Godrej India Culture Lab is a Mumbai-based experimental space that brings together ideas and people together to explore what it means to be Indian. It held a two-day conference, ‘We the Nation: Micro-narratives of change’ on June 30th and July 1st, in Mumbai. The conference, showcased organisations that are documenting the rapid changes taking place in India today, through talks, panel discussions and exhibitions. It featured noted journalist, P. Sainath, who spoke about the work he is doing through People’s Archive of Rural India (PARI), Video Volunteers, a Goa-based organisation that empowers marginalised communities to tell their stories, Digital Desh Drive, an annual report that explores how non-metros are using the internet, Khabar Lahariya, a community-run newspaper published by rural women; amongst other path-breaking and inspiring organisations.
SNEHA’s sanginis (women volunteers from the community) attached to our Prevention of Violence against Women and Children program, who identify and map cases of domestic violence, refer cases to our crisis centre for legal aid or intervention and hold community meetings to discuss gender norms, had the opportunity to attend the the conference and participate in a panel discussion. They were accompanied by Meera Sai, Program Coordinator of the Little Sister project that uses mobile technology to track and report instances of domestic violence in Dharavi.
This was an opportunity for our Sanginis to share their experience in using mobile technology to address the pervasive issue of domestic violence in slum communities. The audience was intrigued to know how Shehzadi, one of our sanginis, who hails from the muslim community, is challenging gender norms. Shehzadi has been part of SNEHA’s efforts in preventing domestic violence for over a decade now. Nikita, another Sangini, shared about how SNEHA has played a pivotal role in shaping her thoughts – ‘Not being educated or not being able to converse in English has not stopped me from being confident,’ she said while telling a tale about how she fought with her family and supported her daughter to pursue higher studies.
For our sanginis, who work on challenging patriarchy and social norms everyday, the conference was a validation of their inspiring work as well as an incredible platform to share their stories. Empowering women and developing grassroots’ leaders is the core of our work in preventing gender violence and platforms like these, are where we want our sanginis to be!
“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.
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.
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.”
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.
“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.
That sexism and patriarchy is deeply ingrained in India is not a matter of debate. But when actively promoted in school textbooks, it becomes a matter of grave concern.
There is much outrage and sarcastic humor over the recent news report about a Class 12 textbook in Maharashtra that lists “ugliness” as a cause of dowry.
To elaborate, the sociology textbook says – “If a girl is ugly and handicapped, then it becomes difficult for her to get married”. It follows this up by saying that families of such girls feel helpless and end up paying more dowries.
The battle against patriarchy, as many NGOs working on the ground will attest, is a long, uphill one. It’s a fight to change mindsets that develop and are fostered at homes – attitudes that both genders are equally guilty of propagating.
Imagine the impact then of school textbooks on deeply impressionable young minds? They should be agents of change. However, instead of damning a system that places girls in a secondary role and fosters practices like dowry, our textbooks are promoting regressive attitudes.
This is not the only textbook guilty of promoting such pearls of wisdom. Read this gem from a textbook in Rajasthan – A donkey is like a housewife … In fact, the donkey is a shade better … while the housewife may sometimes complain and walk off.. You’ll never catch the donkey being disloyal to his master.
A three-year-long study on Indian education, which looked at 22 English and 20 Hindi textbooks, stated that the authors of school textbooks showed a deeply patriarchal mindset. Women are shown as weak, in need of protection and capable only of staying at home.
A study by UNESCO of school textbooks from across the world found that many of them are deeply gender biased and undermine girls’ motivation, participation and performance in school. Regarding India, it said, “half the illustrations in elementary English, Hindi, mathematics, science and social studies textbooks depicted only males”.
The subliminal messages these books reinforce is that of a patriarchal world, where women are capable only of playing secondary, submissive roles. Attitudes are shaped early and such messages at the school level have a dangerous impact, substantially undermining the fight against gender discrimination.
It is now widely recognized that improving the status of women has to involve boys and men. As much as girls, boys too are trapped in stereotypes and they need to recognize and value the importance of building equal and healthy relationships.
Unequal power not only suppresses women and girls, but also oppresses men and boys. Apart from the pressure of being the economic provider, rigid gender roles also limit men’s cultural experience. There is the pressure to appear virile and strong at the cost of suppressing emotions.
