How a Community Worker has the power to help vulnerable women make better health choices

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“Health cannot be bought at the supermarket. You have to invest in health. You have to get kids into schooling. You have to train health staff. You have to educate the population.” – Dr. Hans Rosling, Swedish Global Health Scientist

Mumbai is a truly fascinating location for a case study in Maternal Health due to the large number of coexistent inequalities when it comes to women’s health. The city boasts of world-class health facilities, yet struggles with equitable health distribution for a majority of its citizens. The country’s second largest city has a population of approximately 12.4 million, more than half of whom live in informal settlements (colloquially known as slums).  Some numbing statistics include: Only about one-fifth of dwellings in informal settlements have a private toilet, only 31% of residents have completed 10 years of education, and the total fertility rate is below the replacement threshold at 1.9. The 40% slum dwelling population, including the often-discounted migrant populations, are often shortcharged by the quality of public health services. One of the major reasons for the lack of accessed care is that awareness, uptake and knowledge levels among many of the users of public health services typically tends to be low, especially, in informal settlements in urban areas. Female literacy is only 54%, and women lack the autonomy to make decisions, that affect their own bodies. On the supply side, quality of health services tend to be sporadic and inconsistent.

As part of my research thesis field work, I spent the Summer of 2016 working with a Mumbai-based non-profit, Society for Nutrition, Education and Health Action (SNEHA) that believes in investing in women’ health in vulnerable urban slum communities in four large women’s health areas, Maternal and Newborn Health, Child Health and Nutrition, Sexual and Reproductive Health and Prevention of Violence against Women and Children. In SNEHA, I spent most of my time understanding how they work through their community staff, known as Community Organisers, to motivate and educate their beneficiaries (typically residents of vulnerable pockets in poor urban communities) and nudge them towards better care-seeking behaviour.

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Community organizers hired by SNEHA are members of the community who are trained to provide education to expectant mothers in the area through door-to-door educational interventional programs. Community Organisers also work with health systems, by training, up-grading and building capacity of health workers attached to these systems.

Through my field work, it became abundantly clear that maternal education programs in urban Mumbai work due to the close relationships that are forged between the Community Organizers who work intimately with beneficiaries from vulnerable communities. While studying the various forms of beneficiary compliance and behaviour change, I was able to track that the relationship between the community organizer and the mother was the main determinant in the level of compliance. Even in the least compliant measure of cultural compliance where mothers are expected to follow medical instructions instead of harmful cultural practices, mothers with the most visits from a community organizer were most likely to follow instructions that most mothers in that cultural climate would not. To improve compliance, SNEHA would have to increase the number of times the community organizer meets the mother, and start the antenatal care as early as possible.

The public health system has a negative perception among its users. Previous experiences including long wait-times, lack of required resources, bad behavior by staff and unnecessary referrals, further adds to these perceptions. This prevents pregnant women from seeking regular antenatal care and seek follow-up visits. One of the ways we could prevent loss of follow-up is to enable Community Organisers to accompany pregnant women for their antenatal check-ups. This could start a smooth initiation into the antenatal care process. SNEHA already works with the public health system and intervenes, setting up and managing referral works while working with health posts so that they can handle basic antenatal check-ups. Another intervention mode could include training public health staff in soft skills including patient interacting, communication and information sharing.

Maternal deaths are preventable. Safe motherhood can be achieved as a goal with access to quality institutional care for mothers with complications during pregnancy. Availability and accessibility of skilled birth attendants, basic and comprehensive emergency obstetric care, around the time of birth is also critical. A large proportion of newborn illnesses and deaths can also be prevented using simple, low-cost interventions during delivery and during the week following birth partum, provided both in the facility and at home (where currently 50 per cent of newborn deaths occur). SNEHA’s community workers achieve these aims by their relentless efforts to educate the most affected populations. Education improves health, while health improves learning potential. Education and health complement, enhance and support each other; together, they serve to improve quality of life for women and children in developing countries.

By Shikha Chandarana

Shikha is an undergraduate student in Brandeis University, US. She was a research intern at SNEHA in 2016.

All opinions recorded here are of the author and don’t necessarily reflect SNEHA’s views and opinions at all times.

These angels live on the ground – A Women’s Day Special

Ten years ago, Archana Ramesh Mahapade, 50, was out on a fund collection drive when she saw a large group of women.

“When I saw the line and the women waiting patiently, I became curious. I joined them and found out that interviews were being conducted for the position of a community worker at SNEHA. I was selected and that is how my journey began.”

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Archana Ramesh Mahapade, Community Organizer, SNEHA

It is community workers like Archana that help drive the impact of SNEHA, Society for Education, Nutrition and Health Action, an organization that for many decades now, has been working towards improving the health of women and children in slum communities.

SNEHA’s community centres in the vulnerable areas are key to driving the program. The community organizers are drawn from the community itself, and their ease and familiarity with the local population makes them an invaluable asset.

However, as Anupama points out, the familiarity does not guarantee that their presence or advice is always accepted.

“When we first tell people about SNEHA and the work we do, many look tense and turn away. Some women even shout at us and we do feel bad. But we always come back the next day. Eventually their attitudes change when they realize that we are there for good, and not just for a day.”

Once the ice is broken, it takes a few more sessions before they start talking about their lives. “Initially, when we ask them about family planning methods, they are not honest. They say everything is good but as we probe further, we get to know about the situation at home, the pressures they face.”

Building this intimacy is critical given the many levels of SNEHA’s intervention. It goes beyond maternal and newborn health to child nutrition, and sexual and reproductive health, issues that girls and women have never been encouraged to think about. SNEHA offers crisis intervention, counseling, medical and legal help to survivors of violence. It also works on prevention in communities and enables government systems to respond in an effective and sensitive manner.

Access into the homes and lives of women here is vital,  and the community organizers enable that.

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Saira Shaikh, CO, Govandi

“The women in my area come to the city after marriage and they are lonely and unaware”, says Saira Shaikh, 38, a community organizer at Shivaji Nagar in Govandi. Govandi, one of Mumbai’s largest urban settlements, is home to a large population of migrants, who depend on odd jobs to make a living.

“They face violence at home and have no one to turn to,” adds Shaikh. “The violence is made worse by the low unemployment levels. The husbands spend the daily wages on other women or on drinking. We give these women strength by telling them to come forward and seek help so they can start providing for themselves and their kids. We also encourage them to stand up to their husband. Over a period of time, they start to listen and assert themselves. “

Often it can take as long as two years for behaviour change to set in.

Saira brings up the case of a woman in Shivaji Nagar who was pregnant with her fifth child. Her hemoglobin count was just 7.6 and she was always complaining of feeling dizzy and weak.

“The husband would shout at her for being lazy and as we started visiting her we realized that she hadn’t even registered her name at the local hospital”, says Saira. “This was because her husband would not give her money even to go to the hospital. She was a victim of domestic violence. Her husband would even shout at us when we paid a visit. ”

Saira finally took the help of a senior SNEHA staff member to convince the husband. “We were very patient and calm but it still took three months to get him to agree to a hospital delivery. In the meantime, we took the help of the local municipal health staff and started giving her injections and monitored her diet closely. Because she had little money, we encouraged her to eat dates, which are cheap but high in nutrition. She was able to have a healthy baby. “

The episode offers a glimpse into the level of focus and dedication that the community organizers bring to the job.

“In my experience, women and children’s health is an issue everywhere, “ says Archana. “The kids are weak but the mothers don’t think anything is wrong because they compare them with other kids in the neighborhood. They don’t realize that their child has not met important growth indicators. “

Given the sensitivity of such matters, I ask Archana how she speaks to the mothers without making them feel inadequate.

