July 11, 2017

Over Population- Myths and Facts #WorldPopulationDay

by National Alliance for Maternal Health and Human Rights

The World Population Day is celebrated every year on the 11th of July as a result of a UN Resolution in 1990 seeking to enhance awareness of population issues, including their relations to the environment and development. In India the World Population Day has more often than not been an occasion to highlight the ‘overpopulation’ in the country with a focus on the total number of people living in India and that this number is ‘too much’. This year this focus on overpopulation has been reinforced by a new group of concerned citizens called TAXAB or the Taxpayers Association of Bharat who are calling for a new population control law under the hashtag #Bharat4PopulationLaw.

The overall logic of this campaign is two-fold – the first part argues that as tax-payers of India we should be concerned about the misuse of our taxes by the system towards the development of Bharat. The second part explains the nature of the misuse which manifests as lack of good roads, joblessness, increasing poverty, lack of good food, clean air etc. And this lack of good infrastructure and facilities as well as pollution is due to increasing population – primarily among the BPL.

In quick strokes it creates a division between the tax-payer who is being short-changed by the poor who are growing in numbers, and secondly it attributes all the ills of the country to growing population, though it first argues that there is mismanagement by the system. The problems in the country are there for all to experience, and urban overcrowding is a phenomenon nearly all taxpayers are facing daily – so the logic is bound to be extremely attractive.

However this entire argument is based on myths.

The population growth rate in India is not growing but instead has been slowing for the last few decades. From a high of 2.3 percent per year in the 1970’s and 80’s it is now down to 1.2% per year. At the level of the family the Total Fertility Rate or number of children a woman has in her life has reduced from 5 in the 1970’s to 2.2 in 2015-16. The total wanted fertility is below 2 but women do not receive the contraceptive services that they want. The population growth rate is a function of birth, death and migration. In India, the birth rates are still a little high, but not because women are having more babies but because the number of young couples in India is higher than ever before. And this large number of young couples even when they have fewer babies each, the total adds up. This will come down as the babies born in the heydays of population growth and their children become older. In other words there is not much we can do to reduce their reproductive rate other than provide them with spacing methods. Now understand the various problems that have been attributed to population growth. India was a poor country in 1947 when India became independent, now it is no longer a poor country.
By expert estimates the GDP growth between 1951 and 2011 was over 20 times and food grain output grew by over 4 times while population grew by a little over 3 times in the same period. Clearly the total amount of food or income available per head has grown but poverty seem to be all around us. The TAXAB campaign has highlighted the bad state of roads and infrastructure as a result of overpopulation, highlighting the poor state of infrastructure in cities. This overcrowding of Indian cities is not a result of overpopulation but migration from villages to cities. This migration is often as a result of rural distress, and lack of employment opportunities which is highlighted by the continuing news of farmer suicides from across the country.
The TAXAB campaign also makes reference to pollution in the name of ‘shudh’ and ‘ashudh’ food, water and air. Pollution in India is undeniable, but is overpopulation the cause behind it as the #Bharat4PopulationLaw seems to imply? Pollution is most often contributed by the burning of fossil fuels, either for transportation or for factories or for generating electricity which then powers our air conditioners, or factories. We need to understand that the poor, who are a much larger proportion of the population, require very little fossil fuel generated energy. Their requirements for water too are very little. Research shows that the richer countries and the rich in countries like ours consume 20 – 30 times more energy in their whole lifetimes than the poor. Here if the population of people is to be seen as a problem, it is the fewer rich who pose much more problems for the absolute consumption of resources as well as the contribution to pollution.