Since 2013, SNEHA’s Ehsaas program has been working among adolescents in Mumbai’s slum communities towards breaking these stereotypes. Through a mix of street plays and community sessions with adolescents and their families, gender stereotypes are questioned and challenged.
“The attitude has been to look at boys as problems”, says Neeta Karandikar, associate program director, Ehsaas. “This is especially the case after the Nirbhaya and Shakti Mills incident in Mumbai where the accused were from the slum areas. Boys from poorer communities were seen as problems. But we have to recognize the challenges they deal with”.
Traditional patriarchal attitudes, believes Karandikar, not only oppress women but act as traps for boys and men. By highlighting norms that allow boys to play while girls do hosuehold chores, Ehsaas encourages youngsters to question prevailing mindsets.
“My sisters would eat only after the men of the house would finish their meals”, says Shahid Shaikh, a peer educator with Ehsaas. ‘I never questioned that. It was after I joined the program that I realized how wrong this was and I now make sure they eat with everyone else”.
For decades, gender equality was considered a woman’s issue. Now, there is a realization that the role of men and boys in challenging and changing unequal power relations is critical. There is a stronger focus on the positive role men and boys can play in promoting women’s empowerment in the home, community, and workplace.
Just how distant a dream going to school remains for girls in India is borne out in the new data on female literacy.
According to this study, the proportion of girls who finished five years of primary school in India is 48%, which is far lower than Nepal (92%), Pakistan (74%) and Bangladesh (54%). The data also shows that only 15% of Indian women who studied till Class II can read a sentence.
Gender, location and poverty remain such huge barriers for a majority of girls in India today. The bias against educating girls keeps them vulnerable to female infanticide, early marriage, gender violence, and sex trafficking.
This can only change when education comes to be seen as a vital necessity for everyone, regardless of gender, rather than an advantage that only the privileged have.
Investing in every girl’s education has to be seen as critical for social and economic development, for lifting households out of poverty.
Educating girls is necessary to reduce the number of child marriages, which remain high in large parts of India even today despite being against the law. Studies show that women who get a secondary school education are 92% less likely to be forced into an early marriage. This in turn makes them vulnerable to early pregnancies, domestic violence, HIV and depression.
Education also has a direct link to lower maternal and infant mortality rates. It helps build awareness about better hygiene, vaccinations and nutrition. It enables more informed choices on matters like family planning and employment. Studies show that women who have had the opportunities to go to school are two times more likely to send their own kids to school.
All of which make compelling arguments to ensure we do more to send every girl in India to school.
The impact of early marriage on the reproductive health of women has been well documented, but the effect on mental health often gets overlooked. Child brides often find themselves struggling to cope with anxiety and depression and find little sympathy or support in their marital home.
A sociological study done by the University of Calicut among 600 women who had married before the legal age found that most of them were in conflict with their husbands and other members of the marital home. They were under pressure to take over the household chores and produce a child early.
Any assertion of right or voicing an opinion was treated as a challenge and often met with ridicule, even physical abuse.
A new India wide study by the Delhi-based SAMA Resource Group for Women and Health is also examining the wider impact of early marriage on a woman’s health. Early findings of the report say that when girls are forced to leave school and marry, they experience a loss of mobility. The immediate result is a loss of companionship as they are no longer free to meet their friends. This is a major cause for distress.
Every aspect of their lives comes under close watch – from what they wear to whom they speak to – so there is a constant feeling of apprehension that they might break the rules.
Any sign of sadness or unduly quiet behaviour is regarded as proper and hence gets ignored. It is only when the signs of mental health become very obvious that outside help is sought and this is not professional help, but from traditional faith healers.
“Whenever there is physical violence, it shows up in scars”, says Praful Kamble, Program Officer of SNEHA’s Little Sisters program which has been working towards bringing addressing domestic violence issues in Mumbai’s Dharavi area. “But the impact on the mind is 25% more. There is depression and a sense of shock. And when there is negative support from the family, the woman feels even more isolated.”
Geeta (name changed) experienced verbal violence from her in laws and husband, as her son was constantly ill. Even her sisters-in-law did not support her. One day she threw kerosene on herself and set herself on fire.
“I did it out of despair”, she says. “Caring for a sick child was stressful as it is and then to be constantly blamed for it was a miserable feeling. I was worried for my child and had no idea where to seek help.”
