In a lively anganwadi or daycare center in Godiguda village, the sight of an auxiliary nurse midwife conducting health check ups for more than 10 women, some pregnant and others lactating, reflected the changing scenario in maternal and child health in the Araku Valley of Andhra Pradesh.

Traditionally, delivery cases are handled by a dhai, an elderly woman from the village or the community. For pregnant women, visiting a medical facility or a doctor is considered going against the norm. This has resulted in high rate of maternal and neonatal mortality in the valley, 35-year-old Malati, who has decided to go for an institutional delivery (done in a formal set up and under medical supervision) for her sixth child, told VillageSquare.in.

Because surgery, contraceptives and an abortion by choice are considered sins against humanity in this society, it is common for families to have up to five-six children in the predominantly tribal region. Adding to the plight of the women is the rough terrain and lack of communication facilities to reach the government primary and community health centers in emergencies.

Awareness the key

“In a predominantly tribal society ruled by stigma and superstitions, influencing behaviour to make these women folks attend regular health check up during pregnancy and opt for institutional delivery was a herculean task,” said Pramila, a girl from the Araku Valley who works as an auxiliary nurse midwife in the Aasara tribal health project of Piramal Swasthya.

Piramal Swasthya works with the government systems to make health services available to tribal communities, particularly pregnant and lactating women and their newborns, in times of need. “Despite being from the local communities, we were threatened initially by a few male members for misleading the pregnant women by suggesting them to go for medical check-up and institutional delivery,” Pramila said.

If the mothers and their newborns were to be saved, bringing awareness on maternal and child health, possible complications during pregnancy and benefits of institutional delivery were essential. This idea drove Pramila and her colleagues like P Padma to reach out to people, trace pregnant mothers and motivate them as well as other family members, such as the husband and elderly members, to avail health services for a safe delivery.

A lactating mother is being checked for blood pressure at the daycare center in Godiguda village in Araku Valley. Photo credit: Basudev Mahapatra
A lactating mother is being checked for blood pressure at the daycare center in Godiguda village in Araku Valley. Photo credit: Basudev Mahapatra

Now, most pregnant women, like Malati of Godiguda and 35-year-old Vasanta of Muliagalagu are not only coming for health checkup and consuming iron folic tablets as well as other nutrient supplementations, but have also decided to go for institutional delivery. “Earlier, we were unaware of the benefits of institutional delivery,” Vasanta said.

Making services accessible

However, accessing public health facilities was an issue for most hamlets. One had to walk miles through rough terrain to reach a paved road and get an ambulance to a health center. The time required to reach a hospital always remained crucial to pregnant mothers.

In order to make the facility reach people in need, a mobile hospital service with all facilities to handle a delivery case has been started under the Aasara project. “Many pregnant mothers from remote hamlets who were at the last stage have delivered their babies in the mobile hospital vans,” T. Swarnalatha, program manager of the project, told VillageSquare.in.

While the ANMs visit every hamlet to attend the pregnant mothers, the telemedicine centers with necessary equipment, nurses and a doctor work as the points for periodical health checkup, necessary treatment and expert consultation through teleconferencing. Mothers diagnosed with diseases that need further treatment are referred to government health care centers or district hospitals.

“Most mothers come with anemia and diseases like malaria and hypertension,” said medical doctor Sanmukha Reddy of Dumbriguda telemedicine center.

Nutrition-related challenges

As is the case with tribal communities of India, “anemia is most common among pregnant mothers and children of the Araku valley,” nutritionist Sweta Kuralla of Nandivalasa nutrition hub, a center under the Gosthani project to deal with nutrition-related issues, told VillageSquare.in.

About 88.9% of adolescent girls are anemic, 17.8% being severely anemic. Highest prevalence was seen in the age group of 12-13 and 14-15 years that is 85% and 86.5% respectively, says a study on anemia among adolescent girls in the tribal areas of Visakhapatnam district in Andhra Pradesh.

