More than half of all married women in India are anaemic and one-third are malnourished. No wonder India contributes a quarter of global maternal deaths. Maternal mortality has a direct impact on infant survival, but only 46.6% of mothers receive iron and folic acid for at least 100 days during pregnancy. Rajasthani women are no exception, but in Jhakaron ki Dhani village there are signs of change
India contributes about a quarter of all global maternal deaths, and maternal mortality has a direct impact on infant mortality. What role do nutrition and social practices, like early marriage, play in this grim tableau?
For some answers, I visit Jhakaron ki Dhani village, which lies 25 km from Jodhpur in western Rajasthan. There I meet Shamu Meghwal, who epitomises the health problems that many young women in her community experience. Married at 13, she had her first baby when she was 15. Now 25, she is the mother of four and has just lost her husband. She is visibly anaemic and complains of chronic weakness including back and abdominal pain. In Jhakaron ki Dhani, early marriage and motherhood is the norm.
Dr Kanta Tiwari, a renowned gynaecologist, who has been working in Jodhpur and its surrounding areas for the past four decades, is familiar with the situation in Jhakaron ki Dhani. “The women here are already at a lower level of health when they get pregnant. They don’t receive proper nutrition throughout their lives. This makes them even more anaemic, resulting in long-term consequences for their health and that of their newborn,” she says.
According to Unicef data, it is estimated that more than half of all married women in India are anaemic and one-third of them are malnourished, with a Body Mass Index (BMI) below normal. Moreover, only 46.6% of mothers receive iron and folic acid for at least 100 days during pregnancy; Rajasthani women are no exception.
“In village women, the protein intake could be even lower because women here seldom have pulses. In this region, there are local fruits like ber or the Indian jujube (Ziziphus mauritiana), which grow in abundance and provide some much-needed nutrition,” elaborates Dr Tiwari. Ber, incidentally, is a hardy minor fruit crop that is rich in Vitamin C.
Agriculture and animal husbandry are the chief sources of income in Jhakaron ki Dhani, and because of its close proximity to Jodhpur it has a middle school and access to electricity, tap water, telephones and roads. Some of the villagers have gained employment in nearby sandstone mines and in the local government as well. The main crops that grow in this village, which spreads across 852 hectares in the Narva panchayat, are millet, wheat, sorghum, moong, moth beans, cumin and seasonal vegetables, all of which figure in the local diet.
Today, Meghwal and her sister-in-law Santosh are sharing a thali of raab (ground bajra cooked in buttermilk), moth beans vegetable and bajre ki roti (millet flatbread). Depending on income levels, seasonal vegetables such as cauliflower and cabbage, or sweets like halwa made of wheat flour, ghee and jaggery, or churma, made by crushing wheat chappatis, ghee and sugar, are also included. These are certainly wholesome foods but, sadly, women and girls usually eat last in the family and this could mean that they end up eating the least too.
Despite the legal age of marriage for women in India being 18, the average age of marriage in Rajasthan is 17 years, and the village of Jhakaron ki Dhani reflects this trend. Santosh, for instance, was married at 17 and now has three children. Her second pregnancy resulted in a stillborn. Meghwal’s younger sister-in-law, Bhagwati, 22, who was married at 13, has two small kids. She confesses to suffering from some gynaecological problems and frequent spells of dizziness. As experts point out, too many children and too frequent pregnancies result in women not being able to recover from one pregnancy to the next in terms of nutritional status and iron stores.
Given that only about half the number of new mothers get antenatal care from a health professional, and only about one in three receives postnatal care within the first two weeks of giving birth, it is no surprise that women in this village get hardly any medical attention. Most of them give birth at home with the help of a midwife, and resume their household chores, including strenuous ones like sweeping and washing, within a week of childbirth. Some even toil in the fields in the harsh desert conditions of the Thar desert.
Chuki Devi, 45, who married at 17, can consider herself a little luckier. She is amongst a handful of women in Jhakaron ki Dhani who has had all her four kids in a hospital. Mohani Devi, 30, also had her caesarean section in a Jodhpur hospital. The only reason she says family members decided to take her to hospital was because she had suffered an abortion earlier and they didn’t want to take any chances. This was also why Mohani’s mother-in-law spared her laborious household duties for two months after the delivery. Unfortunately, in contrast, her sister-in-law, Chanani Devi, 35, who gave birth to her four kids at home, had to resume doing the household chores a week after her delivery each time. This could be contributing to the constant back pain she now endures.
Their mother-in-law, Sua Devi, 72, is the one who supervised their diet during pregnancy and after delivery. Generally, for the first seven to 10 days after giving birth, women in Jhakaron ki Dhani are not allowed milk. In most homes, new mothers are fed a fairly large-sized laddoo made with wheat flour, ghee, almonds and other dry fruits, jaggery, sonth (dried ginger powder), ajwain (Trachyspermum ammi) and gond (edible gum) twice a day for about a month-and-a-half after delivery.
According to Dr Tiwari, the laddoo, which can weigh about 200 grams, is a rich source of calcium, iron, vitamins and proteins. “The new mother is also fed turmeric, which has antiseptic properties, and given bajre ki roti with vegetables. Sometimes pulses and lentils or porridge made of wheat or millet is eaten for lunch.”
While there is some attempt to provide an expectant mother with nutritious food during her pregnancy, women generally eat poorly. Take Munni Devi, 35, who was married at 10 and had the first of her four children at 15. Today, she can only afford two meals a day, just enough milk for tea, and pulses/lentils once a week.
