Earlier this month, Banbari Adivasi’s unnamed granddaughter died of severe malnutrition, starving for days after her 19-year-old mother, Jasoda, died at childbirth.
“My son Sajjan works as a labourer in Rajasthan and after his wife’s death, went back and left the baby girl with us,” said Banbari, a 42-year-old resident of Shivpuri in northern Madhya Pradesh’s rural hinterlands. He has tuberculosis and is too ill to continue working as a labourer.
As his wife Ramkumari, 35, now supports the family by going to the forest to forage for fruits, roots and honey to sell, Banbari’s job is to stay home with his five other children and newborn grandchild. “When her mother died, there was no one to feed her.”
In desperation, Banbari even considered giving away the little baby to another family, but then she fell ill. “I tried, but I did not know how to look after the baby,” he says. Admitting the baby to the SNCU (special new born care unit) at the district hospital in Shivpuri could not save her life.
Jasoda and her daughter aren’t the only ones. Each year, 55,000 women die in India from preventable pregnancy-related causes. In most cases, infections and disease are compounded by chronic hunger and malnutrition – and a lack of access to affordable pre-birth healthcare services because of corruption or caste bias.
The maternal mortality rate (MMR) -- deaths per 100,000 live births -- fell from 212 in 2007 to 167 in 2013 but too many women are dying still.
And as the maternal death rates remain the highest in the populous states of Assam, Bihar, Madhya Pradesh, Odisha, Rajasthan and Uttar Pradesh, the total number of women dying is also high.
To tackle this, Prime Minister Narendra Modi launched the Pradhan Mantri Surakshit Matritva Abhiyan two weeks ago to provide free antenatal – before childbirth - care to pregnant women on the 9th of every month at government health centres and hospitals across India’s 687 districts.
Building on the National Health Mission’s flagship Janani Suraksha Yojana (JSY), all pregnant women must be given a physical and abdominal examination, a tetanus shot and 100 iron-folic acid tablets.
They must also be tested for anaemia, high blood pressure, high blood sugar (gestational diabetes) and other problems linked with pregnancy to lower India’s MMR and infant mortality rate (deaths of children under five years of age per 1,000 live births).
Women in the lowest socio-economic sections in India are two-and-a-half times more likely to die of childbirth, largely because they don’t get the medical support they need to deliver a healthy baby. Jasoda’s death is a case in point.
“Maternal deaths are not just about a woman dying, it also adversely affects the health of newborn and surviving children, who get trapped in a vicious cycle of malnutrition, stunting and wasting,” says Ajay Yadav, founder of the NGO Badlav (Change), who has been working on health and nutrition in Madhya Pradesh.
Incomplete antental care also lowers the chances of the mother’s and child’s survival. Malti Adivasi, 19, wife of Ram Lakhan, 25, lost her nine-month-old daughter Lakshmi to malnutrition earlier this year. She had delivered in a hospital but was not given iron-and-folic acid tablets or advice on feeding her baby after delivery. Lakshmi was given the BCG vaccine against tuberculosis and polio vaccine at birth, after which she got no vaccinations.
“Malnutrition begins after six months when the baby needs additional nutrition, which the mother is not able to provide. That’s when weight drops and wasting sets in, making the baby susceptible to infections such as pneumonia and diarrhoea,” said Pramod Tiwari from the Manav Foundation, Sheopur.
State of care
Frequent infections aggravate chronic hunger with most severe acute malnutrition deaths taking place between nine months and five years.
Apart from saving mothers, antenatal care and institutional deliveries boost chances of newborn survival. The mother gets a tetanus toxoid shot to lower risk of infection during delivery, iron and folic acid to boost blood haemoglobin levels, and nutritional advice on feeding the newborn within the first hour of birth.
Breast milk contains all the nutrients a baby needs in the first six months of life and nursing a newborn within one hour of birth delivers highly nutritious colostrum (first milk) that protects against common childhood infections such as diarrhoea and pneumonia and boosts mental and physical development.
Under the JSY, all services for the mother and her newborn are free and incentives are given to families to opt for institutional deliveries, yet corruption and apathy in the public health system make the poor hesitant in accepting services.
“Hospital staff sometimes demand a bribe up to Rs 500 for a delivery because they know mothers get Rs 1,400 for an institutional delivery. But since that money is transferred directly to the parents’ bank account, villagers have no money to give hospital and clinic and so they opt for home deliveries,” says Yadav.
“Caste plays a role in the exclusion from health services, with marginalised tribes like the Saharias losing out both nutritionally, socially and economically,” says Yadav. “Unless delivery becomes inclusive, children will continue to be orphaned.”
Case study: Halki Adivasi, 25
Halki Adivasi delivered a baby boy last month and grieved for her 18-month-old baby girl Parvati three weeks later.
Three of her six children died between the ages of six months and one year over the past five years and now she lives in her one-room mud and thatch hut with her newborn, her husband Vishnu, 30, and two surviving children, son Radhay Shyam,8, and daughter Anjani, 7.
The family is clueless about what killed their children. “They fell ill and died,” is all he knows.
None of the children have ever been vaccinated, including her month-old son Anand.
Since no government health worker has ever visited their home, Halki missed all three of the antenatal screening benefits she is supposed to get free under the Janani Suraksha Yojana (JSY) for mother and newborn health.
Halki delivered at home at 2am “the day before dushherra” and lay with her baby with the umbilical cord attached all night till a birthing assistant reached her the next morning at 11 am and cut the cord.
“I went looking for a midwife at night but she couldn’t come till the next morning, so we had to wait,” said her husband Vishnu Adivasi, 30, who works as a daily labourer.
Like it happened to many other women living in Bhairopura village in Madhya Pradesh’s Shivpuri district, Halki’s pregnancy slipped between the cracks and she did not get iron and folic acid supplementation and tetanus toxoid vaccination. The family will also not get the Rs 1,400 given to every mother who delivers in a government institution.