The overall logic of the #Bharat4PopulationLaw campaign seems to imply that the taxpayers need to be worried because not much has happened through their taxes in the last seventy years. And this is where the campaign organisers have been completely misled. While overcrowding is a fact, it does not indicate a failure of contraceptive related practices among the people. Overall contraceptive usage rates have increased from 13% in the 1970’s to over 56% now. Infant mortality rate, or number of children who die before reaching the age of one year has reduced from over 130 per 1000 children to 41 now.
Overall life expectancy has also increased from less than 40 years at the time of independence to over 64 years now. More people are living, less people are dying, fewer children are being born but more people are crowding to cities where there is inadequate infrastructure, few job opportunities and we see more poor people in our streets.
A population control law is not the solution to the problems that have been indicated by TAXAB. A population control law as we have seen in China will lead to further decline in the number of girls in the country, a problem that our society is already facing. It will lead to reducing opportunities for the poor, and marginalized, including the dalits, as such laws deny benefits to those with more children. Data shows the poor have more children, but not because they want it, but because they don’t receive the appropriate services.
Women bear the disproportionate burden of population control laws, as they bear children and can be faced with repeated abortions or even desertion as men take desperate measures to keep their family size small and qualify for positions for which they can become disqualified. Yes we need changes in policies and the way they are implemented to address the issues that TAXAB has highlighted but the approach is misplaced. . The problem lies not in the population related policies but in economic policies which have not focused adequately on health or education or economic opportunities for the poor.
Yes tax-payers need to rise up and make demands from our government to increase the investment of healthcare so that not only the poor but we all are healthier and more capable, without become penurious due to healthcare costs.
We need to make demands to increase the quality of standards of the government schools so that children educated there are more empowered, and we are all confident enough to send our children to these schools rather than the very expensive private schools that are coming up every day.
Our family planning programme needs to be reoriented towards the needs of younger couples through increased availability of spacing methods. Men need to involved in discussions around family planning.
And last but not the least we need to ensure all young people have adequate knowledge and information about their bodies, and reproductive health which enables them to take decisions that will enable them to live healthy and productive lives.

NAMHHR is an  Alliance of  members from 14 states of India, as well as expert advisors working with research, Right to Food, public health, right to medicines and budget accountability.
Dr Abhijit Das, NAMHHR Convenor

April 26, 2017

Assam – NAMHHR submits comments on the Draft Population Policy

Mr Samir K Sinha,
Commissioner and Secretary to the Government of Assam,
Health and Family Welfare Department,
Government of Assam.
Date 25th April 2017

