“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.