“When we talk to the women, we ask them what the kids eat and the answer almost always is – “I cook but he doesn’t eat what I make”. Then we ask if the kids have been given pocket money that day. The mother realizes that the child has spent the money on buying snacks, and does not want to eat what is cooked at home. We get the mothers to stop doing that. We also show them ways to cook such that the food is to the child’s taste. Like to partially fry an egg and add the roti so the child gets protein and carbohydrates. We have been able to encourage all the women to breastfeed, which was not the practice earlier.”

Ask Archana what difference being a community organizer has made, and her face lights up.

“I am so proud to be a CO. I have helped women who have suffered multiple miscarriages, deliver healthy babies. I have also been able to help couples conceive by telling them about ovulation. The money may not be much but the satisfaction is huge. It has helped to build ties within the community. Now when I don’t go to the community even for a day or two, the women tell me you haven’t come for so many days,” laughs Archana.

SNEHA – A community-based health model that delivers

Public health in urban areas is one of the most persistent, yet neglected, issues facing the developing world. Cities present an especially challenging canvas given the many different factors – migration, inadequate housing, lack of infrastructure, crime, political corruption, pollution, and dysfunctional health systems – that are in play.

Over 50% of the world’s population lives in cities and this number will rise in the next few decades. Due to migration, India’s cities are growing more than three times as fast as the rural areas, and it is likely that more than half of the country’s population will live in urban areas by 2050.

The factors that affect human health are many, ranging from climate change and greenhouse gas emissions to reproductive health and rights. Meeting them is key to India’s success in achieving universal health coverage and improved national health indicators.  96-of-109

The National Urban Health Mission in India aims to enable rightful access to quality health care. This is by setting up an improved public health system, partnerships, and community-based mechanisms. This is to be done with the help of secondary and tertiary institutions, urban health centres, and community outreach. The positive outcomes of such a partnership in Mumbai’s urban settlements, demonstrated by SNEHA, is the subject of a paper recently published in the prestigious medical journal The Lancet.

The interventions of the Society for Nutrition, Education and Health Action, SNEHA, interventions are born out of 16 years of work with women and children in informal settlements. They range from maternal and neonatal health, sexual and reproductive health, childhood nutrition, and prevention of violence against women and children. What makes SNEHA’s model unique and effective is that it integrates these activities, and the model can be replicated in urban settlements across India, perhaps in many developing countries as well, with some tweaks for local, cultural specifics.

SNEHA’s adoption of an integrated approach came after a large neonatal trial conducted in Mumbai. It was felt that this would be an effective method given the multiple health issues faced by women and children, and the belief that communities would be more responsive to an intervention that had both, physical presence and service delivery.

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Every SNEHA centre is equipped with three full-time community organizers with backgrounds similar to the people they reach out to. They are trained to bring together the themes of reproductive, maternal, and neonatal health, child health and nutrition, and prevention of violence against women and children into the community services. They are responsible for home visits, group meetings, organizing day care for malnourished children, and community events, in close association with existing systems.

A survey was done before, and two years after SNEHA’s intervention on three main outcomes – family planning in women (15–49 years), immunization of children, and wasting among children less than five years. The survey looked at secondary outcomes as well, like violence against women or children, number of home births, pregnancies in women younger than 20 years, to name just a few.

There were significant improvements in the met need for family planning, and full immunization. Compared to the NFHS 2015-16 figures of 14% unmet need in Mumbai, the results in the areas of intervention was 22%. Again the NFHS-4 findings showed that 46% of children between 12–23 months in Mumbai were fully immunized. Contrast that with the intervention area rates of 69%. The findings were similar when it came to wasting in children, and diet among children.

There were other positive fallouts seen as well like the use of sturdier material to build homes, building of private toilets and use of safe, drinking water.

The challenges of meeting the health needs of settlements in an urban milieu are many. The shifting nature of the population and specific cultural beliefs can often slow down rates of progress. However, the overwhelmingly positive outcomes demonstrated by SNEHA’s model shows a way forward to city governments across developing countries who are grappling with ways to improve health in informal settlements.

Link to The Lancet paper – http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30363-1/abstract

Why Family Planning must be key priority in Budget 2017

Just this month, a woman died and five others were critical after a surgery at a family planning health camp in Maharashtra’s Yavatmal district went horribly wrong.

The woman who died was just 36 years old. The death, according to reports, occurred because the government doctor at the Primary Health Centre cut the intestine instead of the fallopian tube while operating on her.

The tragedy brings home the critical gaps in India’s family planning programs especially in large parts of rural India. Given this, it is important that the government prioritizes family planning in the upcoming Budget to ensure that young couples are offered information about, and given access to FP options.

In 2015, the Health Ministry announced some welcome measures in this regard, like expanding the basket of contraceptive choices and ensuring their availability in district hospitals. There are now three spacing methods of contraception in the government FP program – Centchroman, Progestin Only Pills, and injectable contraceptive – offering greater choice and independence to users.

But India is still way short of the commitments it has made under FP2020. At the 2012 London summit, the country had promised to provide FP services to an extra 48 million new users by 2020.

The progress report in 2015-16 shows just how far we are from that goal. Less than eight million extra users have been catered to until July 2016. To meet the targeted numbers, the government has to allocate more resources towards meeting the FP needs of the population.

Census 2011 showed that over 10 crore girls in India get married before they are 18 years old. Young couples, across communities, come under great pressure to have a baby within a year of marriage. Many of them want to delay babies but don’t have the information or access to do so.

Expanding contraceptive choices for men and women while important is not sufficient by itself. They have to be empowered about exercising these choices and this has to be done through sustained community awareness campaigns by the government, civil society and other stakeholders. This needs extra staff on the ground and therefore more funds. The budgetary allocations to health and FP need to be substantially hiked.

India spends just 1.3% of its GDP on healthcare, a figure far lower than countries like Bangladesh, Brazil, Russia and China. Even Afghanistan and Nepal allocate more. Budget 2017 needs to address this shortfall.

Innovative approaches to tackling malnutrition

The malnutrition-related deaths of nearly 600 children barely 100 kilometres from Mumbai in 2016 underlines the critical need for various stakeholders to come together to find ways to bring about behaviour change, and ensure that benefits charted out under various government schemes actually get to those who most need them.

The fact is that children do not die of malnutrition but of causes due to malnutrition. Stunting is a better indicator of malnutrition and according to studies 51% of children and adults among tribal populations in Maharashtra are undernourished and stunted. This is a significant figure and one that has not shown sufficient improvement in the last few years.

Across India, the occurrence of wasting among children is serious. Even within the limits of the financial capital Mumbai, NFHS-IV shows that one-fifth of children under the age of five years suffer from wasting. This is very serious indeed given the associated risks of disease, even death, among children who are very underweight.

Since 2011, a program introduced and managed by SNEHA and CRY has shown the way forward when it comes to tackling urban malnutrition, especially wasting. Over a period of two years, the percentage of wasting in children reduced sharply from 18% to 12% in the slums of Mankhurd, Govandi and Kurla situated in the suburbs of Mumbai. SNEHA’s intervention in child health and nutrition in Dharavi showed equally encouraging signs – a fall of wasting from 18% to 13%.

The percentage of children who received full immunization rose from 66% to 73% in the three areas mentioned earlier. There were also other positive changes, like rise in hospital deliveries (12 up to 15%), adoption of family planning methods (34% up to 59%) and a dramatic drop in pregnancies among women below the age of 20 years. (17% up to 4%).