There are multiple linkages between early marriage and health. Mental health is a key one, and needs greater focus in India’s programs and policies.
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.
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.
“Closing the gender gap is not possible without closing the data gap.” – Melinda Gates
One of the key announcements to emerge from the ongoing Women Deliver 2016 at Copenhagen is the launch of a new data and research partnership to monitor and drive progress on gender targets outlined in the Sustainable Development Goals.
Key to meeting these new gender targets is reliable and up to date information on women and girls to help ensure transparency, accountability and citizen engagement. In most countries, this data is largely missing or incomplete, be it on child marriages, dowry deaths, domestic violence, the wages women are paid, or why and how many girls are dropping out of schools. Having the data helps set concrete plans and goals and hold governments accountable.
This is especially critical in these times given the global financial crisis, natural disasters and widespread political instability. Take climate change related disasters for instance. There is evidence to show that every such crisis affects men and women differently. This is especially the case in developing countries where women face greater risks to life and health due to social structures. However the lack of adequate data to support this differentiated impact means they don’t get taken into account at the policy level.
“Making all girls visible in statistics is a critical first step towards holding governments to account and implementing the girl-focused global goals”, believes Anne-Birgitte Albrectsen. CEO of Plan International, which is one of the groups leading the joint research initiative. Progress on gender equality goals are slow because there are no numbers to track it. “We do not adequately measure the number of girls who leave school due to marriage, pregnancy, or sexual violence, simply the number in school. Millions of girls are left invisible”, adds Albrectsen.
This invisibility supports the attitude that girls and women simply do not count. Having hard numbers for where they live, what they go through and what they want will help bring down that wall.
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.
As you walk into the exhibition of Quiltessentially SNEHA, the thought that strikes you is how the sea of rich patterns and intricate weaves is such a powerful expression of SNEHA’s work; conveying both the range of its outreach work and the ties it builds in the communities it works in.
Quiltessentially SNEHA, the livelihood project started in 2009 by the Society for Nutrition, Education and Health Action, aims to equip women in slums with various skills that will strengthen them financially
“I was supervising a tailoring class for adolescent girls and women and that’s when the idea came about. We thought why not start a small unit that makes patchwork quilts”, says Naina Fernandez, project director.
Initially she relied on fabrics donated by clothing and furnishing stores that usually have large swatches left over.
“We taught the women basic stitching skills and we had some sewing machines and we were set to start”, she says.
The women would put the pieces together guided by creative inputs from Fernandez.
Some families took a little convincing at the start.
“There was this young girl who was really talented but in the early stages, the earnings weren’t that good”, says Fernandez. “Her family pulled her out because they felt she was better off working as a domestic help. I stepped in and insisted that she had a gift and they should not stop her from coming to the center”.
From quilts, the range of products has expanded way beyond to dupattas, bathroom mats, bedspreads and cushion covers. And then there are the small and thoughtful items like pouches for sanitary pads, an idea that Fernandez says came from school-going adolescent girls that SNEHA works with.
The designs are never repeated so each product is unique. The demand for the products is huge, especially among corporate houses.
The project employs about 40 girls and women, with 13-15 working on a shift basis. The timings are flexible as many have young children or elderly in-laws to look after. On an average, each person earns upwards of Rs 5000 a month.
Income that Manali, one of the earliest members, says comes in handy, especially when finances run low.
“My husband is a BEST driver and he earns decently but we used to feel the pinch when my children needed books or clothes. Now I contribute and ease the financial burden which makes me feel great”, says Manali. “I am able to support my family”.
Above all, the project offers a safe space for women to get together and bond over shared experiences and issues.
“We stitch together, we share, laugh, chat, give each other advice and in the process feel lighter”, says one of the project members.
“I can often hear them giggling loudly as they work” laughs Fernandez. “People in the nearby units tell me these people make such a racket. So I know they are in a happy space.”
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.
Today is International Women’s Day, and the theme of 2016 is Gender Equality. The theme was set by UN Women, the United Nations organization dedicated to women’s empowerment, within the context of the new Sustainable Development Goals for 2030. The SDGs, which follow the Millennium Development Goals, cover 17 goals across four categories – people, planet, prosperity, and peace. For progress on each of these goals girls and women have to be empowered.