This is with reference to the Draft State Population Policy Assam which has been put up for comments. We would like to make the following observations:
1.       In the Introduction Section we would like to endorse the inclusion of the following as issues of key concerns – promotion of inclusive growth, ageing, urbanization, migration, financial and economic challenges, improving the quality of life of present and future generations, promote social justice and eradicate poverty and so on.
2.       We endorse the context of the National Population Policy 2000 with its focus on Socio Demographic Goals
3.       We would however like to draw your attention to the assertion that the population of Assam has grown by ‘almost 1 crore’ between 2001 and 2011. According to the figures given in the document the population has grown from 2.66 crore to 3.12 or 46 lakh or less than 50% of 1 crore and it is a gross exaggeration  The percentage growth of Assam’s population has been declining consistently from 35% and 36% decadal growth in the 1970’s and 1980’s to 17% now. This decline is more than the decline that has taken place at the National Level.
4.       The decline of Total Fertility Rate in Assam has been from 3.53 in 1992 -93 to 2.3 now which is a 35 % decline in a little over 20 years. There is also an unmet need for contraceptive (10%) which if met would bring down the TFR by a further.2 to 2.1 the desired level of fertility.
5.       We would like to bring to your notice that the reduction in TFR to 2.1 will not immediately reduce the population growth rate to stabilization levels because of ‘Population Momentum’. Population Momentum will continue for nearly 20 years or more because as population growth comes down from high population growth rates, the proportion of reproducing couples increases due to earlier high growth rates and lower mortality among children. Thus the population growth rate continues to be high as higher number of couples now have fewer children compared to the earlier situation of fewer couples having more children.
6.       We also endorse 10 of the 11 Targets of the Policy and would like to draw your attention to the last target – “Encouraging the Two family norm to substantially reduce TFR”. The two family or two child norm which is aimed at encouraging family size reduction through peer pressure has not been found to be successful in India since it was introduced in the Panchayati Raj acts in some states 1990’s. Some states have even withdrawn it. Some of the adverse effects of the two child norm that has been identified and studied through research are as follows:
a.       It tends to penalize women compared to men, because when faced with the option between a job or local leadership, women have to give up their aspirations and have the child, while men go ahead with their option compelling women to have an abortion
b.      It tends to penalize younger people compared to older people because the two child norm applies to children born after a particular date. It does not penalize older people with three four five or more children born before the cut-off date. This is particularly discriminatory because India is a country of young people.
c.       It tends to penalize poor and marginalized communities because the poor and marginalized usually have more children. This is not because they ‘want’ more children but because infant mortality figures are higher in poorer communities, and they are also further away health services. The data provided in the section Assam: The Development and Demographic Challenge, indicates the diversity in the state and how this affects some of the marginalized communities. This a two child norm will vitiate against the ‘inclusive growth’ agenda of the population policy.
d.      The two child norm has also been shown to be against child rights because people with more than two children often hide their third child or give it away for adoption. In such a situation the child is often denied even basic services like immunization. In other cases the third child often gets excluded from development benefits which are intended to ‘punish’ the parents. We must realize that the third or subsequent child has no role in the decision to be born and to deny it any benefits essential for its survival and well-being would be a child rights and human rights violation.
e.      Assam is one of the few states in the country with a ‘healthy’ sex ratio including the juvenile or child sex ratio. However the child sex ratio did show a small decline  of three points between 2001 and 2011 which should alert planners. A two child norm has severe implications for the child sex ratio of the state. In the presence of gender discrimination and son preference when faced with a two child norm families adopt sex selective practices and while it is okay for them to have two boys, one boy and one one girl or one boy, families do not prefer 2 daughters or one daughter. This creates a further pressure on the sex ratio of children. In China a similar one-child has led to a drastic reduction in the ratio of girls and women in the population
f.        We would like to point out that states like point out that states like Haryana, Himachal Pradesh and Madhya Pradesh repealed the two child norm from their Panchayati Raj Acts, and state like UP and Bihar considered the two child norm but finally did not implement it because of the various adverse outcomes associated with this act. China too has relaxed its one  child policy.
7.       We would also like to point out the essential difference between a restriction through a laws like minimum age at marriage and two child related restrictions. Restricting child marriage prevents young girls (and boys) from being exposed to reproductive responsibilities and possible sexual violence before they are capable to being either able to decide for themselves or before their bodies are mature. It is a restriction meant to protect the vulnerable. A two child norm on the other hand has been seen to systematically disadvantage the vulnerable. Since the Population Policy is intended to primarily support and help vulnerable population including children, women, elderly and the poor the two child norm is a totally in appropriate measure.
We do hope you will take these facts into considerations and revise the draft Population Policy accordingly,


National Alliance for Maternal Health and Human Rights (NAMHHR)
Dr. Abhijit Das, Centre for Health & Social Justice, New Delhi
Vasvi Kiro, Torang  Trust, Jharkhand
Kalyani Meena, Prerna Bharti, Jharkhand
Jeevan Krushna Behera, SODA, Odisha
Vivekanand Ojha, Health Watch Forum, Bihar
Smriti Shukla, Maternal Health and Rights Campaign, MP
Adv. Kamayani Bali Mahabal, Maharashtra
Sandhya YK,  Sahayog, UP
 Sandhya Gautam, from NAMHHR Secretariat

1.       Article: Victimising the Vulnerable in Economic and Political Weekly by DrLeelaVisaria and colleagues
2.       Article: Victims of Coercion: in The Frontline by T.K. Rajlakshmi
3.       Press clipping: HP plans to delete two-child norm from Panchayat eligibility Indian Express
4.       Press Note: Two Child norm for contesting elections to be abolished MP Government website
5.       Debate on Two child norm in the Parliament on 10.03.2006 – RajyaSabha proceedings

December 21, 2016

People’s Convention on Maternal and Reproductive Health Rights
Organized by NAMHHR, CommonHealth, Scavengers Dignity Forum & Dalit Alliances, Wada Na Todo Abhiyan, Jan Swasthya Abhiyan