The changes took place because of a sustained merging across different sectors at the community level to enhance child under-nutrition. This was backed up with enabling behaviour change through home visits, one on one counseling, awareness campaigns, and community meetings. This led to greater adoption of FP methods, immunization and better nutrition practices.

Urban malnutrition is a challenge not just peculiar to world cities like Mumbai. Tackling it requires innovative and creative approaches that take the community’s needs and pressures into account. The program by SNEHA and CRY offer a window into an approach that could show results in many parts of India to reduce malnutrition rates.

 

 

 

Need to rethink approaches to infant & maternal healthcare

The figures reporting the decline in infant deaths in India is something to celebrate. Data for 2015 shows that 27 babies died for every 1,000 births, which is two better than the government’s own projected figures.

That is a drop of 53%, which is still far short of 67%, which is what India had promised to achieve under the MDGs. But it is promising in that it shows government programs to reduce baby deaths like incentivizing institutional deliveries, providing supplements to pregnant women, etc., is having some impact.

Data from states like Goa, Manipur and Punjab, which have reported a drop of over 60% in IMR is especially promising. However, compare this to the high rates in Uttarakhand and Madhya Pradesh and one gets a picture of just how patchy and uneven the quality of healthcare services remains.

This is a critical lack and needs to be addressed, as high IMR is a report card of the health of the country and an indicator of the future growth potential. Clearly policies aimed towards maternal and infant health need a rethink given the huge gaps that exist.

While widespread illiteracy, poor nutrition and sanitation, and lack of awareness are key factors that explain the high rates, the poor healthcare infrastructure on the ground is evident in the high number of deaths reported from states like Odisha, which witnessed the deaths of over 50 children in just two weeks in a state-run children’s hospital. 151 deaths were reported across hospitals in Kendrapara in Odisha in just 4 months.

There is a need to address the system on the ground and look at what the shortfalls are. Maternal and child health policies cannot work in isolation. There are important connections between these groups and there is a need to strengthen the continuum of care to ensure that an unbroken curve spans the home, community, health center, and hospital. This would help manage the maternal-newborn-child health scale of care in a more unified way.

A compelling case for contraception

Recently Melinda Gates made a compelling, passionate statement about how giving millions of women access to contraception was necessary to end poverty and disease for both present and future generations.

The Bill and Melinda Gates Foundation, of which Melinda Gates is co-founder, has made it a mission to ensure that millions of women in developing societies have access to safe birth control measures. Since 2012, Ms Gates has been leading a worldwide campaign to get 120 million more women access to birth control by 2020. The BMGF has donated over one billion dollars towards family planning.

Never before has this fight for a woman’s right to decide if, when, and how many children she wants to have been more important. The recent India wide study on how ten million women in the country are forced to resort to unsafe abortions every year underlines the critical need to make contraceptive options available.

The study, done by the IndiaSpend team, highlights that myths and misinformation about contraceptive methods are still widely prevalent despite India having the longest government-backed family planning campaign in the world. Millions of women still lack access to contraceptive options. They are left with no option but to take over-the-counter pills or undergo dangerous, unhygienic surgeries to end pregnancies.

A 2016 Lancet report highlights how distant the prospect of safe abortions remains for rural Indian women. This is the case even nearly five decades after abortion was legalized in India. In the absence of safe methods, sales of popular abortion pills remain abnormally high.

Widening the basket of contraceptive choices, as the government did earlier this year, is a much welcome, long overdue step. But to be truly effective, these choices have to reach the millions of women in our smaller towns and villages. That needs better delivery systems, better training of doctors, and a mass awareness campaign. All of which remains a giant, gaping hole in our FP program.

Malkangiri deaths: The deadly link between malnutrition & disease

The deaths of 61 children due to an outbreak of Japanese Encephalitis in Odisha’s Malkangiri district brings home the gaps that lie in the health care system in large parts of rural India. Over 100 villages across seven blocks in this region have been hit and unofficial reports are that the number of children who have died is much higher than 61.

Japanese Encephalitis, which affects mostly children, derives from pigs and spreads to humans through mosquitoes. The population in this part of Odisha is especially vulnerable as people here depend on pigs for livelihood.

There was an outbreak of Japanese Encephalitis in 2012 as well that led to many deaths. Despite that, the community remains unaware of the dangers of rearing pigs so close to their homes. The administration has also failed to carry out door-to-door monitoring for fever and monitoring.

The apathy is even more shocking when one looks at the data. Malkangiri ranks among India’s top 15 districts when it comes to child wasting, stunting and underweight. One-third of children here below five years of age suffer from wasting, stunting and underweight, mainly due to under nutrition.

The infant mortality rate is reported to be 48 as against Odisha’s average of 56, while the maternal mortality rate is 245 as against the state average of 230.

Given the prevalence of so many red flags, it is shocking how poor the health system on the ground is. Malkangiri district has only one pediatrician while the community healthcare centre at Korkunda, the most affected area, has no doctors. In all, 2,000 posts for doctors are lying vacant in the state.

Reports are that vaccinations are very rarely given even if the government has declared a program. Vaccination for JE in India was launched in 2013, but Odisha is yet to receive it share. According to the government’s reports, less than one-third of Malkangiri’s population is covered under the immunization programme.

Regions like Malkangiri show how far we are from providing equitable development across India. Unless steps are taken to strengthen healthcare infrastructure and enable the poor to take care of the nutritional needs of their children, routine epidemics will continue to take away lives.

 

Need for new approaches to end stunting

The start you get in life determines the future course not just for an individual but for a country.

Just how critical that is, is brought home in a series of research papers published in the medical journal Lancet earlier this month.

The research says that children who lose out on that early start, that is, they are deprived of the required nutrition and care, go on to earn 26% less on average than others. This applies to 250 million children across the world, over 40% of them under the age of five years. This is because stunting and acute poverty will act as a barrier in the way of them realizing their full potential.

Just how critical the need to invest in the first two years of a child’s life has been shown time and again in many studies. The nutrition children get in these years determines not just physical, but also mental growth. Addressing those shortfalls at a later stage is not possible, especially when it comes to cognitive or reasoning abilities. The human brain develops faster at conception and through the first 2-3 years of life.

In terms of numbers, we are looking at 250 million adults unable to realize their full potential. Economically, this translates into income loss and low productivity.

India needs to act quickly if it wants to halt this social and economic loss. The cost of not taking steps to reduce stunting in children, is said to be 8.3% of India’s GDP. We are looking at this lack of action affecting future generations.

A change in approach is called for. Perhaps there is a need to look at programs followed in countries like Peru where under a World Bank-supported program, conditional cash transfers were given to mothers of stunted children. They were also educated about the importance of giving nutritious foods to their kids. Incentives were given to health clinics to support them. The monthly payments depended on how the children progressed.

There is a need for a relook at early childhood and maternal care programs because clearly they are not doing a good enough job of reaching thousands of mothers and babies, especially in large parts of rural India.

 

Time for a Relook at India’s flagship programs

The findings of the Global Burden of Disease 2015 study are truly depressing. The results, published in The Lancet, lists the main factors behind illness, death and disability in countries.

While deaths of children under five years has gone down between 1990-2015 from 12.1 million to 5.8 million, India still tops the number of child deaths at 1.3 million in 2015.