Think about it. Women’s roles are varied – they are breadwinners, farmers, teachers, businesswomen, mothers; they contribute to their homes, the community and the economy in multiple ways. Because they are at the forefront, they are often more affected than men by factors like climate change, revolutions, economic crises and poor health care. Hence, their assistance and direction is needed to achieve the SDGs.
Take SDG 1, which is bringing an end to poverty. This can be achieved only when there is no gender-based discrimination. Gender inequality denies women basic rights and opportunities for wellbeing.
If a woman is not given access to the same wages and services as men, she will remain deprived. For instance compared to male farmers, women farmers have less access to seeds, credit and technology. This in turn feeds into SDG#3, which aims to ensure health lives. Food security affects nutrition, and if women are not healthy, their babies will be malnourished.
The links to empowering women are not always so direct. Ensuring water availability for example benefits men and women. But the fact is that it is women who spend hours everyday collecting and transporting water that the family needs. Also it is lack of water that leads to girls dropping out of school when they start menstruating, a factor that comes in the way of a gender equal world.
“Gender equality is advanced when girls can stay in school because they are able to delay marriage and childbearing”, says Ellen Starbird, Director, USAID office of Population and Reproductive Health, “and when they are empowered to make healthy reproductive decisions and exercise their reproductive rights. Constructive engagement of boys and men to change gender norms must also be part of these efforts. “
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.
On World Cancer Day, here are some India-specific statistics that need immediate attention.
The incidence of cancer is 70-90 per 100,000 population, with prevalence stated to be about 2.5 million cases. Over 800,000 new cases and 550,000 deaths occur each year, with over 70% of the cases being diagnosed at an advanced stage. That means when a person comes for treatment, their chances of survival are very poor.
ICMR data on site specific cancer burden reveals that in males the most common cancers are those of the mouth, stomach and lung/bronchi. In females, it is that of the cervix, breast, mouth and oesophagus. After breast cancer, cervical cancer is the second most common cancer among women in India.
More women in India die from cervical cancer than in any other country, according to a 2014 report by the Cervical Cancer Free Coalition. Cervical cancer kills around 72,000 women in India every year, more than 26% of the 275,000 deaths worldwide.
The report also says that the causes are closely linked to attitudes towards women and unless that changes the deaths will rise. Because it is linked to sexual contact, “cervical cancer is a taboo issue in many places”, said the U.S-based group in a statement. “Unless women’s groups and civil society come together to lead movements that break through stigma, patriarchy and other societal barriers, we will continue to see large numbers of deaths and high mortality rates,”.
Cervical cancer, which mostly affects women between 18-45 years, is linked to human papillomavirus, a sexually transmitted virus.. The virus is believed to be responsible for most cervical cancer cases — more than 80%, according to some estimates. A pap smear can spot the virus at an early stage and HPV vaccines have been developed. In December 2014, the Indian health ministry announced that it wanted to introduce the vaccine in the universal immunisation programme at the earliest.
What is missing however is a countrywide cancer screening program to catch the disease early. Cervical cancer is a preventable disease but it can also be successfully treated if detected early.
The UNAIDS statement calling for a greater integration of health services to tackle cervical cancer is a welcome one. It says “the relationship between HPV and HIV offers significant opportunities to reduce the impact of both viruses, since existing HIV programmes could play an important role in expanding cervical cancer prevention and treatment services.” It goes on to recommend that every woman who tests HIV positive should be offered screening for cervical cancer and follow-up treatment if needed. And that HIV testing should also be offered during cervical cancer screening.
An effective intervention also calls for delivering age-appropriate programmes for adolescent girls, that includes HPV vaccines and regular screening. Steps India has to accord high priority to to rein in the galloping figures.
Standing outside the gate leading to her school, Anjali, a resident of Ghatkopar, Mumbai, 15, points inside to a partially broken door.
“This is the only toilet in the school which has running water. Now do you understand why I prefer to stay home on ‘those’ days”?
“Those” are the days when Anjali is menstruating when she, and most of her friends miss school. That is nearly seven days every month and the frequent absences Anjali fears will come in the way of her dreams of becoming a doctor. Many girls in her neighbourhood have dropped out totally shortly after hitting menarche.
