Burhanpur: All around the Tapti river in Burhanpur district, the fields are lush green. This is southern Madhya Pradesh, in India’s heartland, and monsoon is a good time to be here. The air is fresh, the weather cool and the landscape a visual delight. On the horizon are mountain ranges that seem to guard the fields of rice, cotton, maize and pulses.
A fifth of Burhanpur’s population is tribal. A three-hour ride in a barebone, dusty bus takes me from the railway station to Dedtalai, one of the larger blocks in the tribal belt. In one of the villages on the way, the bus halts in front of a poster with mugshots of Prime Minister Narendra Modi and Chief Minister Shivraj Singh Chouhan. It announces a government scheme to provide cheap electricity to households.
There are still some homes here without electricity. Others face frequent power outages that last hours. Mobile networks are unreliable and internet speeds slow, although they do abruptly increase at two in the night.
The villages are spread out. It often takes an hour to walk from one to the next. During the farming season, some families move into small huts bang in the middle of the fields they are cultivating.
Water, another basic necessity, is a woman’s responsibility.
Morning hours are spent making trips from the nearest hand pump to homes. But first, one needs to queue up. A test of patience later, the women walk with buckets in their hands and pots on their heads so their families have enough water for the day.
A dangerous birth
Mamta does not know how old she is. She sits at the village sub-centre in Rama Kheda Kalan in Khaknar tehsil, holding her eight-month-old son on her lap, her third child. He was born to her after two daughters. Her eldest is five and the second-born is three. All her deliveries were at home. “My stomach hurt for an hour and then the village dai (midwife) massaged it. An hour later my son was born,” she says in a barely audible voice.
She belongs to the Korku tribe that dominates this area. Her home is an hour’s walk from the nearest village. The most accessible healthcare centre by distance is an hour on foot and another in a bus. The ride costs Rs 35, too expensive for most.
Her day starts at 7 am with cooking, cleaning, filling water and feeding her children. She then heads out to the field at 10. The children play in the dirt, the youngest resting in a swing, a tattered saree suspended at its ends from a tree near the field. Her first meal is at 12 pm. A second one follows five hours later. Rice, boiled watery dal with only salt and chilli for flavour and a wheat chapati – that’s the typical meal here. There is no money for fruits or vegetables. Mamta did not get the tetanus toxoid injections meant to prevent infections following her three home births. The government does provide an ambulance service to pick up a mother in labour and bring her to a health centre for delivery – if someone dials 108. So why didn’t anyone in her family call 108? “We don’t have a phone,” Mamta said.
Once every month, she gets iron and calcium tablets at the village sub-centre, has her weight measures and her blood pressure checked by auxiliary nurse midwifery (ANM). That’s all the healthcare she gets.The village anganwadi worker has been asking for a bicycle for four years now so she can reach out to more women like Mamta and tell them about the schemes, including the cash transfer ones. But the vehicle is yet to come. The village ASHA worker, the foot soldier who takes healthcare schemes to villagers, has decided to stop working. The incentives are too low and take months to arrive.
And so, the pregnant women are abandoned.
“There are instances where a rusted sickle is used during a delivery instead of a clean blade to cut the umbilical cord,” says Satyajit Borgohain, 25, who is here on a year-long SBI youth for India fellowship and talks to mothers about maternal hygiene and safe birth practices.
These are dangerous conditions for the expectant mother. The lack of basics can kill.
More children will die soon after their birth in Madhya Pradesh than anywhere else in India. For women, it is the third-most dangerous place in the country to give birth.
Aadhar roadblock
When women give birth in the hospital, the government transfers Rs 6,000 into their accounts. Pregnant and lactating mothers as well as children aged 0-6 get meals in the anganwadi. But those like Mamta, with no Aadhaar card and no bank accounts, don’t stand a chance to get this money or the meals.The anganwadi worker cannot help her get her Aadhaar. Without proof of birth, women like Mamta don’t exist in any government records, nor do her children born at home.
The anganwadi worker at Rama Kheda Kalan now has a new phone and an app to register data about mothers and children. It is a sign of progress but the app requires an Aadhar number to start a new record. The anganwadi worker asks, how can I ensure the mothers get any of the benefits in its absence?