India is followed by Nigeria, which has over seven lakh deaths, and Pakistan with three lakh deaths. Bangladesh has done better. There were 7663 maternal deaths in 2015 in Bangladesh, which is a dramatic improvement from 21,789 in 1990. Maternal deaths in India dropped by half to 63,861 in 2015 from 1,32,239 in 1990

Neonatal mortality, which is death in the first 30 days of life, remains high. While deaths under five years have reduced, it still remains way lower than the MDG goal.

Some of the main causes given in the study are pre-term birth complications, trauma and respiratory infections. Diarrhea-related diseases are the fourth leading cause.

The study says that while government schemes like Janani Suraksha Yojana have been successful in improving access to institutional births, the reach remains patchy with large parts of rural India unable to access the services. This is the demography that remains most vulnerable. A reality we encounter everyday in news reports of pregnant women dying on their way to hospitals.

Clearly, it is time to step back and take a close, hard look at our flagship programs like JSY and the integrated child development scheme, ICDS. The ICDS was launched in 1975 and is one of the world’s oldest nutrition programs. If after 41 years of ICDS, we are still failing so many hundreds of thousands of children, something is clearly going very wrong.

 

Tacking malnutrition in Mumbai

The latest data put out by the Integrated Child Development Services highlights what a tough challenge tackling child malnutrition in Mumbai’s slums remains.

The latest data says that the slums have over 50,000 moderately underweight and over 3,000 severely underweight children. Undernourished children account for a massive 17% of the total children weighed in anganwadis across Mumbai until March 2016.

All this shows how tough challenge malnutrition remains despite the various interventions, both by the government as well as NGOs.

Between 2015-16, eight children, who were suffering from malnutrition, died. Five were infants below the age of one year, while the rest were between three to six years.

Experts say that the figures highlight the challenges of dealing with a migrant population.

“The slums that have reported such high numbers are home to a migrant population, people who come from different castes and religions”, says Dr Yogesh Nandanwar, Head, Gynecology, at Lokmanya Tilak Municipal Hospital. “The mothers are anemic and undernourished and they are in no condition to have health babies. “

Dr Nandanwar calls anemia the nucleus of all problems. “Because of anemia, worm infestation becomes an issue. Low hemoglobin is another major issue.”

Given that migrants account for one-third of Mumbai’s population, the numbers are enormous. And the fact that this is a floating population makes the challenge even bigger, underlining the need to have a specific policy to look at nutrition issues among the city’s migrant population.

Millions left behind in India’s public health system

Two news reports in the span of 10 days bring home just how grave the crisis in India’s public health care system is.

First was the report from Odisha of a tribal man who had to carry his dead wife’s body on his shoulders for over 10 kilometres because he was denied an ambulance to go back to the village for her final rites.

Then less than a week later came the tragic story from Kanpur of a 12-year-old boy who died after he was denied admission at a government hospital. His father, who was holding the sick child in his arms, was told to go to a children’s hospital despite his obvious poor health. The man’s pleas for transport to carry the boy to the children’s facility were denied.

These are just two instances that we know of because they got media attention. Imagine the thousands, even millions of people across the country, who are unable to access medical treatment on time.

The World Health Organization says the ideal norm is 1 doctor for a population of 1,000. Going by that measure, India falls short by 500,000 doctors as pointed out in a recent IndiaSpend report. Going by these figures, there is one doctor for 1,674 persons, which is worse than Vietnam, Pakistan and Algeria. Even this, many experts believe does not reflect the reality and that the ratio is closer to 1:2,000.

The shortfall is evident not only when it comes to doctors but also support staff like midwives and ASHA workers who form a critical backbone when it comes to rural health care. Under the National Rural Health Mission, more health centres have come up in our villages but there are simply not enough doctors and nurses to man them.

The shortfall gets reflected in the statistics relating to infant and maternal mortality. Despite interventions at various levels, the figures are not improving fast enough. All the plans and policies remain words on paper because there are not enough people on the ground to see them through.

We Have the Act. Time to Create the Awareness

The provision of the Maternity Bill extending maternity leave to mothers The provisions of the bill will apply to all organizations that employ 10 or more persons and is expected to benefit over one million women working in the organized sector.

Given the majority that the ruling government enjoys, its passage in the Lok Sabha is guaranteed, after which the Labour Ministry will notify the changes.

As per the amendments, maternity leave for women in the private and public sector will be increased to 26 weeks as against the present 12 weeks. However, those who already have two or more children will get 12 weeks of leave only.

The bill also proposes 12 weeks maternity leave to mothers who have children through surrogates as well as working women who adopt a baby below the age of three months. The Act will also allow nursing mothers to work from home after the 26-week maternity leave ends, depending upon the nature of their job.

However, the real work starts now. While the provisions are a progressive measure, there needs to be awareness created for the benefits of this to come through. The period after birth is critical for both the mother and the child’s health and the root of the amended act lies towards preventing malnutrition. That is the primary purpose of the Act, which is not to be treated as a holiday.

Passing the Act has to go along with creating awareness about breastfeeding and other measures that are to be taken to secure the health of the child and the mother. There needs to be a well thought out policy to promote breastfeeding, which is still lacking in India. Various studies show that less than 25% mothers in India initiate breastfeeding in the first hour after birth.

The WHO says that initiation of breastfeeding within an hour after birth could bring Infant Mortality Rate by as much as 22%. Nearly 77% of child deaths worldwide are attributed to non-exclusive breastfeeding during 0-6 months of life.

Both the WHO and UNICEF recommend breastfeeding within an hour of birth, only breast milk for the first six months, and continued breastfeeding up to the age of two years, along with appropriate complementary food.

 

 

 

 

 

Time to End the Shame Around Breastfeeding

Last week, protests were witnessed across Argentina by groups of women who breastfed their babies in public. They were agitating against the police’s move to throw out a mother from a square in Buenos Aires for nursing her infant in public.

Carrying signboards that said, “Nursing is not up for discussion” and “My breasts, My rights”, over 500 women took to the streets in different parts of the country demanding respect for mother’s rights.

Breastfeeding is a simple, no-cost intervention that boosts the health of children and women substantially, in rich and poor countries. Yet there is little awareness about this. And as we get set to observe World Breastfeeding Week (August 1-7) around the world, experts are calling for programs that encourage ideal breastfeeding practices.

Studies in The Lancet point out that increasing breastfeeding to optimum levels could save over 800, 000 lives every year, most of them children under six months. Also, nearly half of all diarrheal diseases and one-third of respiratory infections in children in low- and middle-income countries could be prevented.

Babies who get no breast milk at all are seven times more likely to die from infections than those who get some in their first six months.

Children who are breastfed also do better at intelligence tests, are less likely to be overweight and less likely to get diabetes later in life. The benefits to mothers are also huge. They show lower risk of developing breast and ovarian cancers.

The awareness is especially abysmal in low-income countries, like India. And it does not help that the government has not aggressively promoted breastfeeding. The focus on bringing down maternal and child deaths has been heavily directed towards promoting institutional deliveries, antenatal check-ups and neonatal care.

There are many barriers that come in the way of early breastfeeding in India and this helps explain why signs of childhood malnutrition like stunting (45%) and wasting (20%), that depend significantly on early breastfeeding, remain high.

According to studies, only one in four mothers are able to start breastfeeding within one hour of giving birth and less than half of all mothers are able to exclusively breastfeed their babies for the first six months after birth.

Supportive health-care systems, workplace interventions, counseling and educational programs are needed to improve breastfeeding. The government’s recent moves to bring changes to the Maternity Benefit Act of 1961 are welcome steps.

There is also a need to break the wider social shame that exists around breastfeeding in public, something the UN has also acknowledged by backing the social trend of belfies – mothers sharing pictures of themselves breastfeeding. It is a welcome step towards ending that stigma and spreading the word about the importance of a mother’s milk.