What is a natural process marking the onset of adolescence in girls is fraught with huge challenges for girls in developing countries. Studies in different parts of Africa have documented how menstruation significantly compromises the education of girls.
The same is the case with India where according to an pan-India sanitation study by Dasra and Forbes Marshall, almost 23% of girls drop out of school when they start menstruating, and as many as 66% of girls skip school during this time. The same study also highlighted that 88% of India’s 355 million menstruating women have no access to sanitary pads – a lack that affects the health of women and adolescent girls.
An unsupportive environment in schools that includes lack of adequate toilets, absence of gender-segregated facilities, poor sanitation and inadequate water is one of the main causes. Another factor that explains the low school attendance is access to sanitary products that girls, especially in rural India, face.
A recent study focused on 53 slums and 159 villages in Madhya Pradesh, Chhattisgarh and Uttar Pradesh found that 89% of girls and women used cloth during their menses, with over half of them using the same cloth for more than one period. Two per cent used cotton wool and ash. Just 7% used sanitary pads.
The reality seems to have been taken note of at the policy level. In his Teachers Day address in 2014, PM Narendra Modi expressed concern about the large number of girls dropping out of school and the need to find ways to make sure girls don’t quit school early. The Swachh Bharat, Swachh Vidyalaya mission aims to build “at least one incinerator in the girl’s toilet block and a niche to keep sanitary napkins”.
What hold out greater promise is innovations in this field. Among the most prominent are those by A. Muruganatham, the Tamil Nadu-based creator of low cost sanitary napkin making units, who is aiding the Uttar Pradesh government’s efforts to reach total menstrual hygiene.
Guided by the UP government and Arunachalam, a pilot unit was set up in the village of Mahoba in 2013 to produce low cost sanitary napkins. The unit employs only women and is part of a decentralized enterprise model. This was coupled with a massive drive on menstrual hygiene across nearly 15000 schools in the district. The program was a massive success with the demand for Subah napkins far outstripping the supply and the UP government plans to take it across the state.
Also effective has been the UNICEF program in Kanchipuram district, Tamil Nadu, under which a vending machine disposing sanitary napkins was installed in schools.
Awareness too has to go hand in hand with affordability and availability. There is tremendous shame and stigma associated with menstruation and schools must address this, among boys and girls, to break the silence.
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”.
Mumbai’s reputation as the safest city for women has taken a beating after the release this week of a new study that shows that the financial capital witnessed a surge of 49% in crimes against women in 2014-15. While this may be a heartening sign that more women are coming forward to report such crimes, the staggering near 50% jump should compel us a society to reflect.
This year’s 16 Days of Activism Against Gender Violence was an opportunity to do just that. Violence against women in India takes many forms. From sexual assault, public humiliation, abuse, domestic violence trafficking or ‘honour’ killing, crimes against women have more than doubled in the last 10 years according to the latest data of the National Crime Records Bureau.
One of the aims of the 16 days campaign is to raise awareness about this violence at different levels – local, national, regional and international. As part of this, campaigns and training workshops were conducted at various settlements across Mumbai city by SNEHA in collaboration with local organizations.
At community centres in settlements in Dharavi and Kandivili, daylong workshops were held with Safecity, a Mumbai-based organization that conducts campaigns to spread awareness about gender-based crimes.
The tone of these workshops was informal and interactive. Participants were asked about public spaces, their notions of what was safe and unsafe and interestingly there were several similarities in what boys and girls regarded as unsafe public spaces. The conversation would then broaden to include issues of sexual violence and harassment. The idea was to create a safe zone where participants could voice their opinions honestly about issues like consent, victim blaming, marital rape and domestic violence. They were also asked to map their localities, marking out areas that were regarded as safe or unsafe.
“Through the maps, we saw the reasons why many areas were considered safe and unsafe”, said a member of the Safecity team. “Safe spaces generally were areas that people frequented, or areas near places of worship and police stations. Unsafe spaces were much more in number and included spaces that were dark and secluded and where crime had happened before.’
The next step in this campaign would be for this group of youngsters to conduct a survey of their areas based on a survey form SNEHA has prepared that is based on perceptions of people regarding sexual harassment.
Violence against women is one among the most important factors preventing their full participation in the economy. Above all it’s a fundamental violation of human rights. Involving boys and young men in such campaigns send out the message that it is time they got involved in ending the scourge of violence against women and girls in their homes and communities
The stage of adolescence is a vulnerable, turbulent one, especially so for girls in India who face barriers on so many fronts – social, political and economic.
