In June, 18-year-old Parsula Takre attended the funeral of her first child who she did not have a chance to name. A few villagers gathered and buried her son. Takre gave birth when she was just seven months pregnant, weighed only 45 kg and was anaemic. The premature baby weighed just 1.9 kilograms instead of the ideal 2.5 kilograms or more. Takre had been too weak to breastfeed her child.
Every resident in the region seems to know of a family who has lost a child that is almost always a premature baby. According to records in Dadra and Nagar Haveli's only hospital, 167 newborn babies died within four weeks of birth in 2014-'15 – a 128% increase from 2011-'12 when 73 newborns died.
The leading cause of death, according to the records, is septicemia, which is an infection of blood, but underlying factors seem to include starvation among adults and infants and poor health facilities. The sharp rise in the number of deaths could also be due to many more poor ailing patients coming to Dadra and Nagar Haveli hospital from neighbouring districts in Maharashtra and Gujarat. But health officials point to teenage pregnancies as the major cause of high infant mortality.
According to social mores in the hamlets of Dadra and Nagar Haveli, where 80% of the families are classified as Adivasis, marriage is not a pre-requisite to have a child. Takre is not married to partner Artul who works at a company in Naroli in Dadra and Nagar Haveli. However, when a boy brings a girl at her home and once they start living together, families expect the girl to conceive.
“If there is no child, there will be no marriage,” said an elderly woman from Mandhoni village. “If they don’t have a child, the girl will be sent back.”
Asmita Rabad is three months pregnant. A 10th standard student at the local government school, Rabad dropped out for fear her friends will tease her once her stomach starts showing. The local accredited social health activist or ASHA was not surprised when she learnt about Rabad’s pregnancy. “We have started her on folic acid,” said the ASHA. Folic acid is a supplement administered to pregnant women and women planning to conceive to prevent neural tube defects in the child.
Acknowledging the issue of teenage pregnancies, the health department at Dadra and Nagar Haveli has started administering folic acid tablets to all teenage girls in case they end up conceiving.
The local ASHA counsels Rabad to continue her schooling but she is keen to stay home. The ASHA secretly asked Rabad if she was aware of contraception to which the girl promptly replied, “Mala pahije hota baal." I wanted the child.
Unlike Rabad, 16-year-old Kajal Sapta who is four months pregnant wanted to abort her child. However, her partner Deepak’s family were against it. “These children do what they want and if you go against their wishes they go and drink poison,” said Sapta’s mother. “I spoke to the boy’s family that we should abort the child but they didn’t agree.” Kajal, who dropped out of school, was working as a sweeper in a resort in Khanvel where she met Deepak who worked as cook.
The Dadra and Nagar Haveli health department has achieved a 99% institutional delivery rate, which means that almost all women are delivering their babies in the hospitals and not at home. Ideally if the mothers are giving birth in the hospital there are less chances of infection and complications during birth which can lead to mortality.
"Yes, institutional deliveries are good but they are not an indicator for the quality of antenatal care that the mother receives," said said Dr Aparna Hegde, founder of ARMMAN, a non-profit working for improvement of maternal and child health. "The entire system is focused on providing emergency care and not preventing the complication by monitoring the mother throughout the pregnancy."
The Dadra and Nagar Haveli health department is seeking to address the problem of twin health challenges of teenage pregnancies and infant mortality through monetary incentives. The department announced in April this year that a woman who has a her first child at the age of 20 or more is eligible to get Rs 10,000. “If the same woman has the next child after a minimum gap of five years, she will get an additional Rs 10,000,” said Dr VK Das, director of health services at Dadra and Nagar Haveli.
"Incentive is a quick-fix and not a long term solution," said Hegde whose non-profit works in both urban and rural areas. "What we also need is behavioural change which is a long term process."
Dadra and Nagar Haveli's monetary incentives are an attempt to plug the gap that lack of contraception use has created. As the official in charge of maternal and child health Gargi Majumdar points out, if a girl starts conceiving when she is 14 or 15, she continues to have children till she crosses her 30s. “It is very challenging for us to convince the mother to undergo sterilization or use temporary methods of contraception," she said. "Their husbands don’t agree.”
Health workers at Dadra and Nagar Haveli sometimes secretly ferry the woman to the hospital to place an intra-uterine device to avoid conception. “Women are willing but men are not so we just take them to the hospital for some other purpose and put the Copper-T,” said the auxiliary nurse midwife. Copper-T is a T shaped intra-uterine device commonly used for spacing between two children.
Last year, health workers were able to convince 28-year-old Kakdi Tokre to get an intra-uterine device. Tokre has seven children. Her eldest daughter is 11-years-old, which means that Tokre had her when she was just 17 years old. “We had four daughters one after another,” said Tokre. “We wanted sons.” Tokre's fifth and sixth children are boys while the youngest is a girl.
Low birth weight and malnutrition
One–year-old Pratik Valve was recently admitted in a sub-district hospital in Khanvel. Valve has severe acute malnutrition and is not growing according to his age.
Severe acute malnutrition is a very low weight for height characterised by visible severe wasting or nutritional oedema and is directly or indirectly responsible for for 35% of deaths among children under five around the world.
The nutrition rehabilitation centre at the hospital has treated 31 babies like Valve with severe acute malnutrition. According to his mother, Kalpana Valve, the boy weighed just 2 kilograms at birth. "He was always very weak. When he could not sit properly, we suspected that there is something wrong with him," she said.
Late to the hospital
Before taking Valve to the Khanvel hospital, his mother had taken him to a faith-healer who branded the child on his chest to “cure” him. Many adivasi residents often seek out faith healers first. “They go to the bhagat first and then when the child deteriorates they tell us to take the child to the hospital,” said an ASHA.
Local health workers have a tough time convincing mothers to take their sick children to the hospital. “Women do most of the work here,” said Majumdar. “They leave their children under the supervision of older relatives or siblings while they are gone to the farm.”
According to paediatrician Dr Prashant Patil, who works at the district hospital, most women with premature babies have hardly taken any rest during pregnancy. “They continue to work in the farm under the scorching heat even when they are heavily pregnant,” said Patil. “When we are expecting complications, we tell them to come to the hospital which they never do. They just disappear and come on the day of labour.”
Patil, who has treated many children from the bordering districts between Maharshtra and Gujarat at the Vinoba Bhave Civil Hospital, observed most of the infant deaths are finally due to septicemia and premature birth. "Till they reach the hospital already 48 to 72 hours have passed and the child is in distress," he said.
But health officials’ focus on social norms as obstacles to good maternal and child health and behavioural change as necessary deflects from the government's responsibility to provide proper nutrition and good healthcare. Nutritional support programmes that focus only on pregnant women rarely provide greater services that the distribution of folic acid tablet.
The Khanvel hospital where Valve was treated was recently refurbished with LCD televisions in the hallways but the nurse attending to Valve did not have a growth chart to trace his improvement. The hospital has a 25-bed neonatal intensive care unit but no neonatologist who is a doctor specialising in treating newborns. The hospital has not been able to find a neonatologist willing to work in the union territory leaving the paediatrician Patil to look after all children including those in intensive care.
This reporting project is made possible partly by funding from the New Venture Fund for Communications project, which receives support from the Bill & Melinda Gates Foundation.