A lifetime of poor eating is responsible for the malnutrition endemic in this area, and this in turn impacts levels of maternal and infant mortality. “We have low birth weight babies and premature babies here, all of which indicate the poor nutritional profiles of their mothers,” observes Dr Tiwari.
Dr Pratibha Sharma, who has been a practising gynaecologist in Jodhpur for nearly 16 years and runs a 12-bed nursing home, also reports cases where the woman is anaemic, physically poorly built or has had an early miscarriage and tends to go into post-partum haemorrhage requiring a blood transfusion.
But change is in the air, even in a village like Jhakaron ki Dhani, and education is proving to be the real game-changer. According to Dr Tiwari, with more girls getting educated, women are becoming mothers much later than they did a generation ago. “First-time mothers are now between 20 and 22 years of age; earlier they used to be between 16 and 18 years old,” she says.
This augurs well for young girls like Chuki Jhakhar, 17, who is appearing for her Class 12 exams, bucking the traditional early marriage trend. More and more girls like her are now studying and even educating their mothers and aunts.
Empowering rural women in villages like Jhakaron ki Dhani, through education, employment, easy access to healthcare, and sensitising them to the importance of institutional deliveries could go a long way in preventing infant and maternal deaths and putting India on the path to meeting the United Nations Millennium Development Goal targets for maternal mortality rate, infant mortality rate and total fertility rate.
(Neena Bhandari is a Sydney-based foreign correspondent writing for international news agencies. She did this piece for WFS during a visit to India)
Maternal deaths in Barwani
80,000 women die of pregnancy-related causes in India every year, two-thirds in Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh, states with the poorest health and development indicators.
The majority of maternal deaths can be traced to conditions which need emergency treatment in a health centre or hospital. The government’s Janani Suraksha Yojana in these nine states provides women below the poverty line Rs 1,400 if they deliver in an institution. However, the government seems to be pushing women to deliver in institutions without ensuring that they will receive adequate care.
From April to November 2010, there were reports of 27 maternal deaths from the district hospital in Barwani, a predominantly tribal district in Madhya Pradesh. An investigation team interviewed the families, health workers, medical staff and government officials, and examined medical records. Some of their findings:
No prenatal care: Only one of the six women on whom ‘verbal autopsies’ were conducted had received any antenatal care. The case records had no information on the other 21 women. Auxiliary nurse midwives did not visit the villages to provide antenatal care. Accredited social health activists were unaware of the basic obstetric complications for which they needed to refer women for emergency care. And though anaemia is a known contributor to pregnancy-related complications (22 of the 27 women who died had severe anaemia) and is a common problem in the district, government programmes to reduce anaemia were not implemented.
Shunted from one hospital to another: All 27 women had sought care in an institution once complications developed. However, in the six cases for which verbal autopsies were done, three were shunted to two or three institutions before finally arriving at the district hospital, which has the necessary facilities. The primary and community health centres are expected to provide initial emergency obstetric care and stabilise the women before referring them onwards if necessary. However, they were not equipped to do this.
Forced to pay for free treatment: Even when the women were certified to be below the official poverty line and thus eligible for free drugs and services, many families had to pay out of pocket for drugs, diagnostics and other services.
Transport unaffordable: Of the six deceased women whose families the team met, only three managed to use state-run ambulance services. Several families reported having to spend considerable sums of money on hiring private vehicles for transport of the women, resulting in long delays, when there were referrals from one facility to another. Thirteen of the 26 women treated at the district hospital were referred to a government medical college four hours away but could not afford to make the journey and died in the district hospital.
Negligence in treatment: At least 10 of the 27 women were given delayed treatment in the district hospital: starting treatment for eclampsia, controlling haemorrhage, operating for obstructed labour and managing shock. None of the 27 women who died in the district hospital had had any emergency operative intervention, despite this being clearly indicated in at least seven cases. In some cases, the quality of care was so poor that it may be considered negligent.
Severe shortage of skilled staff: The entire women’s section of 60 beds, including the labour room in the district hospital, was staffed with five nurses, two on morning shift, two on evening shift and one on night shift.
The district hospital was fully equipped to do obstetric and gynaecological surgery, but no emergency operations were being performed at night because the hospital did not have the staff to handle the increased patient load.
Deliveries in primary and community health centres were conducted by nurses or nurse-midwives who had not received any training or certification in skilled birth attendance. In the district hospital, most deliveries were managed by traditional birth attendants as there was a severe shortage of nurses.
Poorly equipped facilities: One community health centre, which is supposed to provide comprehensive emergency obstetric care, did not even have facilities to provide basic emergency obstetric care. Post-partum care is often not given and women are discharged from facilities soon after delivery instead of 48 hours later, as mandated by the programme, because of lack of space.
Unethical behaviour: Women patients reported instances of verbal and physical abuse by staff during delivery, and tribal women felt they were discriminated against by healthcare providers. Twenty-one of the 27 women who died belonged to scheduled tribes, the poorest and most vulnerable sections of society.
Lack of accountability was demonstrated by the poor quality of care and apathy among health professionals at the institutions and the frequent flouting of ethical principles in the provision of care. There was also a lack of any kind of grievance procedure or mechanism for redress. Instead, there were threats of punitive action against families that filed complaints.
Subha Sri, B, Sarojini, N, Khanna Renu. ‘An Investigation of Maternal Deaths Following Public Protests in a Tribal District of Madhya Pradesh, Central India’. Reproductive Health Matters. May 2012; 20(39):11-20
Infochange News & Features, December 2012