Click here for More pictures
Over the past 10 years, maternal and child health has taken centre stage in health policies and programmes in India. In order to tackle high rates of maternal and neonatal mortality, the government of India has taken various measures to incentivize institutional deliveries, strengthen health systems, increase allocations, remove financial barriers, improve immunization coverage, and implement regular tracking systems. In this time, India has apparently experienced a decline in its maternal mortality ratio (MMR) from 301 (in 2006) to (178 in 2013) maternal deaths per 100,000 live births, however, these numbers are likely highly under-reported. Similarly Neonatal and Infant Mortality continues to be a serious challenge for India. Although rates of mortality have dropped over the past three decades, one fourth of all deaths of children under six years of age, occur in India. According to UNICEF, 1.34 million children aged under five, 1.05 million infants, and 0.748 million newborns die every year in India. Even going by conservative estimates, about 45,000 women die due to childbirth every year in India, and most of these deaths are preventable. The rates of decline of MMR vary widely between different states with 12% of global maternal deaths occurring within nine states of northern and eastern India. Although institutional delivery coverage has increased over the years, this in itself has been insufficient to reduce MMR. Critical issues such as quality of antenatal and post natal care, risk identification, availability of emergency obstetric care, behavior of staff during delivery, availability of abortion and contraceptive services, continue to be a challenge. Survey data shows that out-of-pocket expenses for poor families have not reduced, despite the efforts to reduce financial barriers. Moreover, the government of India is pushing for privatization of in various modes such as contracting out services via Public Private Partnerships, for which there is no evidence of increased equity, but on the contrary they have been known to encourage unscrupulous practices.

Why Should Other Social Movements Care about Maternal and Infant Mortality

The issue of maternal and reproductive morbidity and mortality is intersectional in that social location plays a role in determining outcomes for women and children, and social determinants such as access to nutrition, sanitation and poverty also strongly influence health. The biggest burden of maternal and infant mortality falls on women from marginalized communities and the poor. The latest available national level survey data – the NFHS3 (2005-6) shows disparities in women’s access to maternal health services – women belonging to scheduled castes and tribes are less likely to receive antenatal care and skilled birth attendance. UNICEF also notes that there are gross disparities in mortality indicators with Scheduled Castes, Scheduled Tribes and minorities having a higher IMR and U5MR. Further, there are specific problems faced by women belonging to marginalized communities – such as abusive behavior, neglect and culturally inappropriate services. Despite overwhelming evidence that there are disparities in maternal health indicators, the government of India does not publish disaggregated data on these. In fact datasets from three rounds of the annual health survey which were conducted in high-focus states with the express purpose of contributing to meaningful tracking of progress towards improved health status have not been released and any kind of disaggregated analysis is rendered impossible. Although maternal death reviews are meant to fix accountability, they are not being conducted in many cases and the findings are also not made public. Thus there is a situation of prevailing silence around issues of equity and accountability, suggesting that it is a problem that is being wished away rather than tackled. In this situation it is critical that civil society actors raise the issue in a concerted manner and facilitated a grassroots demand for accountability.

The Need for A People’s Convention:

Over the course of the Millennium Development Goals, indigenous civil society organizations have continuously dialogued with the state to influence its “input” – i.e. policy and program design, to make it responsive and relevant to women’s realities. Coalitions like NAMHHR and CommonHealth have systematically documented maternal health rights violations in the field and repeatedly held policy dialogues at the national level, to impress upon policy makers the need for rethinking their approach to address emerging issues. The policy dialogues have received attention from policy makers and elected representatives, however there is a need to complement this with mobilization and dialogue with the system, closer to the grassroots to demand accountability for maternal and child health services. It is critical to make maternal and child health a core concern of communities, especially marginalized communities, and grassroots movements that represent them.
Building on these experiences, we perceive the need for greater synergy among groups working at the grassroots level, to generate a nationwide campaign to demand maternal and child health rights. Not limiting ourselves to health rights groups, a wider alliance of political groups (especially those representing marginalized communities, including dalit rights groups, minority rights groups, disability rights groups, groups working on other social rights such as right to food) must be built so that the agenda of maternal health is owned by us collectively. The Sustainable Development Goals, several of which address reproductive and child health, are meant to guide the government of India’s future policy and programmatic priorities and for which India will be held accountable at international forums; these can become a rallying point around which communities can be mobilized to demand for better maternal and reproductive health services, building on such mobilization that has already begun through networks such as the Wada Na Todo Abhiyan.

