Suman Devi tried to get up from the charpoy but collapsed. Her daughters-in-law were busy with work and the children were playing. Suman Devi reached for a bamboo stick and stood up slowly, balancing her frail figure on it. The 38-year-old is a mother of eight and a grandmother and is pregnant for the 11th time.

Usha Devi is the Accredited Social Health Activist or ASHA in Salarpur village in Bahraich district of Uttar Pradesh where Suman Devi lives. In India’s healthcare system, an ASHA worker is responsible for monitoring the health of pregnant women, giving them free supplements and medicines supplied by the government, ensuring they have four medical check-ups at the nearest hospital and are taken there for delivery.

But Usha Devi did not know of Suman Devi’s pregnancy. She claimed to have misplaced the register that had the names of the village’s pregnant women. “If I knew about her pregnancy, I would have supplied her with the iron folic acid tablets,” she said.

The supplements are given to expectant mothers to prevent maternal anaemia, low birth weight and pre-term birth.

On her part, Suman Devi did not seek out the ASHA worker. Through all her pregnancies, she has never taken any supplements, visited a doctor or had an ultrasound scan to monitor the growth of the foetus. The nearest hospital from Salarpur is 35 km away. She did not know that the Uttar Pradesh government offers a free ambulance service to take pregnant women to hospital for their delivery and bring them back home. She also does not have a mobile phone that she can use to dial the ambulance helpline.

Such a lack of knowledge of the medical facilities available to them is common among women in Uttar Pradesh’s terai region, where districts such as Bahraich and Balrampur have the worst maternal and infant mortality ratios anywhere in India. On average across India, 167 women die during childbirth for every 100,000 live births. In Devi Patan mandal, which includes Bahraich and Balrampur, the maternal mortality ratio is 366 for every 100,000 live births, according to the Annual Health Survey 2012-2013.

The National Family Health Survey 2015-2016 shows that in India, 41 infants out of every 1,000 die within the first year of being born. Uttar Pradesh has the highest infant mortality ratio in the country with 64 newborns dying for every 1,000 live births within a year.

Infant and maternal mortality are linked: undernourished women who have multiple pregnancies give birth to weak babies, leaving both mother and child vulnerable.

What endangers mothers and their babies in Bahraich and Balrampur even more is that these districts have among the lowest indicators for social and economic development in India. They also have very poor health infrastructure.

But this crisis rarely gets attention, except when something drastic happens – such as 30 children dying over two days in August in the region’s largest hospital in Gorakhpur after a disruption in its oxygen supply. While this was a case of negligence, the real challenge lies not in the poor state of hospitals but in the absence of basic healthcare in villages.

This series of reports from eastern Uttar Pradesh’s Terai region takes a closer look at why the government’s efforts to reduce infant mortality are failing. The failure begins with the government’s inability to bring pregnant women into the fold of formal healthcare.

Childbirth and deaths

In October, 49 infants died at the government district hospital in Bahraich. Paediatrician Dr KK Verma said many women have their babies at home, which results in birth asphyxia – in which oxygen supply to the baby’s brain is disrupted, mostly during labour. “By the time they bring the child to the hospital, half the battle is lost,” he said.

All of Suman Devi’s children were born at home, and two of them died immediately after birth. There are no records of their deaths and no one knows why they died. “If children die at home, the family just performs the funeral,” said ASHA worker Usha Devi. “There are so many women and children dying during childbirth but we cannot report all of them. Sometimes, we get to know about it very late.”

According to the National Family Health Survey, 70% of pregnant women in the state do not receive antenatal care (medical care during pregnancy) because they do not visit public health facilities. In Bahraich, only 4% of pregnant women receive antenatal care.

One ASHA, many duties

A major weakness in the Indian healthcare system is its over-reliance on a single worker to administer a variety of services. ASHAs like Usha Devi – the government’s frontline health workers – register pregnant women, ensure institutional deliveries, monitor the health of newborns, distribute condoms and oral contraceptive pills. They also help anganwadi workers and Auxiliary Nurse Midwives discharge their duties, such as identifying malnourished children for nutrition schemes and getting children vaccinated.

“In foreign countries, they have skilled workers who deliver a specific service,” said Dr Yashodhara Pradeep, a senior gynaecologist at the Dr Ram Manohar Lohia Institute of Medical Sciences in Lucknow. “In India, we expect our ASHAs to explain all health concepts, contraception, breastfeeding and immunisation.”

