Our Bodies, Ourselves: Listen to Kalahandi's Women
Ever since she gave birth to a stillborn boy, Sajana Sabar, 20, has not spoken a word. A resident of Uchalla village in Golamunda block of Kalahandi district in Orissa, Sajana lives 75 kilometres away from the nearest hospital. For the delivery, her family had to hire a jeep for a princely sum of Rs 1,000 (US$1=Rs 42) to get to the sub-divisional hospital in Dharamgarh. There, the doctor demanded a fee of Rs 1,000 and then with another Rs 2,000 to pay off the medicines and food bills, Sajana's father-in-law, a marginal farmer, was compelled to sell off the entire year's stock of paddy when the first offer came along. The family spent over Rs 6,000 on the delivery but ailing Sajana came home - from the brink of death - bereft.
Mana Jhankar, 24, is a daily wage earner in village Kuturukhamar of Bhawanipatna block, 12 kilometres from Kalahandi district. Her husband sells puffed rice and the couple finds it difficult to make ends meet. Understandably, when Mana was expecting, an institutional delivery was out of the question. The couple could ill-afford the government hospital expense of Rs 2,000. When Mana first experienced birth pangs, her husband was 15 kilometres away and unaware that his young wife was soon to endure a horrific labour: The baby emerged in a sitting position - buttocks out, head and feet stuck inside. By the time Sabita Nayak, an Auxiliary Nurse Midwife (ANM), reached Mana's house, the expectant woman had bled for five hours. Desperate to get her patient to a hospital, Sabita pleaded with the bus drivers on the highway to ferry them across but to no avail. Nayak then boarded a bus to return with an ambulance. Mana's tangled umbilical cord had to be cut into several pieces to extract the asphyxiated foetus. She was hospitalised for a week.
Lakhmani Sabar of Uchalla was a mother by 17 - just a year into her marriage to Dana, a daily wage earner. Their only surviving child, a daughter, is now 14. Motherless, the teenager is testimony to the district's high Maternal Mortality Rate (MMR). Lakhmani's subsequent four pregnancies had resulted in stillbirths and eventually her death. She had not been given a single antenatal check-up and was administered just one dose of tetanus toxoid, instead of the requisite three. Perhaps her life could have been saved had she been able to reach the hospital in Dharamgarh before she began to haemorrhage.
These pitiful tales are common to Kalahandi, where the official MMR is 364 per 100,000 live births as against the state's 358. But the district could well have an MMR of anything between 400 to 500 if the unregistered cases are factored in, states Dr B.C. Roy, Asst. District Medical Officer, Family Welfare Department. According to the NGO, White Ribbon Alliance (India), MMR goes up to 620 in rural Orissa - a level comparable with that of sub-Saharan Africa.
The three main reasons for a high MMR in Kalahandi - where nearly half of the populace comprises vulnerable Scheduled Tribes and Castes - are early marriage, low institutional deliveries and low intake of vitamin supplements during pregnancy. Poverty, educational backwardness and lack of health education and awareness - only 29.3 per cent of women are literate - are the other causes. Ironically, six out of 10 maternal deaths in the district are avoidable, says Roy.
But why do expectant women have to suffer at all? At the Jan Sunwaye (public hearing) of the Janani Suraksha Yojana (JSY) or Safe Motherhood Scheme, under the National Rural Health Mission (NRHM), conducted in Bhawanipatna, Kalahandi - one of the 22 held in backward districts by the Orissa State Commission for Women (SCW) and UNICEF over the last year - Sajana's mother-in-law arrived with a pertinent query. Embittered ever since she lost her grandchild, she asked, "Why should families like mine be compelled to sell land and foodgrain to get basic health services that should be ours by right?"
At the hearing, Sabita, as a medical professional, wanted to know why basic health services were so expensive and difficult to access for Kalahandi's Below Poverty Line families who form 62.71 per cent (1997 BPL survey) of the population.
Given this ground situation, the public hearing offers the most, and perhaps the only, effective communication method for women whose lives are at risk. They give them the opportunity to directly place their concerns in an open forum before rights commissions such as the State Commission for Women (SCW), decision-makers and planners. In the long run, public hearings help improve health service delivery, hold service providers accountable and build up a case study-based social audit system for policy changes. The 700 to 1,000 women who attended the public hearings certainly realised the power of their voice.
"Wherever we have visited, specifically in Koraput, Rayagada and Malkanagiri - all drought-prone areas, women demanded the posting of women doctors to address their problems," observes Namita Panda, Chairperson, SCW. Numerous complaints about defunct Primary Health Centres (PHCs) have also been made. Other issues raised included corrupt practices and bribery; medical negligence; poor health facilities; avoidable pregnancy-related deaths; lack of quality medicines provided by government facilities; and denial of medical services on grounds of caste.
The hearings have already had a promising impact. The World Health Organization in its 2007 advocacy mapping and analysis of maternal and infant survival in developing countries has included Orissa's public hearings as one of the case studies along with approaches from Pakistan and Tanzania. They have also resulted in a Rajya Sabha (Upper House of Parliament) discussion on the Centre's action plan in order to help the SCW in its safe motherhood social audit programme in the tribal/rural belts of the state.
At the ground level, awareness about entitlements under government health schemes has risen among beneficiaries; and both the Accredited Social Health Activists (ASHAs) and Panchayati Raj Institution (PRI) members are now expected to play a decisive role in grassroots health management under the NRHM.
The hearings have also led to prompt and effective redressal of complaints. A number of complaints against ANMs in Kandhamal, who demanded a sum of Rs 150 from the Rs 500 that each JSY beneficiary receives under certain guidelines, were documented. Official show-cause notices have been issued to health functionaries.
Further, a doctor charged with bribery - the complainant had been compelled to mortgage her land to cough up Rs 2,000 - was summoned to a hearing in the district. He was issued a show cause notice by the Chief District Medical Officer (CDMO) on the spot.
The hearings have given a platform to health functionaries as well. Anganwadi Workers (AWWs) have highlighted the poor quality of food and its irregular supply; corrupt practices of 'sarpanches' (village council heads); and the fact that AWWs often have to spend their own funds to transport food to 'anganwadi' (community) centres.
An immediate impact has been the placement of a complaint box at every CDMO's office, which is attended to on a weekly basis. People no longer have to travel to Community Health Centres (CHCs) to lodge a complaint. The box ensures that their voice reaches the appropriate authority.
According to many beneficiaries, public hearings have resulted in fewer instances of abuse and of having to bribe health workers. More people now seek healthcare facilities. The Daringbadi PHC records show a 100 per cent increase in institutional deliveries. In Kalahandi, more mobile health units (MHU) are being deployed to bring succor to the Sajanas, Manas and Lakhmanis of the district.
An UNICEF official summed it up this way, "The public hearings have meant greater collective responsibility."
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