As a first step towards building such an alliance, we propose to host a 2-day “People’s Convention on Maternal and Child Health Rights” in Delhi in mid-December. This convention would bring together organizations and movements working on various issues and across different states, to amplify voices of their constituencies at the national level and develop a common and synergistic agenda for a grassroots campaign in the future.
The objectives of the convention will be as follows:
1 – To understand the issues of maternal and reproductive health and its determinants from the life experiences and field realities of diverse marginalized groups
2 – To explore synergy between various field-based and issue-based groups and campaigns to generate a nation-wide collaborative accountability agenda to address preventable maternal and reproductive morbidity and mortality
3- To strengthen the conversation between rights groups working at the national and sub-national level, and build intersectional cross-movement alliances to address maternal and reproductive health
The 2-day Convention will bring together approximately 100 participants from across the country, who are advocating for the rights of women and would be interested in taking on board the issue of maternal and child health in their mobilization. These include grass root organizations, movements and Networks like Right To Food Campaign, Bebaak Collective, other groups working on Tribal’s Rights, Right to Education, LGBTQ rights, minority rights, land rights and Rights of Single Women (Ekal Nari Shakti Sangathan).
Dates: 16- 17 December
Venue: Indian Social Institute, New Delhi

September 26, 2016

Chronicles of Deaths Foretold: Part 2 - Policy recommendations

Data from the health ministry shows that only 42% of maternal deaths are being reported. Out of them 67% are institutional deliveries. Nearly 20% of women are dying during transit.
Experiences from the field indicate the same.

“We have 120 medical colleges, only 55 are reporting maternal deaths to us. We have sensitized them, but it is not picking up,” saidDr. Veena Dhawan from the Ministry of Health and Family Welfare.
She listed many initiatives of the government to reduce maternal deaths. “But the implementation lies in the hands of the State governments. We can only make policies at the Centre,” she said.  
The report was presented to Dr. Veena Dhawan, assistant commissioner, maternal health, Ministry of Health and Family Welfare and Dr. Prasanth of National Health System Resource Centre.


In the two-day consultation, organized during the release of report “Chronicles of Deaths Foretold,” activists strongly demanded accountability for lapses when a woman dies. They said that there should be enquiry into maternal deaths, responsibility fixed and culprits punished. When there are protocols, then someone should be punished if they are not followed and lead to deaths.

Based on the report and the consultation on maternal health, the civil society organizations came up with recommendations. Five suggestion that NAMHHR believes have to be implemented immediately are:
  1. Ante-natal check-up (ANC) must identify high-risk cases – use RED FLAG to signify a high risk for all providers
  2. EMERGENCY HELP DESK in all facilities used by ‘populations at risk’ with compounded vulnerabilities
  3. Develop Adverse Outcome Management protocols, monitor use in HPDs
  4. Blood storage at all FRUs; in emergency situations, no donor requirement
  5. Free REFERRAL transport to tertiary facilities with paramedic (EMT)- even if across state border; a simple PHONE CALL to next facility  
The 10 medium-term recommendations are
  1. System of using MCTS information to prevent/prepare for any adverse outcomes
  2. Skill training of all nurses and ANMs in safe childbirth, including ANMs in sub-centres/community
  3. Adequate  nurse/ANM posts & appointments according to case-load
  4. Ensuring visits to each CHC by a Gynaecologist at least once every 15 days
  5. Ensuring  essential drugs for maternal survival are available, and using generics
  6. Providing Iron-sucrose injections for very anaemic women at CHC/PHC
  7. Strong feedback loops for JSSK, with User participation
  8. Acknowledgement and Regulation of the private sector  including informal providers
  9. Stronger monitoring of data based on AHS estimates; counting numbers of anaemic women, checking maternal death reports and doing CB-MDR with CSO support
  10. Involvement of PRIs in identification of maternal deaths, process of death review & community awareness
  11. Free hearse service for bereaved families
Dr. Abhijit Das, director, Centre for Health and Social Justice, said that the government should create a feedback mechanism from community experience. We can use ICT for a platform through which every citizen can provide their experience. It will be anonymous but will have important indicators like geographical area and facility where the person was treated. This can further be consolidated and feedback sent to specific facilities for their improvement.