 

 

 

Pregnancy prevention is still a woman’s problem

An RTI report has uncovered that a total of 26 women died while undergoing sterilization in Mumbai over the past five years, ten in 2015 alone. They went through a tubectomy, which has been the mainstay of India’s family planning program since Independence, a method that the government has promoted as safe, reliable and effective.

Yet time and time again, come reminders like this one of how perilous the procedure can be, especially when the women have persistent and deep-rooted health problems. The most heartrending was the aftermath of a government sterilization camp in Bilaspur, Chhatisgarh in 2014. Thirteen women died and over 120 left with serious health problems after the procedures were botched up due to poisonous medicines and medical negligence.

Be it a rural health camp or a thriving metropolis like Mumbai which reportedly has better access to healthcare, the point is that female sterilization is fraught with risk and there has to be a move away from pushing this. Since April this year, the Ministry of Health has finally introduced the much talked about basket of choices in family planning methods across district hospitals, an acknowledgement that a move away from female sterilization is long overdue.

However, making those choices available is a challenge, especially in rural areas. Making sure that stocks of contraceptives are made available at hospitals and primary health centres is just one part of the challenge. Creating awareness and counseling is also an important aspect.

These are demands that cannot be met adequately given the huge shortage of health workers and doctors across urban and rural areas. The main reason why sterilization continues to be used so widely is because it is a gunshot intervention. It requires no follow up, any check ups or counseling over a period of time, which makes it a popular choice with the medical staff.

The same BMC data for Mumbai also tells an interesting story. Between April 2015 to March 2016, 18,910 women in Mumbai underwent a tubectomy, as opposed to just 810 men who opted for vasectomies in the same period. This is despite considerable evidence that vasectomies are less invasive and require less post surgery care.

All this points to how women are so disempowered when it comes to childbirth. She has no say on when, or how many children to have; yet when it comes to preventing a pregnancy, it remains entirely her problem.

“Vasectomy and safe family planning methods need to be aggressively promoted if we care about women’s health”, says Dr Vijaya Sherbet, a gynecologist at Bengaluru’s Columbia Asia Hospital. “That sense of empathy, of political will has been largely missing.”

Signs of a change are evident. Tubectomy rates are down and doctors at government hospitals are promoting alternate FP methods. But this is in Mumbai, the financial capital. Rural India, or even the outskirts of Mumbai city offer an entirely new set of challenges.

 

 

An app that is saving women’s lives in Dharavi

One of the most positive fallouts of the rapid mobile phone penetration in India has been the impact on education and health in rural India. These are parts of the country that have been left out of the benefits of the economic boom and progress seen in urban parts, either due to poor infrastructure or lack of political will. Be it apps that provide health updates or learning tips, start ups are coming up with creative, innovative ways to reach a constituency that was regarded as difficult to access for the longest time.

One such initiative that has received much attention, and for the right reasons, is SNEHA’s Little Sister project that deals with the sensitive subject of domestic violence. DV is rampant in India but has never been given the attention it needs given the scale as most women do not report it. Many of them don’t even see it as an issue as a nationwide survey in 2013 found out. Over 50% of women said it was justified on many counts.

Apart from being a human rights issue, DV is also a health issue. It impacts women’s health in a myriad ways – from causing Post Traumatic Stress Disorder to depression and even affecting maternal health outcomes. Also think of the impact on a child who watches his mother get verbally abused or physically beaten up? You are looking at a generation that will grow up to be either abusers or victims of abuse.

SNEHA’s Little Sister app works by offering women in Dharavi a safe space to seek help. It is private, non intrusive and effective. Most victims of DV are not looking to walk out when they seek help. Often they want a shoulder to cry on before deciding what to do next. Little Sister does just that. It allows the woman to set the pace. Its the comfort of reaching out to someone who you do not have to see again if you don’t wish to and who will not judge you, or your situation.

To find out more about the Little Sister project click here. There is a video link about the project as well. 

 

 

 

Telangana polio scare indicates flaws in immunization program

This week Telangana declared a global health emergency after an active strain of a polio virus, but one derived from a vaccine, was detected in water collected from a drain in Hyderabad. Two lakh vaccines from Geneva were flown in to vaccinate children in Hyderabad as a preventive measure.

The scare is unlikely to make a dent on India’s claim to be polio-free since 2011 as this is not a direct case of polio.The strain found is from the oral polio vaccine, which contains a small amount of the weakened virus that stays in the child’s intestine and helps develop immunity. India can justifiably feel proud of its campaign to end polio, which was a long and tough battle to win.

However, there are concerns about the larger immunization program, as a recent study by the University of Michigan has found. The study says that two thirds of children under five years of age in India had not been vaccinated at all, or had not received the dose prescribed on time.

Every year, in India, over 1.5 million children die due to diseases that can be prevented by vaccines. While the Universal Immunization Program has helped reduce the numbers substantially from the figure of 120 in the nineties, the current figure of 48 is still high. And one possible explanation could be that vaccines are not being given on time.

Experts say that typically a child’s natural immunity after birth starts falling by the time it is  nine months old and it is critical to administer crucial vaccines like measles and rota virus in this period. Delaying this even by a few weeks, not only makes the child vulnerable to the disease, but also other infants in his or her proximity.

Ignorance among new mothers and poverty are major factors for the delay as is the lack of immunization records. Issues that initiatives like mMitra and Immunize India are attempting to address by taking rising on the mobile technology spread across India. Initial results from these initiatives show a lot of promise and given the many challenges of providing healthcare to a country as vast as India, technology innovations like these show the way forward.

Not enough in this budget for Family Planning

Among the most widely reported statements at the International Conference on Family Planning held in Indonesia in January this year was that of the Indian Health Minister JP Nadda who said that the country was committed to meeting the FP2020 goal of providing 48 million additional women and girls with access to modern contraceptives by 2020.

A global partnership, Family Planning 2020, works with governments, civil society and the private sector to enable women and girls to make decisions regarding if, when, and how many children they want.

The Indian Health Ministry team also announced that women would have access to better quality family planning services. A promise that is being met with. Since April, injectable contraceptives and pills are being supplied to all district hospitals across the country.

However, the recent report by the Population Foundation of India points out just how distant that goal of recahing 48 million women and girls is.

While the provision for health in 2016 has grown by 22% over 2015, with FP seeing a substantial increase of 67% compared to previous years, health remains hugely underfunded in India. The rise this year, it points out, is insufficient to compensate for the whopping 54% decline in allocations to family welfare between 2013-14 and 2015-16.

Meeting the 48 million number needs more than simply expanding the basket of choices. It needs awareness campaigns and better rural health facilities to ensure that babies and mothers survive. Campaigns have to be tailored to meet the specific challenges that a country as varied as India throws up.

While the shift away from female sterilization is welcome, there seems to be widespread official myopia in acknowledging just how deep the links between family planning and broader development goals go, and this is disturbing.

Guttmacher Report underlines need to meet adolescents’ contraceptive needs

Twenty three million – that’s the number of adolescents at risk of unintended pregnancies in the developing countries.

The statistic, part of the Guttmacher Institute’s May report Adding It Up: Costs and Benefits of Meeting the Contraceptive Needs of Adolescents, again points out the huge gap in contraceptive services among adolescent women. The report says that many women who want to delay childbearing are not getting the services they need.

