth does not wait for a doctor’s availability,” comments Garada, with a wry smile. Even the much-touted Janani Express in Nawrangpur – transportation to take expectant mothers to local health institutions – is unaffordable. Patients are charged Rs 250 for a 10 kilometre distance, although there is now a plan to charge the cost of a litre of petrol for every 10 kilometres, which the woman can pay from the Rs 1,400 that is due to her.
Institutional childbirths have certainly risen in Orissa from 23 to 39 per cent between the 1999 (NFHS II) and 2005-06 (NFHS III) period and IMR has come down 20 points since the Orissa government went into mission mode through the Infant Mortality Reduction Mission in 2001 till 2008. This change, however, is unsatisfactory, hindered mainly by the sluggish change seen amongst the large tribal population in the state.
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.
“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.”
Despite the grim scenario, in the state capital, Bhubhaneswar, Dr P.K. Senapati, State Maternal Health Programme Manager, believes things are changing. He points out that there are now many government programmes – like the integrated management of neonatal and childhood illness – that focus on strengthening home-based care by training grassroots health workers. Health workers are being instructed to keep track of births – from inception to delivery – for the timely detection of complications; special newborn care units are also to be established at district hospitals.
But clearly the authorities need to do more, and fast. Says Sanjukta Satpathy, a member of the National Alliance of Women (NAWO), a Bhubaneswar-based NGO for women’s rights, “There are even problems in the selection of the ASHAs. It is done by the village panchayat and is often based on vested interests.” According to Garada, often these women are too young and know nothing 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. In Nawrangpur, some ASHAs have been given bicycles and two vans have also made available to them at the block level, but access and training continues to remain a huge challenge.
There is also petty corruption. In the Daringibadi block of Kandhamal, for instance, cases of women having their deliveries at home but being put on the hospital delivery registers to get the requisite Rs 1,400, have surfaced. The doctor and the health worker also often connive to cheat bona fide patients of their dues.
These are the ground realities. By the government’s own estimation India is likely to fall short of its MDGs target by 28 percentage points in terms of child mortality. Which is precisely why the lessons from Laxmi’s story need to be learnt and institutional correctives put into place.