“We do not need new schemes and announcements. We need to ensure implementation of what already exists. We need to hold people accountable when they do not implement policies,” said Renu Khanna from Sahaj, Gujarat.
Jashodhara Dasgupta from Sahayog, nodal organization that prepared the report, said that an overhaul of the current system is the need of the hour. “Our evidence through the report shows that the current way of working has not produced results. The model of JSY+ ASHA+ EmOC/JSSK has not worked, especially in marginalised areas and communities. We have rethink and look beyond the existing system”.

Sterilisation judgment: Beginning of a longer battle to reorient family planning programme

-- By Maya Palit
In April 2012, Salamuni and her husband, a rickshaw puller based in Bundelkhand, visited a hospital in Chitrakoot. She was pregnant and ill, and they assumed she would get better medical treatment there. The doctor on call, Ranjana Sharma, was aggressive in her attempts to convince Salamuni to have a sterilisation operation. Despite Salamuni insisting that she was too weak, Sharma made her sign a document, gave her an injection, and initiated an abortion as well as sterilisation before the anaesthesia kicked in. According to Salamuni’s account, the doctor spent three hours pumping air into her to locate the nerve, and when she screamed from the pain, the sari she was wearing was stuffed in her mouth before she lost consciousness. She had to spend eight days recovering at a hospital in Allahabad after the ordeal because the bleeding wouldn’t stop, she told activists from Sahayog, a women’s reproductive health advocacy group.
Salamuni’s case was an extreme version of the scores of botched sterilisation jobs that are frighteningly common in India. Earlier this year, the central government reported 113 deaths caused by tubectomy surgeries in the last year, but several women’s health activists have rejected this as a conservative estimate, and the National Alliance on Maternal Health and Human Rights (NAMHHR) suggested during a press conference last Friday that approximately 1,000 of the 4 to 5 million women who undergo sterilisation die every year. This has been attributed to the appalling conditions under which the abdominal operation is conducted – often in dharamshalas, under torchlight at night, sometimes with very poor hygiene and unsanitary tools like bicycle pumps and rusty scalpels.
The particularly horrific case of the 18 women who died in 2014 after contracting septicemia and other complications in a sterilisation camp in Bilaspur, Chhattisgarh is now widely known. RK Gupta, the doctor who operated on 83 of those women over five hours was briefly put in police custody but then released because of insufficient evidence. The news that in the same year he had been rewarded for his ‘record’ career of 50,000 surgeries only epitomises the target-obsessed mentality of the Family Planning programme.
It was the gory details of a similar incident that took place four years ago — when 53 Dalit and Scheduled Caste women were operated on at night in a government school in Araria, Bihar — that convinced the Supreme Court last week to direct the Centre to end sterilisation camps across the country, acting on a petition filed in 2012 by health rights activist Devika Biswas. Activists working on maternal health and human rights have since organised meetings to discuss the implications of the judgment. While they welcomed the decision, they were not optimistic about the 3-year transition period which the Court provided the Centre, and said that until an actual blueprint is written out to end these mass camps, it is difficult to say what impact the judgement will have.
Kavita Krishnan, Secretary of the All India Progressive Women’s Association and member of the CPM pointed out at the conference that the family planning debate is still very much centred on tackling population control rather than focusing on women’s reproductive rights: "The question [should not be] about which is the next best technological fix in contraception but about what actions will empower women to gain control over their bodies, and encourage men to take responsibility for contraception," she said. Unfortunately, the focus on population control has governed family planning since the late 80s, ever since the Pomeroy method of tubal ligation through laparoscopy made abdominal operations easier to conduct. And as Deepa Dhanraj’s 1991 film Something Like A War shows, doctors had begun conducting them in unsanitary situations early on: “I spend 45 seconds per operation. I have conducted 3,13,939 operations, this year, more than two thousand in schools and government halls…” says one gynaecologist in the film.
Abhijit Das, co-founder of Healthwatch Forum and a trained doctor working at the Centre for Health and Social Justice in Delhi, added that paranoia about the population explosion has been so deeply ingrained in the public mindset that the government feels justified in its search for quick-fix solutions. The alternative, he says, is aiming for population growth to be spread over years: “India has a very young population. What you want is for reproduction to take place over time, rather than people having many babies and getting sterilised at 24. Sterilisation should also happen later because it has been associated with high regret and hysterectomy rates.”
One of the most crucial questions that was raised at the NAMHHR conference concerned the (lack of) temporary contraceptive and alternatives in the family planning programme. The post-partum intra-uterine contraceptive device (PPIUCD) is another measure that has been gaining popularity. Rajdev Chaturvedi, from the Gramin Punarnirman Sansthan in Azamgarh, Uttar Pradesh, spoke about increasing cases of the device being inserted without women’s consent or knowledge after they give birth. He was also skeptical about the impact of the judgment, claiming that the real change would involve the improvement of access to counselling for women regarding contraception, as at the moment they are targeted while they are vulnerable and in pain during deliveries.
Jashodhara Dasgupta, a coordinator of Sahayog who also works with Healthwatch Forum, UP, emphasised the importance of expanding the objectives of family planning to include a variety of contraceptives so that women can make “informed choices”. These include measures for those who find the PPIUCD invasive or adolescents at the start of their sexual lives, for whom sterilisation is entirely unnecessary. “The government has put off a long-term vision that encompasses the diversity of people’s needs for so long,” she said.
But the reason that non-consensual sterilisation is so rampant in the first place is because doctors are given annual (unofficial) targets or ELAs (Expected Levels of Achievement) to fulfil. Although the recent Supreme Court judgement directs the government against encouraging “incentivised consent” or setting even informal targets for health workers, this may well conflict with India’s commitment to providing contraceptive services to 48 million additional users as part of its family planning goals for 2020. And as of last year, more than 80 percent of the annual family planning budget was spent on promoting sterilisation. Even though the most recent National Family Health Survey statistics suggest that female sterilisation has decreased overall in many states in the last decade, in states like Andhra Pradesh, as many as 68.3 percent of women across rural and urban areas have undergone sterilisation — it doesn’t look like a problem that can be completely eradicated right away.
It remains to be seen, then, whether this judgement will be the beginning of a much longer battle to reorient the family planning programme.
The Ladies Finger (TLF) is a leading online women’s magazine delivering fresh and witty perspectives on politics, culture, health, sex, work and everything in between.

