Nine months later, when the day came, her mother-in-law decided that the delivery would take place at home. Unfortunately, the newborn child did not survive as it was weak and anaemic and needed medical care. The incident left Binita traumatised for months on end.
When she was expecting her second child she spent the entire duration of the pregnancy in misery. What if this one too didn’t survive? Not only was she physically weak but the child was born anaemic and malnourished this time around as well. Miraculously for her, the Accredited Social Health Activist (ASHA) of her village, Martha Diggal, 24, arrived at her doorstep and managed to convince her mother-in-law to let Binita and the newborn be transferred to the nearest hospital. Though it was a tough battle for survival, the child pulled through. And today, Binita is the proud mother of not one but three healthy children – her last one was delivered at the hospital.
She shares, “In our village, institutional deliveries were a big no-no due to certain traditional norms. For instance, a pregnant woman had to remain in isolation for many days after child birth. But things are slowly changing. During my third pregnancy, thanks to Martha, I ate well and took supplements regularly. Moreover, she gave my family and me valuable advice on how to derive benefit from health schemes, especially the Janani Suraksha Yojna (JSY). Then when I was ready to give birth she took me to the hospital right away. It was a normal, safe delivery.”
Martha proved to be a saviour for Binita because she had the guidance of the activists of the Centre for Youth and Social Development (CYSD), a Bhubaneswar-based non government organisation that has teamed up with Oxfam India to implement the Department of International Development (DFID)-supported Global Poverty Action Fund initiative, ‘Improving Maternal Health Status in Six States in India’, launched in October 2012.
This special intervention is currently underway in 70 villages across Kandhamal and Sundergarh districts. Kandhamal is a tribal-dominated district where factors such as chronic poverty owing to livelihood insecurity, illiteracy, superstition, and limited access to basic health and hygiene services have conspired to increase the overall vulnerability of the people. A look at the dismal health indicators only reiterates the need for a focused maternal health project here. As per the Annual Health Survey 2011-12, the Maternal Mortality Ratio (MMR) in Kandhamal is 297 (state average 237) and the Infant Mortality Rate (IMR) is 86 (state-wide it’s 59), highest among the 30 districts.
Says Akshay Kumar Biswal, Regional Manager, Oxfam India, “In order to improve the maternal health outcomes at the grassroots, we decided to build the capacities of the community, local institutions like the Gaon Kalyan Samiti (GKS), or the Village Health and Sanitation Committee, mandated under the National Health Mission, as well as the anganwadi workers and ASHAs because they are responsible for rolling out government health schemes. Under our community monitoring approach, what has worked wonders is the creation of the Village Health Atlas.”
So, what is the Village Health Atlas? Anil Rout, District Coordinator, CYSD, explains, “In Kandhamal, across 34 project villages in the three blocks of Tikabali, Chakapada and Khajuripada, we have undertaken an extensive exercise to create the Village Health Atlas so that the community at large, GKS members and the health workers become aware of the number of pregnant women in their village and the status of availability of health services in their area, among several other critical aspects that can play a decisive role in improving the odds of survival for the mother and child.”
The health atlas is a collaborative effort – it is prepared by the villagers, in general, and GKS members, in particular, using select Participatory Rural Appraisal tools. A series of activities is undertaken before all the information is finally collated. For starters, a walk through the village is organised to assess the number of households, settlement pattern on the basis of caste and other factors, distance from the main road, location of resources, and so on. All these impact the manner in which pregnant and lactating mothers avail of maternal health care. Following this, a detailed map is made, which includes information like the nearest anganwadi centre, location of anganwadi worker’s home and number of expectant women or adolescent girls. The next step is creation of a household well-being ranking chart – on a scale of comparatively better-off, in the middle and the poorest – to identify the most vulnerable families. Thereafter, discussions are held with women to better understand their specific issues like the problems faced during pregnancy, lack of familial support, pressures of producing boys, and so on. Later, a Relation Diagram Analysis and Family Map are put together. While the former presents a basic picture of the availability of health facilities and challenges in accessing them so that women know where to go to get the best service, the latter lists out the family demographics – age of parents, age of marriage, age and sex of children, miscarriages/still births, immunisation record, pre-and post-natal care, etc.
All these different components make up a comprehensive health atlas, which at a single glance allows the GKS members and health workers to take appropriate measures to enhance the health outcomes for the women. Biswal points out, “There are several advantages of making the health atlas, which is updated on a quarterly basis. Firstly, it enables the community members, particularly women, to get involved in the health planning process. Secondly, it aids the GKS members to prepare a village health plan with an emphasis on maternal health. Thirdly, it links eligible households with the government’s various social security schemes.”
In Rajikakhol, the health atlas has equipped ASHA Martha Diggal with all the right tools to do her job well. She says, “Illiteracy here is high and everyone is struggling to make ends meet as they are mostly marginal farmers or wage labourers. Earlier, concerns about the health of the women or children were never really a priority. This resulted in high maternal and infant mortality mostly due to pregnancy related complications, high levels of anaemia and low incidence of institutional delivery. But ever since we have come together with CYSD to make the health atlas, there is heightened awareness and a perceptible change in attitude. Now all the pregnant women in my area get regular health check-ups and there is 100 per cent immunisation.”
On their part, the women feel empowered as not only can they voice their concerns but even the age-old social customs that affect them adversely are slowly disappearing. Whereas till a couple of years back, elderly women in the homes of Binita and Basanti Kanhar, 29, another tribal woman from the village, would forbid them from having supplements, getting a medical check up or going to a hospital for delivery, it’s a very different situation right now. “Being uneducated and ignorant I used to insist that my daughter-in-law follow what I did as a young woman. In my day, we were told not to eat nutrition rich food lest we became too heavy and had difficulty in child birth. Also we had to be in isolation after delivery. I realise I was wrong,” says Binita’s mother-in-law.
This attitudinal transformation is reflected in the numbers. “In the last two years, no maternal death has been reported from the 34 villages. Of the 294 deliveries that took place between February and August 2014, 259 happened in a hospital. Besides, 210 women have availed of the Mamata Yojana and 246 women have derived benefit from JSY,” states Rout.
Mother of two, Basanti Kanhar, whose second delivery took place in a hospital, sums up perfectly, “Ever since we took part in making the health atlas, during which we learnt the importance of marrying at the right age, proper birth spacing, and availing the ante- and post-natal care made available by the government, motherhood is no longer the frightful experience it used to be.”
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