the guardian

Corruption, a lack of political will and poor medical facilities are a lethal mix for new mothers in India’s Assam state. Armed with cheap Nokia phones, local groups are taking a stand

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Tea plantations – photo by Joshua Carroll

In Assam, health workers say 70%-90% of tea garden workers have anaemia, which can cause fatal haemorrhaging.

Until recently, Monika Singh would never have dreamed of taking on corrupt medical officials to defend the rights of pregnant women. The demure 21-year-old, who is from north-east India’s marginalised Adivasi community, has learned a lot since joining a project to tackle the region’s alarmingly high rate of maternal deaths.

So when a malnourished woman she was working with was told she had to pay for medicine while hospitalised in her fourth month of pregnancy, Singh wasn’t intimidated by the doctor on duty. “Why are you charging for medicine?” she demanded, “it’s supposed to be free for pregnant women in a government hospital.” Surprisingly, a lot of women in Sonitpur district are unaware that maternal healthcare should be free by law.

Singh won the dispute, a small victory in the fight against rampant maternal rights abuses that often have deadly consequences in India.

As part of a team of 40 volunteers, Singh routinely visits a cluster of villages to interview expecting and new mothers and their families. The aim is to unearth failings in the medical system and report them by text message using specially allocated codes.

Texting the number 25, for example, means no ambulance was available when needed. Another team receives the reports and verifies them before publishing them on an interactive online map.

The End Maternal Mortality Now (EndMMNow) scheme, which is run by three NGOs, has mapped 70 cases in Sonitpur since starting in April last year. These include women dying on their way to hospital after being denied treatment at several different clinics and patients suffering because facilities are drastically understaffed and short of beds, blood and medicine.

Demands for bribes and undue payments for treatment are rife. In one case nurses performed a cut to help with a difficult delivery and then left the woman with an open wound for hours. When she eventually passed out from bleeding, her sister-in-law begged for help from the nurses. They replied: “Show us how much you want her to survive,” according to a report by the group. They stitched her cut only after receiving a bribe of 100 rupees, or about £1, each.

Another woman, Anjali Mazundar, who had just delivered a stillborn baby, was made to sleep outside on the veranda on a pile of clothes because there were no available beds. As she slept, exhausted, a nurse told her mother-in-law that it would cost 800 rupees to remove residual tissue from Anjali’s womb and cremate the baby’s body.

“I told them I was poor, and could give them 200 if they cleaned her womb, but I didn’t let them take the baby,” said Bamuni Mazundar. Instead, one of Anjali’s uncles cremated the body in his garden.

The 40 volunteers attended a series of workshops to learn about violations like this, before going into the field armed with cheap Nokia phones and a list of codes.

They also learned about the laws that are supposed to protect women and children, like the right to a round-the-clock delivery service. A 2009 survey found that despite this law, only a fifth of facilities in Sonitpur offer the service.

EndMMNow’s work shines light on a severely dysfunctional healthcare system that is failing the region’s most vulnerable women. In Assam the famed tea-growing state where the project is based, 328 women a year die for every 100,000 live births, the highest maternal mortality ratio in India (which itself is the country with the largest number of maternal deaths in the world with just under 50,000 in 2013, 17% of the global total).

The country has reduced its overall maternal death rate to 190 deaths in 2013 from 370 in 2000, but it is still expected to fall short of reaching its UN Millennium Development Goal of 109 by the end of this year.

Under the UN’s proposed sustainable development goals, due to replace the millennium goals at the end of this year, governments will aim to bring the global maternal mortality ratio down to less than 70 deaths per 100,000 by 2030.

Tackling malnutrition will be a key part of achieving that – anaemia, for example, suffered by between 70-90% of Assam’s labourers, is a leading cause of maternal death across the developing world. The Indian government has set up programmes to distribute food and supplements to mothers and children via local centres called Anganwadis. But in Sonitpur, people are often denied their rations, either because health officials failed to order supplies or because they sold them and pocketed the cash.

Since the volunteers began working in the district’s villages there has been an almost immediate improvement, says Arpana Choudhury, who follows up cases and helps map the data submitted by the women. “The Anganwadi workers fear these volunteers. They’re afraid they will report a case about them, so now they do their jobs properly,” she says.

It’s a startling shift; the volunteers used to be the ones who were afraid of the health officials. “Since the day they joined the project they started feeling empowered,” says Choudhury.

Still, there are significant challenges. Convincing government officials that there is even a problem is one of them. “From their perspective everything is okay, these issues do not arise and whatever you are saying will not be correct,” said Kindo.

Despite the resistance, some local health officials have expressed interest in some of the group’s recommendations, though so far there has been little progress.

Without political will, there is no way of addressing the main underlying causes of high maternal and infant deaths in the region. The first cause is that existing laws are poorly enforced, say Pajhra and its NGO partners, two groups called Nazdeek and the International Center for Advocates Against Discrimination. The second is that healthcare facilities are badly monitored, which is why the NGOs have had to start reporting violations themselves.

Another challenge is that victims can be reluctant to talk to the volunteers because they feel intimidated by authorities. One of the women Singh deals with has stopped talking to her about her experiences after being scolded by the medical officer at her clinic for reporting him when he asked for payment for medicine.

“They don’t have the courage to pursue their rights proactively,” said Singh. “That’s the challenge”

EndMMNow is not just looking to change attitudes. It has practical suggestions that it believes will immediately reduce maternal and infant deaths in the district. The requests are based on detailed local research but are very simple: more ambulances, more blood banks, better hygiene at hospitals and an easy way for patients to complain if they feel they have been mistreated.

At the Dhekiajuli community health centre, those wishes seem a long way from being fulfilled. The postnatal ward is full, so new mothers wait on rusty beds in a spillover area in the corridor, where stray dogs wander freely.

The volunteers have documented cases here of discrimination by staff and patients being charged for medicines, which are in short supply. A whiteboard by the entrance announces whether HIV tests are available. Today they are, but Kindo says the last time he was here they were not.

The blood bank is out of service because there is no haematologist, meaning anaemic women in desperate need of transfusions have to be turned away.

“If you want quality healthcare you need staff. We need more technical staff,” said a senior staff member at the clinic, who declined to give his name.

“In India this is very complex because of a lack of manpower, a lack of infrastructure,” he said.

The Dhekiajuli clinic was just one of several places where Anjali Mazundar, the woman made to sleep on a veranda, was referred to before she miscarried. That was in 2012. In 2013 Anjali miscarried a second time after once again being referred to several different hospitals that couldn’t or wouldn’t treat her.

Her modest, two-room home, shadowed by mango trees, has no children in it. A print on the living room wall depicts the sun setting beyond a river with the caption, “The course of nature is the art of God.”

On the wall opposite is a mass-produced poster showing two smiling babies who belong to someone else.

Read it on the Guardian’s website here.


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