September 23, 2016

Chronicles of Deaths Foretold:Part 1 - Experiences from the field

Sunita Devi (name changed) breathed last in a district hospital in Godda district of Jharkhand while delivering her baby. Devi was 28 year-old and died due to absence of blood in the hospital. She was already delayed in reaching the hospital as her family took time in arranging money for the ambulance.

The family had to mourn two deaths as her child too was still born. The family also had a debt of Rs 15,000 by the end of entire affair.

“Such experiences discourage people from going back to the public health system. If a woman delivers her first child in a health facility, she resists going through the same experience for future deliveries,” said Jiban, an activist from Odisha.

Devi’s story is one of the 20 from Jharkhand that have been documented in the report “Chronicles of Deaths Foretold,” released 19th August, 2016 in Delhi. Like her, most of the women died of heavy bleeding. Either there was no provision of blood in the hospital, or they were asked to pay a hefty sum of Rs 2000-3000 per bottle. By the time families from economically weaker sections arranged for the money, women were dead.

Prepared by the National Alliance for Maternal Health and Human Rights (NAMHHR), the report documents in details the events that led to 139 maternal deaths in seven districts of four states of India – Jharkhand, Odisha, Uttar Pradesh and West Bengal. All these women are from marginalised communities. Study areas like Godda in Jharkhand or Mayurbhanj in Orissa are tribal dominated, Murshidabad and Malda and West Bengal have poor Muslim populations whilst in Azamgarh, Banda and Mirzapur in Uttar Pradesh, most women who died were from either Dalit or OBC or Muslim backgrounds.

The aim of the report was not to look at medical reasons of death – which are usually recorded as heart attacks. The aim was to find causes that led to delays in their treatment that ultimately resulted in their deaths.

The narratives show that women are going to health facilities, but the health facilities are not equipped to handle emergency cases, leading to colossal number of deaths. This situation is different than what existed a decade ago when pregnant women were seen as not seeking services of a health facility.