In these unsupervised areas, the anganwadi gets limited rations. The anganwadi worker then makes a practical choice. No food to pregnant and lactating mothers and children aged 3-6. The most vulnerable age group, 0-3-year-olds, gets food. So Mamta does not get the daily meals at the village anganwadi that she is supposed to get. Even if she did, she wouldn’t eat while her other children go without food.
In private, the mothers talk about the other gaps. Since the self-help groups of the village manage the anganwadi rations, some of the ration is siphoned off, they allege. The village panchayat members who are required to keep a watch also take a part of the bounty, they add.
Private healthcare in these areas is in the form of a tribal healer. He holds no degrees but for all practical purposes is the healthcare provider here.
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When the deprivation hits children hard and they slip in the severely malnourished category, they are referred to the nearest Nutritional Rehabilitation Centre (NRC) by the anganwadi worker. The centre in Khaknar is close to an hour’s bus ride from the village. Run by the government, and supported by UNESCO, it is where children are admitted for 14 days and fed a high-protein, high-sugar diet. One primary care taker, usually the mother, is allowed to stay with the child. It is a strategy to keep the ones on the verge of death alive.
At Khaknar’s NRC, there are 10 beds. They are always full. During monsoon the authorities are forced to increase the number of beds. It is when the tribals, who often work in construction sites in bordering towns, return home to cultivate their fields. With them come their poorly nourished children.
Parvati Ganesh sits with her two-year-old daughter Saraswati on a bed at the NRC. Saraswati weighs 5.6 kg, which is half of what those in her age group ought to. This is the second time her mother has brought her here. The first time was when Saraswati was six months old. She got better but soon after Parvati got pregnant again and was unable to care for Saraswati, who slipped back in the severely malnourished category.
Pami Gite, the dietician who has helmed this NRC for over a decade now, says that the mother, herself often a teenager and malnourished, has too much on her plate. The policies emphasise her role and not that of her partner. The mother needs to breastfeed, she is informed. She needs to watch out lest the children slip into the malnutrition cycle again, she is told. Isn’t she concerned about family planning, she is asked.And so, in this deprived area, where giving birth can kill, as many as half of the women in the reproductive age group opt for sterilisation – a procedure that has a high death rate even in the best of health systems.
But through the entire journey, a crucial component of the healthcare system is missing: the doctor. That is because there are barely any here.
A reluctant doctor
The primary healthcare centre that caters to a population of 30,000 has only the ANM nurse and a helper. The NRC in Khaknar is attached to the secondary healthcare centre. The building is an airy, two-storey structure. Those inside have the task of providing healthcare to close to 65,000 people living in the surrounding villages.
There is one full time doctor.
This is not to say that there are no posts for doctors. There are five. Four are vacant.
And so, the administration has resorted to filling these positions using contract AYUSH doctors. The only full-time doctor also holds the post of the block medical officer. Most of his time is spent in official meetings and functions where attendance is mandatory. Before he was appointed, the interim charge was given to the principal of a local government school.
Vacancies of close to half of the paramedical staff also lie unfilled.
Medical students are required to do a mandatory rural stint and every year, one or two are posted here. These students either request a change in their location to a centre in urban Burhanpur or use political connections to get a new posting altogether. No one wants to work in this deprived area without basic infrastructure for limited pay. Sachin Lad, the block program manager, told The Wire that every year they expect up to two new doctors to come but then no one turns up. “Hum toh bas sirf list dekhte hi reh jaate hai” (‘All we can do is stare at the list’), he says.
“Vacant positions are our biggest problem. What’s worse is the officers heading departments are not domain experts. A history graduate might be heading schemes for breastfeeding. It doesn’t work,” says R.B.S. Dandotiya, the CEO of the district panchayat, Khaknar.
In the absence of guidance from anyone about her health, Mamta often turns to her husband. “No one talks about anything here. If I have a doubt I ask him,” she says. Often, he has no answers and then neither does she. Her family, including her husband, were clear about one thing though, that pregnancies have to continue till a male child is born.
As the bus leaves Dedtalai, the lush green fields give way to brick homes and a dusty, crowded station area. Soon after the monsoon ends, the migrants will take the train out of here to the nearest cities, women and young children in tow.
Disha Shetty is a freelance science journalist.