UNICEF findings suggest a high rate of maternal deaths occur in tribal and Dalit communities; despite this, policymakers have been slow to recognise the need for targeted policies to address this problem
New Delhi: Maternal mortality continues to be a serious health challenge for India despite its impressive progress in reducing maternal deaths over the years but the problem is even worse for marginalised sections of the population such as adivasis.
In the third National Family Health Survey, the all-India average of women who had a skilled attendant during childbirth is 46.6 per cent; but the same statistic for tribal women is 24.4 per cent. According to UNICEF, “the [maternal death] data strongly suggests that socio-economic and educational factors make the Scheduled Caste/Scheduled Tribe population particularly vulnerable. Although they may make up for a small part of the general population, they had a disproportionately large proportion of maternal deaths.”
In fact, UNICEF findings suggest that more than half of all maternal deaths occur in the tribal and Dalit communities. Despite this, national surveys have not disaggregated their maternal death data according to socio-economic parameters.
In December 2010, Barwani district in Madhya Pradesh was the focus of attention as around 1,000 women and men owing allegiance to the Jagrit Adivasi Dalit Sangathan sat on a dharna to protest against the death of Vyapari Bai, along with whom another eight pregnant women had died in the District Hospital. From April to December 2010, 25 women had died in the same hospital due to maternal causes, among whom 21 were from tribal communities. In August 2013, Godda district in Jharkhand was the focus of similar attention when an article in the Economic and Political Weekly showed that between April 2011 and March 2012 within just two tribal-dominated blocks of the district, 23 pregnant women had lost their lives—of whom 17 were from tribal communities.
The exclusion of tribal communities is not limited to geographical isolation but a host of other factors. Their context is economic marginalisation, and the prevalence of poorly paid, informal labour, hazardous occupations, leading to poverty, hunger and extreme deprivation. Though the Reproductive, Maternal, Newborn and Child Health plus Adolescent (RMNCH+A) programme did recognise their specific vulnerability due to geographical isolation, their marginalisation due to political, social and economic factors needs to be addressed too, participants at a two day National Advocacy Dialogue on ‘Maternal Health in Tribal Communities of India’ held here recently said.
The meeting was organised by the National Alliance for Maternal Health and Human Rights and brought together 75 civil society activists from states with significant tribal populations, researchers and experts, key officials, media-persons and Members of Parliament.
Calling for the need to document traditional folk medicinal and midwifery practices in different communities, the meeting’s recommendations say that there must be more studies of ethno-medicine practices with subsequent recognition of practitioners.
Different tribal areas and their health problems should be studied (within tribal belts of India) while also trying to understand the underlying reasons, and investigate what health services are acceptable for different tribal groups.
Recognising beneficial or more acceptable practices—such as birthing positions, the presence of a birth companion, traditional diets—related to maternal health and incorporation of these into the training of providers as well as integration into formal health service delivery could go a long way in improving the condition of tribal women.
Although there is alienation, the idea that the so-called ‘tribal mindset’ poses an obstacle is largely a myth. Where services are good and sensitive, the usage of the formal health system has increased as much as five fold. In areas where tribal groups have actively participated in monitoring of services, their participation has brought them closer to the health system, it was said.
However, tribal blocks are under served in terms of health infrastructure and workforce; the poor quality of services in institutions, along with isolation, distrust, alienation, has played a role in contributing to home deliveries.
The high prevalence of malaria and malnutrition in tribal communities emerged again and again. Prevalence of malaria and anaemia contribute to the risk of bleeding to death with an obstetric complication. With blood transfusion not easily available in rural areas, this becomes a major cause of death, participants noted.
Speakers said some tribal communities have a very sophisticated system of healing which has not sufficiently been documented or acknowledged by the formal health system.
Recognising that the report of the high-level Xaxa Committee on tribal health has highlighted the poor access of tribal communities to maternal health services, the participants in their recommendation to the Centre sought strengthening of the health system by ensuring basic standards of quality health care services in tribal areas with adequate monitoring.
Deployment of skilled human resources in accessible points like sub-centres with the ability to manage normal delivery, if necessary in the community in case of home deliveries who need to be backed up by telecommunications and refresher trainings. Also, training and deployment of tribal youth as nurses and paramedics and training them locally, would increase ownership and reduce the alienation of tribal populations.
On ensuring availability of emergency obstetric care, the recommendations suggest the recruitment of specialists and upgradation of designated First Referral Units are essential to respond to complications.
Blood transfusion services which are a critical life-saving component must be immediately instituted in District Hospitals and FRUs. Unbanked blood donation must be decriminalised in order to ease access to blood in case of emergencies, it has been recommended.
Since sickle cell anaemia as well as falciparum malaria are highly prevalent in tribal communities, it is imperative that these be screened for in antenatal care and appropriate treatment be provided. In addition to this, TB and silicosis have also been reported as occupational hazards among communities working in stone quarries – and provision must be made to address these.
Importantly, in order to identify underserved areas requiring greater attention, all health data needs to be disaggregated by social group. This will help to ascertain which communities and areas are being neglected and allow special mechanisms to be put in place for addressing their specific problems, the participants said.