Lack of blood transfusion facility, disruptive ambulance services, lack of empathy from staff and unavailability of doctors are reversing the trend, as is evident from data on Janani Suraksha Yojana.

According to an analysis by Centre for Budget and Governance Accountability (CBGA), there has been a steep decline in JSY beneficiaries in the last five years. Devi’s home-state saw a decline of as much as 35.4% from 2010-11 to 2014-15. While in 2010-11, JSY was used by 386354 for pregnancy related services, by 2014-15, only 249455 women were using it. Women in other states are also rejecting the model.  In West Bengal, the decrease has been of 37.1%, in Odisha 6.6% and in Uttar Pradesh it has been 0.7%.

Experiences from the field, as captured by the report, show that public health facilities are equipped to deal only with routine check-ups and deliveries. They are unable to manage emergency situations. To begin with, high-risk women are not even picked up by the health system to take care of during delivery. Devi was aneamic and weak. Her weight was lower than required of a pregnant woman. She had delivered five children before. All these were clear signs of her being high risk. But still, not only the health system did not register her as someone who needs special attention, but could not treat her when she reached the district hospital, with meager support from neighbouring primary health centre (PHC)and Community Health Centre (CHC).

Devi died of heavy bleeding. The child had probably died even before reaching the hospital

In another case in UP, a woman was referred to a CHC by the PHC. The nurse at CHC realised that she needed to be taken to District Hospital (DH). But the woman had to wait till next morning for the doctor to arrive for referral to the DH. By the time doctor at CHC arrived, she had died, leaving her unborn child also dead.

“These are common stories in Azamgarh in UP. Government officials keep saying that there are no maternal deaths, but our experience and data show otherwise,” said Rajdev, who conducted the study in Azamgarh, UP. He was speaking at the national consultation organized during the launch of the report.

Health activists and experts showed their frustration saying that things have not moved in the right direction despite presence of so many schemes, programmes and incentives.

“It is the government’s duty to conduct maternal death reviews (MDR). As civil society, we can only tell them “how to,” said Abhijit Das, director, Centre for Health and Social Justice.

The government is not regular in conducting MDR. Even when it does, data is not made public. There is no analysis based on the reviews to improve or change the situation.

“We need to realize that a pregnancy is not a disease. It is something that can be managed and we all know it is simple. Unfortunately, in the lack of political will, saving women has emerged as a big public health issue,” said senior journalist T K Rajalakshmi, who works with fortnightly Frontline.

Jashodhara Dasgupta from Sahayog, the nodal organization which conducted the study, said, “The report is titled such because the formula of institutional delivery has not worked. Women reached the hospital as soon as they realised that they need care, but the hospitals failed them as they were not ready with the required facilities. Thus, scripts of their deaths were written while drafting policy and their deaths were foretold."

The report also shows that Janani Shishu Suraksha Karyakram (JSSK) --  entitlement to free maternal health services -- does not work at the point of delivery. Violations have been reported from every state from where the case studies have been collected. Often women’s families have had to arrange money for ambulance and expected expenses on diagnostics, medicines, supplies and in some cases informal payments, which led to delay in reaching healthcare facilities. For poor families this is catastrophic and discourages them from going to hospitals the next time.

Failure of the health system in providing something as simple as contraceptive services and counseling kept cropping up time and again in all the regions. A 40-year-old woman in Banda district of UP died during her 12th pregnancy. She had 10 live births and went for induced abortion by consuming pills for the 11th time. As the 12th pregnancy was also unwanted, she went for abortion by similar method. The woman consumed five pills without any proper medical advice. She died in less than 24-hours due to heavy bleeding. Despite reaching a public hospital, she could not be saved.

The public health system is clearly not reaching women for guidance on contraceptives. It is then doubly failing them by not providing access to safe abortion services, even after, like in the present case, they have previous record of abortions. The State’s neglect is responsible for innumerable deaths and morbidity. Behavioural issues of healthcare staff in public health facilities were faced by majority of families interviewed. Coming from marginalized backgrounds, they are not treated as equals by the government staff and this discouraged many women from seeking care in public health facilities.