Madhya Pradesh (MP), a state that projects itself as India's heartland, is also the region that witnesses the highest number of maternal deaths in the country. For decades, women here continued to die because of pregnancy and childbirth-related causes, but the media and the government largely ignored the issue.
In the year 2000 India pledged to bring down its Maternal Mortality Rate (MMR) to 109 per 100,000 live births as part of its Millennium Development Goals. But making maternal mortality a public concern in the heartland of Madhya Pradesh took some doing. Recalls Sachin Jain of the Vikas Samvad, an MP-based advocacy organisation, "Five years ago, when the Maternal Mortality Rate (MMR) was around 498 per 100,000 live births in Madhya Pradesh, it was just a number for many of us. Then some activists, after working out the figures, put out information that 13,000 women in the state died every year, during and after delivery. That was when the issue started getting more attention. Local organisations and different networks like Jan Adhikar Manch and Jan Sangarsh Morcha, Mandla began raising the concern."
Media tracking done by Vikas Samvad showed the steadily rising graph of media stories: In 2007, there were 654 stories on maternal and infant mortality in mainstream newspapers and regional editions of mainstream newspapers. By 2009, the figure had touched 1,256.
This media focus led to two important developments. One, maternal deaths became a political issue. Observes Jain wryly, "Earlier no politician talked about it. Now the state assembly discusses maternal mortality at least three or four times in every session! What's more, in the 2008 assembly election, almost every political party promised to reduce maternal mortality in the state."
The other impact was at the level of public awareness: People's right to proper health care became a community issue. For instance, in May 2008, in the predominantly tribal Pati block of Badwani district, there was a campaign led by Jagrut Adivasi Dalit Sanghthan and Cehat. Some 1,500 locals - completely disillusioned with the local health services - undertook a community monitoring of the Pati Community Health Centre. They sat in at the premises of the health centre for four days. Their scrutiny led to several eye-opening discoveries. For instance, while the government claimed that iron tablets were being regularly administered to pregnant women, they were actually being destroyed.
"Clearly, information is the key in addressing the big gap between government claims and the existing realities," observes Jain, and adds, "When we heard that one Shivkali Baiga in Mandla district had died because of the negligence during her delivery by service providers, we alerted journalists about the case and important Hindi papers such as the 'Dainik Bhaskar', 'Dainik Jagran', as well as an English daily, 'The Hindustan Times', covered the story. Incidentally, Shivkali's father has now filed a Public Interest Litigation (PIL) in the Madhya Pradesh High Court. We hope to keep the pressure on."
If information is a game changer, so is local expertise. While MP has an estimated 57,000 'dais', or traditional birth attendants, the state government has kept them out of the maternal health delivery regime. Yet in another region of MP, interesting evidence has surfaced about how, when poor local women are trained and empowered to deliver on maternal and reproductive health, they can make a huge difference.
Suguna Solanki, a Bhil tribal 'anganwadi' helper, lives in Jeet Nagar - a shanty town on the outskirts of Indore, known as Madhya Pradesh's financial capital. She is a health worker and came into the sector almost by accident. Suguna describes that moment, "Once, a few years ago, I took a 16-year-old unmarried girl from our slum, who was five months' pregnant, to a doctor who was actually a quack. He gave her a potion, pressed hard on her lower abdomen and aborted the foetus. Later, the girl began to bleed profusely. We rushed her to a government hospital where her uterus was removed and her life, saved."
The experience helped Suguna understand the serious obstacles that poor women living in her neighbourhood faced. The problem was two-fold. Not only were women ignorant about their right to a functioning healthcare system, they also had very little idea about the state of their own bodies.
The first challenge then was to break the culture of silence, whether it was about the health entitlements of the community or tabooed topics like sexuality and menstruation. Suguna joined an initiative undertaken by the Urban Health Resource Centre (UHRC), New Delhi, in 75 slums in Indore, in collaboration with five local NGOs, with funding from USAID. The main thrust of the programme, which began in 2003, was to assist the local community to gain access to the government's reproductive and child health services.
Suguna, along with a few other 'anganwadi' workers from other slum pockets in the city, like Rajeev Gandhi Nagar, Bhavana Nagar and Pavanpuri, were trained as community workers in reproductive and child health. They were also given the task of mobilising local communities to seek better health services. The women organised monthly health camps in which doctors conducted regular check ups and provided free medicines.
But they soon realised that they needed to do much more if their work was to have an impact. Rekha Patode of the Rajeev Gandhi Nagar slum, says, "For instance, menstrual hygiene is a big problem here. In most cases women use the same pieces of cloth after washing them, and since the rags are not dried properly because their public display is tabooed, women end up suffering from various infections, including pelvic inflammation."
At this point, the UHRC decided that these field health workers should be made to form their own NGO, so that they would be able to carry on working for the community even after the project ended. Recalls Urmila Javre, a field worker from Pavanpuri slum, "Seven women field workers came together and helped to form and register an NGO by the name of Parivar Sahayog Samiti (PSS) under the Madhya Pradesh Societies Act. We were given training on how to run it and we told the trainer about our desire to work on women's reproductive rights to counter the prevailing male-dominated mindsets."
Soon, the monthly health camps began to be reoriented towards treating gynaecological infections. The local women welcomed these initiatives warmly. For the first time in their lives, they were properly examined in privacy by trained gynaecologists. They were given appropriate medication and sanitary napkins. Within a space of three years, these slums began showing visible results. The incidence of pelvic inflammation came down markedly, and there was also a reduction in anaemia levels. This led, in turn, to the better health profile of expectant mothers.
In 2009, the funding for the project ended. But Suguna and her colleagues are determined to carry on. The PSS is a remarkable example of how local expertise can make a real difference on the ground. They also understood intuitively the connections between maternal and reproductive health. Millennium Development Goal 5 - that seeks to improve maternal health - recognises this very link.
According to a recent UN estimate, maternal mortality levels in South Asia continue to be among the highest in the world, next only to sub-Saharan Africa. If this has to change, India would have to do better, and for India to do better a state like Madhya Pradesh would have to bring down drastically its MMR, currently at 335 deaths per 100,000.
The information driven campaign of the Vikas Samvad, and the local expertise inherent in the PSS model could be important pointers to the way forward in a state that has long neglected its expectant mothers.