Since 2005, the Government of India has launched a series of initiatives like the Janani Suraksha Yojana (JSY) and JSSK to address high maternal mortality, and the SRS surveys over the last decade show that maternal mortality has been steadily coming down in all states including in Jharkhand. In August 2013 a paper examining 23 maternal deaths occurring in one year among young, poor women mostly from tribal communities (including Particularly Vulnerable Tribal Groups (PVTG) in just two blocks of Godda District in Jharkhand was published in EPW (Stairway to Death: Maternal Mortality Beyond numbers, Banerjee et al, Economic and Political Weekly Vol XLVIII no. 31, 2013 Aug 3).
In this context the National Alliance for Maternal Health and Human Rights (NAMHHR) conducted a Fact-Finding Mission (FFM) in Godda district of Jharkhand to explore the status of maternal health services and the role of related social determinants of health. The FFM team visited three villages selected on the basis of different tribal communities, varying distance from the block CHC, as well as different accessibility to roads. The team also visited one Community Health Centre (CHC), one First Referral Unit (FRU) and the Godda District Hospital; where the health providers and managers were asked about their assessment of barriers and challenges.
Godda district is part of the Santhal Parganas division of Jharkhand which is dominated by tribal communities. Sundarpahari is a backward block in Godda. The block has an entirely rural population, with 79% belonging to the Scheduled Tribe category, and more than half the villages are inhabited by particularly vulnerable tribal groups (PVTGs). Nearly 50% of land in Sundarpahari block is forested and hilly and most habitations are not connected to the few roads that exist. The literacy rate in Sundarpahari is 27%, and AHS 2011-12 data indicates that childbirth at home is 75.2% for district Godda.
The team met with a large number of women in three villages of Sundarpahari block who had delivered in the last couple of years; all the women had given birth at home even though some had complications and near-miss experiences. There was also a maternal death in one of the villages. Yet the women did not consider going to the local health facilities as an option, and had no information about JSY or JSSK. Due to local health beliefs and the lack of community outreach, the communities visit local informal practitioners, eg. Dom and Ojha and the RMP.
These women did not have access to basic health services such as ANC, and even immunization services for children was unavailable in the case of PVTG communities. The ANMs did not go to the villages for either ante-natal care or for home births; the health sub-centres were not easily accessible for many hamlets in the village, and the VHND was not taking place in even half the villages of this block owing to shortages of human resources and transportation issues. There was no functioning blood storage and transfusion facility in the entire district although a large number of the pregnant women present with high anaemia and comprehensive emergency obstetric care had to be accessed (by those who could afford it) in Bhagalpur Medical College in Bihar. In other blocks where ante-natal care is provided, it is not identifying any danger signs such as anaemia, malnutrition or pre-eclampsia.In the more remote villages there were no Anganwadi centres (AWC), and the Supplementary Nutrition does not reach the pregnant or lactating women. In other villages, the AWC sporadically provided THR, and even then information that THR is available did not reach all the women.
However the PDS (free supply of x kg of grains) was being used by the community even though the concerned distribution centre was far. The PDS does not incorporate the local grains that are richer in nutrients and instead provides the standard cereals that are given all over the country. The traditional food patterns of the tribal communities which were linked to the forests and the robust practice of mixed organic farming has been disturbed by the introduction of PDS grains.
Local practices and resources have been ignored and women have been asked to take iron-tablets during pregnancy instead of promoting consumption of local iron rich foodstuff.Given the geographical situation of Godda district, it is difficult for health services to reach communities located deep in the forests. The tribal communities are seen as ignorant and uneducated, and their practices are looked down upon.
The health system has made no efforts to integrate the tribal health system (based on local herbs) and integrate some of the good practices so that the tribal feel less reluctant to use the health facilities. As it stands now, they avoid using government health facilities until matters have gone too far, and then it is usually too late. Different tribal areas and their health problems need to be seriously studied both within Jharkhand and other areas of Tribal communities.
The PVTGs or particularly vulnerable tribal groups require socio-cultural studies, to understand their health-related practices and related disruptions which may provide ideas about the underlying reasons for high anaemia and poor health.The report concludes with a detailed set of recommendations.