India: Where Pregnant Women are More than Statistics

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When Champa, pregnant with her first child, was diagnosed with malaria, neither she nor her husband knew what to do. So her maternal relatives took her from her marital home in Hatimanda, a tribal village, in the West Singhbhum district of India’s eastern state of Jharkhand, to her natal home in another nearby village. There, as was the local tribal custom, a witch doctor was called upon to cure her. Despite several attempts, Champa remained ill, and was sent back to her current village. A few days later when members of the local women’s self help group spotted her during a meeting, they were alarmed to see her deteriorating health condition. Having been part of participatory learning and action meetings that focused on causes of maternal and neonatal mortality, these women knew that unless they acted quickly, Champa could die. Malaria during pregnancy could lead to hemorrhage causing maternal and neonatal death. Funds were immediately arranged by the women’s group to cover transportation and other costs to rush Champa to the hospital.

This is just one example of why India has recorded a 22 percent reduction in maternal mortality rate (MMR) since 2013, representing a decline from 167 in 2011-2013, to 130 in 2014-2016, according to the latest official figures. This translates to nearly one thousand fewer women dying of pregnancy-related complications per month. Still, lack of information, knowledge, and access to health services in many parts of the country remain, causing an estimated 44,000 women to die annually due to pregnancy-related causes.

For Champa and her child, it was a near miss. They would have become just another statistic had not she been brought to the hospital in time. Timely interventions like hers have also saved the lives of numerous other women enabled by the sharing stories and playing games with picture cards depicting preventive care-seeking measures through participatory learning and action (PLA). These sessions, facilitated by Ekjut, a not-for-profit organization, have enabled women to learn, recognize and prevent the two main causes of maternal and child death: women delaying their need for professional care,  and their inability to find an appropriate healthcare facility.

But today, by translating their newly-found knowledge into action, women have been able to bring about a 20 percent reduction in maternal deaths and a 30 percent reduction in the neonatal deaths in 600 villages encompassing rural Jharkhand and the neighboring state of Odisha, according to an evaluation of Ekjut’s work. Impressed by their approach and its impact, the national government announced its decision in 2016 to use the Ekjut model to bring down maternal and neonatal deaths in eight states. Presently, PLA meetings are being conducted by government frontline workers trained by Ekjut in 40,000 villages, empowering approximately one million women to take charge of their own health.

By using the unique approach of empowering women on maternal and newborn health through a monthly participatory learning and action cycle, during which women first identify, prioritize and analyze local maternal and neonatal health problems, and then develop strategies to address them, they were able to bring about a substantial decline in MMR and NMR. Within three years of launching its PLA intervention in 2005 in 193 villages in three largely tribal contiguous districts of Jharkhand and Odisha, there was a 45 percent reduction in newborn mortality, a 20 percent decline in maternal mortality, and post-partum depression decreased by 57 percent.

“It is the power of stories to engage, stimulate, and challenge that has brought change. The strategy was to share knowledge and not push it down their throats,” says Dr. Prasanta Kishore Tripathy, Secretary and Director of Ekjut. “We wanted to break the culture of silence among marginalized communities who always accept and attribute whatever happens to them to fate. So the meetings are not prescriptive or technical,” he continues, “It is an attempt to make them believe that they too can change things and together they can make change happen.”

This is why Ekjut first chose articulate women from the community to train as facilitators. These facilitators were given responsibility for reaching out to the women in two districts (West Singhbhum and Saraikela) in Jharkhand and in the district of Keonjhar in neighboring state Odisha. According to Dr. Nirmala Nair, co-founder of Ekjut, the reason why this model is so robust is that “it ensures that no mother misses out.”

In fact, the efficacy of the PLA’s contributions to better maternal and neonatal health outcomes was further validated in 2010 and again in 2013 after Lancet, a prestigious medical journal, and the World Health Organization evaluated Ekjut’s work in 600 villages in Jharkhand and Odisha. It affirmed that participatory meetings had decreased neonatal and maternal deaths. “This model has therefore been upgraded to include Power Dialogues (Shakti Varta), currently being used by the Odisha government with women’s groups and civil society facilitators in 15 high risk districts, and through Accredited Social Health Activities (ASHAs) in two states, Jharkhand and Madhya Pradesh” says Shibanand Rath, Ekjut team leader, Odisha.

Further, Ekjut, which received the 2015 WHO Public Health Champion honor for its innovative PLA initiative, is now using its strategy to address gender-based violence. Thus far, the initial findings in Jharkhand, where approximately 40 percent of married women age 15-49 experience some form of domestic violence, have been encouraging. “This is because women are no longer passive recipients here,” adds Dr. Tripathy, “They are the change.”

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