About 40 million of the over 250 million adolescent women between 15–19 years in developing regions are sexually active and want to avoid pregnancy, yet 23 million of them have an unmet need for modern contraception. Most adolescents with unmet need are using no contraceptive method while the rest depend on traditional methods, which have been proven to be not so effective.

All this underlines the need to make sure modern contraceptives is made available in developing countries. This, according to the report, will not only prevent unintended pregnancies but also prevent the 3,000 adolescent maternal deaths reported every year in developing countries.

At 21% India has among the highest unmet needs for contraception in the world. This is despite the fact that we were the first country in the world to launch a government-backed family planning program. However, today countries like Bangladesh and Indonesia, which started their programs much after India, are faring much better.

The government has recently launched a wider pool of contraceptive choices for women. Welcome steps, but there needs to be more focus on behaviour change communication. Young women and couples want to plan their families but do not know where to get the information.

Maternal deaths in Mumbai down but there are areas of concern

 

The recent data released by the Brihanmumbai Municipal Corporation showing a drop in maternal deaths in Mumbai is good news. According to the report, maternal deaths in the city fell to 311 in 2015-16. This is welcome given that the figures on this front have seen a steady rise over the last few decades, except for 2013-14.

One of the main factors is that anaemia, which has been the single largest contributor to the high maternal deaths, has seen a major fall. According to the report, anaemia is behind less than 2% of the maternal deaths in 2015-16. Until a few years ago the figure was as high as 25%. This shows that interventions by the BMC alongwith various organizations like SNEHA in slums have paid off. There is greater awareness about the importance of taking folic acid tablets, calcium and iron from the early stages of pregnancy.

As women I spoke to in Dharavi point out, they would rarely remember to take these supplements during pregnancy. And even when they did, they had no idea how to. They would simply club them together.

“Now I am aware that I have to space them out through the day so they are effective,” says Vandana, who is pregnant with her second child. “These are things that I learned from counselors who visit the area”.

Another positive is that the fight against tuberculosis is showing results. It contributed to 6% of maternal deaths in 2015-16 compared to 11% in 2015-16. Proof that DOT centres in the slums and awareness campaigns by the BMC is paying off.

However, what is worrying is the threat posed by poor sanitation and hygiene. The BMC data shows that a majority of maternal deaths are due to hepatitis – both A and E. Both strains are directly attributed to poor hygiene and the lack of clean water. Around 14% of the deaths in 2015-16 were due to hepatitis.

Experts say the figures highlights the lack of clean water in the slums, Most of the slums, especially in the tertiary areas like Govandi, rely on water from tankers. Lack of safe water is a major risk factor during and post pregnancy.

Apart from ensuring clean water supply, there is also a need to strongly promote better hygiene and sanitation practices like boiling water, washing hands and using public toilets to reduce infections. The solutions are many and entirely in our hands. Like the fight against anaemia, this too is a battle that can be won.

 

Water crisis has links to women’s rights & economic progress

Just how grave the water shortage in India is brought out in IndiaSpend’s latest report, which says that India is facing the worst crisis in a decade, with the shortage likely to create drought-like conditions in many parts of the country.

We are already seeing the worst of it in many regions. Farmers in Bengaluru led a protest over water scarcity that lasted days. The water crisis in Karnataka is affecting Tamil Nadu and Andhra Pradesh, which are among the states that will be worst hit this year.

The impact of this scarcity will be felt most by women and children, especially girls, on every count, be it health, education or nutrition.

In Bundelkhand, Uttar Pradesh, the acute drought has led to an alarming drop in nutrition levels. 86% homes have cut down on dal intake, while 84% have cut down on milk for their children.

The threat of food scarcity is not limited to Uttar Pradesh alone given that there is not enough water to irrigate farmlands. So we are looking at a potential food shortage across the country.

Clean water affects education. It helps keeps children in schools. This is especially true of girls because in rural India, the task of fetching water still remains the primary responsibility of women. Families in Marathwada, in rural Maharashtra, which is facing severe water scarcity, are pulling their children out of school so they can help fetch water.

Perhaps the biggest concern is the impact on health. The acute shortage of safe, drinking water will lead to a spiralling of diseases like diarrhoea. There are over 300,000 diarrhoea-related deaths in the world every year. 45% of them are from India.

Access to clean water is not just a supply and demand issue. It has links to women’s rights, maternal and infant health and overall economic progress. Its time we looked at water from a larger perspective rather than battling it from season to season.

 

International Day for Maternal Rights – Time to Act

This week the world marked the second International Day for Maternal Health and Rights. High time the world paid attention to maternal health given that even today, in circa 2016, a woman dies in childbirth every two minutes. Clearly there is a need to promote and set up a comprehensive and rights-based approach to maternal health.

These rights are abused in many different ways, be it in terms of lack of access to quality health care during pregnancy, lack of information on birth control and availability of methods, or the abuse and disrespect that women are subject to during pregnancy and childbirth in hospitals and primary health centres.

Applying a human rights-based approach requires policy makers and health care providers to see women not as clients or patients or victims, but as those whose rights should be maintained and upheld in the context of health care.

It’s an approach that has been missing in the Indian government’s single-minded focus on increasing institutional deliveries. Broader sexual and reproductive health issues like access to safe abortion, setting up of adolescent friendly services, access to pap smears and mammograms, and promoting gender equity in family planning have been mostly neglected.

While nationwide surveys may show the maternal deaths rate declining, the statistics bury some hard realities. Anemia, which has a direct bearing on maternal health, continues to affect over 55% of Indian women. The poor and the marginalized face discrimination from healthcare providers. Caste continues to dictate access to immunization and other factors that help determine safer pregnancies.

These are factors that cannot be addressed by simply increasing the number of hospitals, healthcare providers or contraceptive choices. While structural changes like building stronger health systems makes a difference, maternal mortality is closely linked to development and cultural factors that are harder to change. Parts of the bigger picture may have shown some improvement, but what is missing is a rights based approach.

Tackling the diabetes challenge

That the Indian government is thinking on the lines of imposing a tax on sugary drinks and junk food is welcome news. Given the alarming rise of diabetes in India, there is active intervention needed to control the rise.

A WHO report says that the number of people with diabetes in India is likely to cross 101 million by 2030, while Lancet published a study  just a day before World Health Day that said there has been a fourfold increase in the number of diabetics from 1980 to 2014 – from 108 million to 422 million. It ranks China, India and the US are among the top three countries with the most number of people with diabetes.

Prevalence has more than doubled for men in India and risen 80% among women. While the incidence is higher in urban areas with states in the South reporting especially high rates, what is worrying is the rise in rural India, a result of rapid urbanization.

Of special concern is Gestational Diabetes Melitus (GDM), which remains neglected in India and has a severe impact on child and maternal health. India has one of the highest rates of GDM in the world, with over five million women affected every year. While the worldwide prevalence figure is 15%, in India it is 22 to 25%.

The increasing prevalence of GDM is linked to growing urbanization, reduced levels of physical activity, and changes in dietary patterns and rising obesity

Women with gestational diabetes report pregnancy-related complications like high blood pressure, large birth weight babies and obstructed labour. They are also more likely to develop Type 2 diabetes in the future and therefore special attention needs to be paid to this population in India.

A 2013 study by the Kerala-based Achutha Menon Centre for Health Science Studies found that women diabetics are even more vulnerable as they cannot abandon their role of looking after the family and are expected to put the health of other family members above their own. This leaves them with far less time and resources for their own health.

One major reason for the rapid rise in India is lack of awareness. A 2012 study by the Brussels-based International Diabetes Federation found that over 60% of diabetics in India had never been screened or diagnosed because of this, while over 63% were unaware of the complications that arise from the disease.