Pradeep contends that an ASHA who is unable to dedicate time and energy to one activity often fails to effectively communicate public health messages to the community she works in.

While their responsibilities are many, ASHA workers are often poorly paid. In May, ASHA workers in the state protested against low wages and delayed payments. While some states pay ASHAs nominal salaries, Uttar Pradesh is one of several that pays these health workers through incentives based on the type of service they provide and the number of cases they handle. For example, an ASHA gets Rs 600 for ensuring a pregnant woman gets all her tetanus vaccine and folic acid doses, has four antenatal check-ups and comes to a hospital to deliver her baby. On the other hand, the incentive for convincing a woman to get sterilisation surgery is Rs 300, and Rs 400 in case of a man.

“Owing to the incentive-based approach, they focus on activities that can get them maximum money,” said Pradeep.

Moreover, the ASHAs are paid for outcomes and not for effort. “Sometimes we try hard to convince mothers to get immunised, go to the hospital for childbirth but they refuse and we don’t get any money for our effort,” said Usha Devi. “So, many ASHAs don’t work too much.”

Usha Devi makes Rs 500 a month on average. Some months, she earns nothing at all.

Then there are times the ASHA manages to persuade women to go to the hospital for check-ups or delivery, only for the health system to let them both down. For instance, the free ambulance service often does not work.

Uttar Pradesh has 2,270 ambulances dedicated to ferrying pregnant women and newborns across 75 districts. Women who want to avail of this service have to dial 102. The ambulance helpline number for all other medical emergencies is 108. There are 1,488 ambulances operational under the 108 helpline. “Even if pregnant women call 108, they will be taken to the hospital,” said Dr PK Shrivastav, who is in charge of the ambulance service in Uttar Pradesh.

Shrivastav said ambulances are sometimes not available because there are too many calls or because there is no cellphone network.

Shrivastav claimed most women in Uttar Pradesh knew about this helpline, but found that many women were not aware that such a facility existed.

Many women also told that they preferred giving birth to their babies at home for even when they managed to get transport to reach the district hospital, they faced corruption and other challenges. “I went to the hospital and the nurse told us she would not touch me unless we paid Rs 200,” said Nagina, adding that her husband Barkat Ali paid the nurse from the money he had saved for clothes for the baby.

Nagina with her children. (Photo: Priyanka Vora)

Hospital officials are aware of the corruption that exists but express helplessness in combatting it. “Even if someone complains, there is no evidence that the hospital staff has demanded or taken money,” said Dr Ghanshyam Singh, chief medical officer of Balrampur. “My headache will only increase [if I fire hospital personnel] because there is already a shortage of staff, so the very little service we are able to provide will also stop.”

Shrivastav admitted the community distrusts the government and the health system, which in turn makes it difficult for ASHA workers to carry out their duries. For instance, Sabrun Begum did not go to the hospital for check-ups during her pregnancy, nor did she take her iron folic acid tablets. “Sarkar ki davai se asar nahi padta,” she said. (The medicines supplied by the government have no effect).

Much of this mistrust once again stems from the fact that an ASHA caters to a large community and is often unable to pay attention to individuals. Each health worker is expected to take care of a population of 1,000 but most ASHAs in Uttar Pradesh cover larger populations. For instance, Usha Devi is responsible for 1,400 people.

Usha Devi’s supervisor, ASHA facilitator Poonam Sharma, said the religion or caste of an ASHA worker also comes into play at times, presenting yet another challenge. “In a Muslim dominated village, it is tough for a Hindu ASHA to convince villagers,” she said.

Left in the lurch?

For pregnant women like Suman Devi, the smooth functioning of the healthcare system can be the difference between life and death. Usha Devi is worried Suman Devi may not survive her 11th pregnancy. “She is too weak,” the ASHA worker said. “Lagta nahin ke iss bar bachegi.”

Suman Devi’s survival depends on the availability of the ambulance service, an operational ultrasound facility close by, and a doctor at the nearest health facility when she goes into labour – none of which is certain. The odds are clearly against her.

Suman Devi is pregnant for the 11th time and has no health support. (Photo: Priyanka Vora)

Graphics by Anand Katakam and Manas Sharma.