Which makes the decision to call this year’s International Day of the Girl Child “The Power of the Adolescent Girl”, a welcome one. It’s an occasion when we need to seriously examine the various fronts – social, economic and political – on which their empowerment continues to be undermined in India.
India has the largest adolescent population in the world – 25% of them are girls. These girls have the potential to become leaders and effect change but they continue to receive lesser priority compared to boys within the family when it comes to education. 70% per cent of girls between 7- 16 years drop out of school.
Their empowerment is also hindered due to early marriages, early pregnancies, gender-based violence and limited access to reproductive health services. India has the highest number of child brides in the world – an estimated three million a year, which is third of the number of girls who marry as children every year worldwide.
Child brides are especially vulnerable to domestic violence. Studies have shown that sexual violence from husbands is most common among adolescent wives. These are factors that compromise mental health and have even been linked to depression and high suicides according to many studies.
Over the decades there has been an encouraging rise in the number of programs supporting adolescent girls, especially offering home-based and vocational skills to help them earn an income and play a greater role in their communities.
What needs to be beefed up is the availability of programs that offer information and access to public services and educating married adolescent girls on sexual and reproductive health issues. The unmet need for contraception continues to be high – at 21% India reports the highest in the world.
On this International Day of the Girl Child, let us think of ways in which we can empower girls to make meaningful choices in all aspects – economic, social, sexual and reproductive – free from bias, force and violence.
When one talks of “access to toilets”, the first thought that pops in the mind is “sanitation”. In Dharavi, however, the immediate association with “access to toilets” is “safety of women and girls”. Why ‘safety’, you ask?
– groups of men and boys are always hanging around outside public toilets, loitering, drinking, gambling, sexually harassing women and girls.
– men and boys sexually find toilets an easy place to target a large number of women. Men and boys see public toilets as opportunities to stare, ogle, pass comments, whistle, grope, pinch, abuse, rape women and girls.
– women and girls feel uncomfortable, violated, targeted, harassed, denied of their basic human rights of access to safe toilets and a life free from violence.
– women and girls (and their families) feel like the onus is on them to ensure their own safety.
– women and girls are the ones who are forced to find solutions to ensure their safety such as going to the toilet early in the morning to avoid harassment and their harassers or going in a group with friends or with a family member or avoid going to the toilet several times during the day.
The 2011 Census of India found out that nearly 12 per cent of urban households resort to open defecation and another 8 per cent use public or shared facilities. Not only is this a health hazard, but it undermines the dignity of women and girls and makes them vulnerable to harassment and violence.
SNEHA addresses both, the issue of health of women and girls and the issue of gender-based violence in Dharavi, through campaigns, street theatre, meetings, support groups and vigilance groups. We raise awareness of these basic human rights in the community, and encourage and support collective, indigenous responses to combat violations of these rights. SNEHA’s men’s group members also act as vigilantes against sexual harassment of women and girls in public places, which includes the areas where public toilets are located.
The patchwork quilt displayed above represents everything about the Livelihood Project and SNEHA as an organisation. “It weaves the lives of people and communities we work with,” summed Naina Fernandez, the programme coordinator of Livelihood Project.
The project was started in 2009 as a way to provide livelihood to women, and also help them learn a skill set that can help them gain financial independence. It involved educating the women on the basics of stitching and using of sewing machines. Currently 20 women are working and training at SNEHA.
“The women working for us do have stitching skills. We hone their abilities. I am particular about the finish of the products and insist on a professional look. I was also considering enrolling them for workshops which will increase their skill set and help us produce more products,”said Fernandez, who designs the products with inputs from her staff.
The flagship products are silk and cotton patchwork quilts. The product range has been diversified into bags, pouches, wallets, table linen, cushion covers, curtains, gift pouches, wine bags, among other products. The fabric that is donated by well wishers is used optimally. The products are sold in pop-up exhibitions such as Lil Flea, corporate houses for gifting, individuals who place orders, among others.
As a way to increase their confidence, the women who make the products are now encouraged to talk about them in the exhibitions. “Their body language changes when they start talking about their products. They are slowly gaining confidence,”said Fernandez.
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