A combination of food patterns, sedentary lifestyles, obesity and genetics makes Indians more vulnerable to diabetes. It is time we acknowledge that and tackle the problem at a war footing.

Apart from nationwide screening programmes, early detection and treatment must become a part of primary health services. Awareness has to be created about dietary habits as well, with greater emphasis on fiber rather than sugar and starches.

Zika outbreak: Lessons for India

The fear and panic over the spread of the Zika virus disease has helped highlight the inadequacies many countries face in providing family planning and reproductive health services. The outbreak may be far from India’s shores, but those lessons hold true for us as well.

Zika has been declared a global public health emergency. There are fears, not entirely proven, that it is linked to birth defects in babies whose mothers contract the virus during pregnancy. Over 3000 cases of microcephaly—an oddly small head and an immature brain—have been reported in Brazil.

Given that the virus is spreading rapidly, with no proven vaccine in the horizon, women who are pregnant, or are likely to become pregnant, are in a spot.

In many of the countries affected, abortion is illegal. In some regions, contraceptives are in short supply. But going by the statements coming from political leaders, the onus seems to be entirely on women.

In El Salvador, women have been told to postpone getting pregnant for up to two years. How will they given that it’s not always accessible?

The public health system in many of these countries is in a poor state, much like in India. Rural areas, which are understaffed, are worse off. Again, much like in India. There is also great stigma attached to contraception.

Like India, the societies in many Latin American countries are deeply patriarchal. Cases of rape, including marital rape, are high. So where is the question of women exercising the choice to not get pregnant?

Zika is already out of the headlines, swept away by another crisis in another part of the world. But the outbreak has thrown up relevant questions. Like the need to build a strong public health infrastructure, make available a range of contraceptive choices, and most important, empower women to exercise those choices.

 

 

How Aahar is making a change: A community speaks

Approximately 50% of children under 5 years are malnourished in India. Nearly 39% are stunted, that is low in height for their age. And in the financial capital Mumbai, 26000 children die every year because of malnourishment.

Aahar, which means food, is a program that combines home-based and facility-based care to reach out to a large number of vulnerable children in need of monitoring. In order to make maximum impact, it reaches out to mothers when they are pregnant and  addresses nutrition and feeding practices throughout the first 1,000 days of child’s life. The program was launched in Dharavi, Mumbai’s largest slum colony in 2012 by NGO SNEHA, and works in partnership with the Centre’s Integrated Child Development Scheme, the Municipal Corporation of Mumbai and the Lokmanya Tilak Municipal General Hospital.DSC_0395

This week SNEHA will felicitate the many champions that help Aahar make a difference. A series of events will be held to honour the dedication and commitment of mothers, the municipal staff and community workers.

 

Here are some of those voices:

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Mukesh Kumar Jaiswal

Mukesh Kumar Jaiswal, 25

“I was 21 years old when I got married and I have two young children. My children used to fall sick very often when they were babies and my wife and I struggled to cope. We gave them whatever was cooked in the house, sometimes we fed them chips and biscuits. It was only when my youngest was nearly 6 months old when we realised that what they eat makes a substantial difference to their health. This was after SNEHA workers came to our area and held camps. They talked about the importance of breastfeeding and immunisation and it made a big difference to our children’s well-being and those in the neighbourhood as well. 

It is not like children don’t fall sick now. They do but not as often as they used to. We not only feed our children green vegetables, dal and fruits, but we eat healthy too”

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Renuka Kadam

Renuka Kadam, Community Organizer, SNEHA

“I started working in Dharavi 4 years ago and it was initially very hard to convince the families here to change their habits. They did not understand the importance of eating green vegetables, fruits and protein. We received a lot of support from the local anganwadi where these women would gather. Gradually they started to trust us and attend our sessions.

There was no awareness of the importance of breastfeeding. Most women would not nurse their babies due to misconceptions and myths so we had to work a lot on that aspect. They did not understand how important it is to take adequate rest, eat regular, nutritious meals while pregnant or take vitamins and supplements so their babies are healthy. They are so busy taking care of their families that they forget to look after themselves. They forget to eat. So we draw a clock on a sheet of paper and mark out the hours when they should eat. 

We hold camps twice a month when babies are weighed and their growth is recorded in charts. As the mothers see the improvement they are convinced. We also advice them about spacing babies and the various contraceptive methods.

From the time we started Aahar, there has been a big improvement in baseline indicators. But the challenge remains. Dharavi is home to a large migrant population so we have to monitor constantly”.

 

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Sangeeta Gupta

Sangeeta Gupta, 30

“I have three children and earlier I would never bother too much about what I fed them. If I could cook a meal I would. Otherwise I would give them some money so they could eat chips or biscuits. After SNEHA’s camps I have changed. I always give them a dabba for school with vegetables and roti or rice. I have seen what a major difference it has made to my children’s health”.

 

Breastfeeding: Promotes a smarter, healthier, equal world

The lives of over 800, 000 children and 20 000 mothers could be saved each year with universal breastfeeding says a new series by the respected medical journal The Lancet.

Breastfeeding leads to fewer infections, enhanced IQ, probable protection against obesity and diabetes, even breast cancer prevention in mothers, says the series which has been hailed as the most in-depth analysis done so far into the health and economic benefits that breastfeeding can lead to. It also highlights that breastfeeding leads to economic savings of 300 billion dollars

The data published is based on analysis led by scientists at the Federal University of Pelotas in Brazil who looked at data from previous research.

Reporting on the findings, The Independent,  a UK daily, quotes the study head Professor Cesar Victora as saying, “There is a widespread misconception that breast milk can be replaced with artificial products without detrimental consequences…. The decision not to breastfeed has major long-term negative effects on the health, nutrition and development of children and on women’s health.”

However, globally, only 37% of children under the age of six months are exclusively breastfed in low and middle-income countries.

Women avoid or stop breastfeeding due to many reasons ranging from medical, cultural, and psychological, to physical discomfort. Turning to formula milk, which is heavily pushed by multinational companies and many hospitals, becomes a convenient option.

There is a need to create a supportive environment for a mother who is breastfeeding says Dr Armida Fernandez, Founder, SNEHA. This includes addressing the many myths and misconceptions that are still widely prevalent.

“Mothers, and this includes women from poor backgrounds, want to breastfeed their babies. But if their baby keeps crying, and this happens due to many reasons, they feel it’s because they are not producing enough milk and so they resort to formula or diluted cow’s milk leading to malnutrition”, says Dr Fernandez.

She believes that doctors need to aggressively and consciously encourage breastfeeding.

“I find many doctors do not support it at all. The moment the baby is a little underweight they tell the mother to start a top feed. “ Dr Fernandez suggest that health centres and clinics must have counsellors on their staff who actively encourage women to breastfeed.

Currently India is still some distance away from reaching its targets on improving infant nutrition as per an assessment report by the Breastfeeding Promotion Network of India (BPNI) and Public Health Resource Network (PHRN) published in late 2015.

The report says that nearly 15 million babies, who comprise of 55% of newborns in India annually, are deprived of optimal feeding practices in their first year after birth.

The assessment also points to gaps in policies and programmes outlined for enhancing breastfeeding rates. Countries like Afghanistan, Bangladesh and Sri Lanka fare better than India in comparison.

Aggressive promotion of baby foods by companies, lack of support to women in the family and at work places, inadequate healthcare support, and weak overall policy and programmes were some of the reasons identified as responsible for lack of improvement in infant and young child feeding practice indicators.