According to National Family Health Survey 2015-16 (NFHS-4), 60% of women in Andhra Pradesh have anemia. Malnutrition being particularly common in the younger age groups of the scheduled tribes, 59% of children between the ages of 6 and 59 months are anemic. Girls are more likely than boys to have anemia.

While tribal mothers have high rates of anemia, and girl children receive less than the desired nutritional intake. All told, the whole tribal community is deficient in adequate food intake, says a report on reproductive health status, issues and concerns of tribal women.

Nutrition hubs

The nutrition hubs work to address the issue of undernourishment among pregnant women and children. Apart from advising them to take iron folic acid tablets during pregnancy, as provided by the government, “mothers are told to consume variety of vegetables, leaves and ragi in different forms for adequate micro-nutrient supplementation,” Kuralla said. “The nutrition hub trains the community on how to grow leaves and vegetables and prepare different types of foods for better nutrition.”

After years of efforts, “during pregnancy, women are now taking iron folic tablets,” said Golleri Lakshmi, the accredited social health activist or ASHA worker at Godiguda village.

However, there are many issues to be overcome for sustainability of the changes that have come after the interventions.

Child marriage

The primary social issue in the valley is child marriage. As per National Family Health Survey-4 data, in rural Visakhapatnam, 34% of women between 20-24 years of age married before 18, and at least 10.5% of women between 15-19 years of age have either become pregnant or become new mothers.

The scale of child marriage and early motherhood could be higher in tribal population. At least three in every five marriages involve brides below 18 years of age. “Normally girls in the communities marry after 14 years of age,” said B Abhiman, a political worker in the valley.

The mobile van that works as occasional hospital for tribal mothers. Photo credit: Basudev Mahapatra
The mobile van that works as occasional hospital for tribal mothers. Photo credit: Basudev Mahapatra

It is established that girls aged 15-19 are twice as likely to die in childbirth than women in their 20s, and girls under 18 face a higher risk of pregnancy-related injuries such as fistula. Infants born to early adolescent mothers have a three-fold higher risk of post-neonatal death compared with adult mothers, studies found.

Need for education

Promotion of education among girls of tribal communities can address the issue and minimize the risk of child marriage and early pregnancy, says the UN report “The Girl Child”. In Visakhapatnam, female literacy in the tribal population has remained 34.67% only, according to the statistical abstract of Andhra Pradesh government. Rate of girls completing 10 or 12 years of education is abysmally low.

In regard to nutritional status of newborns, it is believed that the newborn must not be fed with the first milk of the mother, which deprives the child from highly nutritious colostrum and the antibodies the first milk contains. Apart from this, the tribal people of the valley do not consume cow milk, believing that it’s for the calves only.

Encouraging outcomes

Changing customary and normative beliefs and practices take time, said Vishal Phanse, Chief Executive Officer of Piramal Swasthya. “However, through the interventions so far in coherence with the government and district administration and by making use of technology for social good and development in public health sector, maternal mortality rate in all registered cases in the valley has come down to zero,” said Phanse.

This is despite the fact that Visakhapatnam district has a maternal mortality rate of 115 per 100,000 registered live births. “Our focus is now on improving the status of health of adolescent girls,” he added.

Once restricted to their communities, pregnant tribal women are now showing interest in medical check-up, taking medicines and nutritional supplements, and in institutional delivery for their own safety and the health of the child, Vasanta, a pregnant mother of Muliaguda village said.

“Covering 181 villages under the Aasara project, we deal with 250-300 cases of pregnant mothers almost every time,” said T Swarnalatha, the programme manager.

Changing scenario

Overall, the scenario is changing. Women have understood the benefits of modern healthcare facilities. As the women and others in the communities are changing their minds, the government mechanism has also become active to respond to health related issues of women, B Abhiman said.

“Tribal women in the valley have become conscious about their health during pregnancy, a safe delivery and the health of their babies,” Sanmukha Reddy said.

Other than the issues like child marriage, education of girls and normative beliefs left to be addressed through a holistic approach to make the impacts sustainable, results of intervention in the arena of maternal health and nutrition in Araku valley have no doubt made it a model for wider replication across tribal India.

This article first appeared on Village Square.