 

Family Planning is a Rights Issue

Starting January 25, thousands of activists and experts from around the globe will gather at Bali, Indonesia, for the 2016 International Conference on Family Planning. It’s an opportunity to take stock of goals that have been met with, and for countries to evaluate how to boost workforces and tweak their approaches toward achieving the new Sustainable Development Goals.

India has a lot to feel proud about. Its population growth rate has dropped considerably – from a near 22% in 1991-2000 to 17.6% in 2001-11. With a fertility rate of 2.3, we are now just 0.2 points away from reaching the replacement level. And the good news is that nearly 60% of our population lives in states where replacement fertility is already reached or will soon meet the target.

That’s the good news. There is plenty however to be done when it comes to how we approach family planning at the policy level. On this count, India lags far behind countries like Sri Lanka and Bangladesh which is surprising given that w were the first country, globally, to have a government-backed family planning program.

For one, India still reports the highest unmet need for contraception worldwide at 21%. In Bihar it is 31% among women between 15-19 years and 33% between 20-24 years. Maternal and neo-natal mortality is five times higher among girls who conceive before they hit the age of 20. They are also more likely to experience spontaneous abortions, infections and anemia.

This is largely because on the ground the emphasis on female sterilisation remains extraordinarily high. According to UN data, in India, over 37% of women between 15-49 years use sterilization as a method of contraception. Only 3.1% use a pill and 5.2% rely on condoms.

“The rights perspective on family planning is missing at the policy level and it is high time that this changed”, says Dr Pranita Acharya, gender, poverty and HIV/AIDS specialist at the International Centre of Research on Women. “It is the right of couples to decide when and how many children to have. This is only briefly touched upon at the policy level and forgotten on the ground”.

Other contraceptive choices require counseling and careful monitoring – an investment that most states find burdensome. Sterilisation, on the other hand, is a one-time, gunshot intervention. The result is that many women have been sterilized even before they need it.

There is a near complete lack of awareness when it comes to contraceptive choices among married adolescent girls and newly married couples. Filling this gap is critical given that India accounts for 17% of maternal deaths, worldwide. Educating newly married couples about various contraceptive methods could help prevent many more such deaths.

It is also important to involve men in family planning matters believes Sushma Shende, Program Director, Maternal and Newborn Health, at NGO SNEHA. This will help couples make better informed and collective decisions.

“Considering the socio-economic set-up of the areas in which we work, it is difficult for women to take decisions with respect to FP”, says Shende. “Her husband and mother-in-law play an important role in decisions regarding child bearing and family planning. Moreover, the pressures of bearing and rearing the child is considered to be the responsibility of women so increased awareness amongst the men will make them more supportive and help address misconceptions or fear”.

No quick fix solutions for child stunting in India

Why despite years of economic progress India continues to report high rates of child malnutrition has been a matter of endless discussion. One that has received renewed attention following the announcement that the 2015 Nobel for economics has gone to Angus Deaton.

Much of Deaton’s work has revolved around India, covering issues like nutrition, poverty and health gaps. Alongwith fellow welfare economist Jean Dreze, Deaton has analyzed the reasons why under nutrition levels in India are consistently higher than far poorer countries in sub Saharan Africa.

Nearly 39% of children in India are stunted due to poor nutrition. Two of five stunted children in the world are in India, making it the epicenter of global malnutrition. India reports a far higher figure than Burkina Faso or Haiti.

Stunting, which is the fallout of chronic malnourishment, has permanent consequences. It is accompanied by a host of problems – poor immunity, risk of disease and a greater risk of dying before the age of five. On the whole Indians are stunted compared to people in most countries, including Africa and China.

It’s not just a question of a shorter height than normal, but is a marker for an array of developmental problems, explains Dr Armida Fernandez, former dean at Lokmanya Tilak Municipal Hospital, one of Mumbai’s largest public health facilities.

“When you are short there are many things that are affected”, says Dr Fernandez. “The brain is not developed and as the child grows older, there is the risk of early onset of diseases. Children who are born small run the risk of hypertension and diabetes.”

The impact on brain development is a cause for great concern and is seen as an explanation for why stunted children drop out of school early.

There are many factors responsible like poor maternal nutrition, poor feeding practices, substandard food quality as well as frequent infections. However, nutritional interventions are only a part of the solution because stunting also occurs among well-fed children. Lack of access to adequate hygiene sanitation and clean drinking water are compelling factors as well. The WHO estimates that 50% of malnutrition is associated with repeated diarrhea or intestinal worm infections from unsafe water, poor sanitation or hygiene.

Studies have also shown that women’s roles play a strong role. The low status of women in India means poor levels of maternal nutrition. Many children are therefore malnourished in the womb itself.

“We need to look beyond just the lack of toilets”, says Dr Fernandez. “We need to look at the quality of food girls are given, women’s health, domestic violence and what a mother undergoes during pregnancy. There is no simple cause and effect factor for stunting”.

Family planning in Dharavi

A vasectomy surgery is the end of “manhood”. A Copper-T can prick the body, rust inside the body, or ride up to the chest. Condoms give no “satisfaction”. Oral contraceptive pills can cause weight gain.

These are the the notions and misconceptions that SNEHA team working on the Family Planning programme has to deal with and dispel effectively. The Family Planning unit of SNEHA has been working hard in Rajiv Gandhi Nagar, Dharavi to dispel these misconceptions and notions since 2011 and have induced behavioral changes in many women and men in the area. As per SNEHA estimates, as much as 46% of the population has an unmet need for family planning.

For instance, Karishma, 30, (name changed) was reluctant to use any form of contraception, till she conceived again. She already had two children. She then approached a SNEHA community organiser who helped her get an abortion at Family Planning Association of India (FPAI) at nominal rates. The incident motivated her to get Copper-T fixed to avoid pregnancy for five years.

Social exclusion and lack of information limit access to services such as family planning which are crucial for reducing unwanted pregnancies, saving lives, reducing poverty and slowing population growth. A woman’s ability to control her fertility directly impacts the quality of her life and that of her children. Access to family planning can reduce the number of maternal deaths and child deaths.

“Instead of sermonising to the community to have less children, we have adopted a different approach. We tell them that having fewer children, it is easier to feed and educate them. We tell them that their families can be better and healthier,”said the programme coordinator, Family Planning, SNEHA.

SNEHA has adopted the Peer-educator model, whereby women from the community have been roped in to educate the other members and also provide contraceptive such as condoms, oral contraceptive pills and other services at the doorstep. SNEHA also gives the community information about safe abortion practices, post-partum family planning, spacing between two children and using methods of contraception by choice and mutual decision making. It has also strengthened the referral system to service providers such as municipal hospitals, and FPAI.

Some of our peer educators have made good choices and have fewer children. They help demonstrate the benefits of family planning in the community,”said Bapat.

There is also intervention by way of events and campaigns, group meetings, and home visits. Women who avail of SNEHA services and referrals to FPA agree to speak in group meetings that help in motivating other members of the community.

SNEHA also involves men in the project, a neglected target group of most family planning interventions. Men are important to target becuase usually they make all the decisions regarding family planning. To effectively deal with men in the area, SNEHA hired a male community organiser who conducts group meetings with men and is able to engage with men in the area well.

For instance, a SNEHA personnel were counselling a man who was in a live-in relationship with a woman. When the girlfriend recently got pregnant, SNEHA personnel helped her get an abortion and also helped the man understand the importance of using contraception to avoid such unwanted pregnancies.

“It is important not to judge such people and provide intervention whenever necessary,”said the programme co-ordinator.