In a region untouched by mommy blogs or dog-eared copies of What to Expect When You’re Expecting, this is a look at mother and child health care in India’s remote villages.
By Katie Hewitt
Photos by Sara Cornthwaite
Mulki Bai spends her days walking, in search of expectant mothers.
In the Rajastahani village of Kalthana, she is the asha at the local anganwadi, a health centre and refuge for maternal care that offers free check-ups, immunizations, nutrition packets, and preschool for children until age six. On paper, this seems like a mecca for the kind of social services that many Western nations can’t even reconcile. But for Mulki, whose job is recruitment, it can be a hard sell.
Mulki walks over hills and through wheat fields, in the blistering heat of summer and in spring’s monsoon rains. The most difficult part of her job, she says, is walking. Not approaching new mothers about how to care for their children, not easing the fear that comes with creating life—but the physical act of putting one foot in front of the other, over unforgiving terrain. She canvasses Kalthana’s 14 hamlets, spanning several kilometers, knocking on at least ten doors per day. It’s the kind of grassroots, door-to-door development that is still necessary where communication is almost entirely word-of-mouth; the key to connecting with close-knit tribal communities weary of strangers.
Kalthana’s anganwadi opened over 20 years ago, to low attendance. In 1975, a government scheme designated the centres mandatory resources for the country’s urban slums and rural villages. Though the state will erect a building to meet requirements—one for every 1,000 people—infrastructure and awareness can be lacking. Many potential program candidates, young women and new mothers, have never attended school. They can’t read flyers or news items about child welfare policies.
So Mulki walks.
About six months ago, Mulki found Kamla Gameti. Married at 16 and now in her early twenties, Kamla was pregnant with her second child. Her three-year-old son Naresh played at their feet while Mulki tried to sell Kamla on a hospital delivery for the upcoming birth, told her about the anganwadi’s free inoculations and patiently explained preventative medicine, potential complications, and how the hospital was equipped to react swiftly in the case of an emergency. All of these concepts were foreign to Kamla.
Up until this point, Kamla had no formal medical care. She and her first born, Naresh, had no prenatal consult, blood test for hemoglobin levels or screen for pelvic cancer. No stethoscope to check for two heartbeats. It was Kamla and her baby, against the odds.
The most recent World Bank data from 2015 puts India’s maternal mortality rate at 174 per 100,000 live births. (In Canada, the ratio was 7 in 100,000 that same year.) India’s figure is slowly declining, but still substantially higher than the UN’s Sustainable Development Goal—a push to get the global average below 70 by 2030. Ninety-nine per cent of maternal deaths occur in developing countries, and most are preventable.
Rajasthan, Kamla’s home province, is one of the poorest in a newly industrialized nation where child brides and adolescent mothers are especially vulnerable during childbirth. Here, maternal and infant mortality rates are higher than the national averages. If you’re from the tribal population, an indigenous group historically socially and economically marginalized, the rates are even higher.
Kamla didn’t know any of this when she considered Mulki’s proposition. She only remembered the fear that shrouded her first pregnancy.
“Darpani” and “santa ve” are the Mewari words Kamla uses. Fear because she didn’t know anything about the health of her baby. Worry that stress from her fear would harm the life inside her. She and Mulki tell their stories through a translator, relaying their first meeting.
Even with Mulki’s insistence and the fresh memory of panic, Kamla was hesitant about a hospital delivery: the cold, sterile room miles from her home. The doctor, a stranger. Three years ago, a dai delivered Naresh at Kamla’s parents’ home in Jardhol, a few towns over. Despite a lack of formal training, dais, or village midwives, are trusted community members.
Many mothers in all parts of the world choose home births for the same reasons, but can retreat to a hospital in case of complications during labour. For Kamla and other women without access to health care, there is no such thing as a “complication.” No knowledge of healthy birth weights or organ development, infections, high blood pressure or breeching. A litany of potential risks are unheard of—anemia, asphyxiation preeclampsia—with no known safety net. A “normal” delivery means the baby survives. “Abnormal” means stillbirth.
There is only life and death. All the variances between these extremes are unknown—unless someone intervenes.
If Mulki had met Kamla three years earlier, knocked on her door and delivered her pitch, it’s even less likely that Kamla would have been swayed. The look of the original anganwadi wasn’t exactly appealing. Its thatched mud roof leaked incessantly in the rain. Ink-and-paper medical records were vulnerable during monsoon season. Nutrient packets set to deliver vital protein and vitamins to pregnant women and toddlers—a dry mix of wheat grind, sugar, soy and lentils—spoiled in the damp.
In 2016, WE Charity refurbished the roof and floors, and provided furniture as well as winter clothes and educational posters for the children. Towers of tiny orange plastic chairs now sit stacked against one wall. And there are toys—in the anganwadi’s sunny front yard, a little girl and a little boy play tug-of-war with a green plastic rocking horse.
“They used to be afraid,” Mulki says of the mothers she first met when she started at the anganwadi seven years ago. “They were not confident in me.”
Not many women apply for asha positions because so few attend school—you need a Grade 12 education. Mulki was contacted by a government recruiter once she completed high school, a rare feat for a tribal woman from Rajasthan. Now 30 with her own two children, she’s realizing a dream held since childhood, to work in health care and help other tribal women. She walks to make sure Kamla doesn’t become a statistic.
Since the refurbishment, attendance at the anganwadi is up; mothers are much more inclined to receive services at a waterproof structure. Mulki says that with WE’s intervention, her pitch is well-received, her reputation bolstered by the integrity of the building itself. WE staff join the door-to-door canvass, an extra layer of invitation.
Now a mom of two boys, Kamla sits on the floor of the anganwadi’s open veranda, cutting a small shadow in the Indian sun. Naresh nestles tightly beside her with a chalkboard, scribbling. Bored by the adult conversation, he makes a fuss to win back his mother’s divided attention; she chides him gently in Hindi. Her youngest was born two months ago, at Sayra Hospital in the nearest city of Kelwara. Baby Vinod now nurses under a blanket.
Kamla produces a mamta card, the first formal health records in her name that detail, among other things, her weight and blood pressure at various anganwadi appointments, vaccine dates and records for Vinod. Mamta is Hindi for “maternal love.”
The card is filled with guidelines for prenatal care and early childhood development. “If the child looks dull, give him more nutrition. If he still looks dull, seek a doctor,” it reads in Hindi. “By age two, children should speak some words.” Anganwadi staff help Kalthana’s new mothers read the guidelines, a low-tech tool to navigate parenthood in a region untouched by mommy blogs or dog-eared copies of What to Expect When You’re Expecting.
Carrying Vinod, Kamla did many things differently, following all schedules and consuming all advice. She ate more green vegetables. During her first pregnancy, “I wasn’t aware that if I ate good food, the baby would also have good food.” After delivery, she and Vinod spent 48 hours in hospital under observation.
Kamla’s boys now receive health care, day care, and preschool lessons at the anganwadi. When they’re older, they will graduate to the nearby Kalthana Primary School and its bright classrooms built by WE Charity. Kamla hopes for more children, and wants a girl, she says. Her sons will have a sister to participate in Raksha Bendhan, an annual festival held in India every August. Sisters tie rekhi, a kind of friendship bracelet, on their brothers’ wrists, and brothers promise to protect their sisters. It’s a national celebration to mark the bond of siblings.
In India, girls are still often marginalized, not often hoped for. Kamla has reason to hope, with the support of the Anganwadi sisterhood. In fact, in English, asha means “hope.”
Mulki dons the blue button-up shirt, almost lab-coat-like, that is her uniform. A simple and clinical symbol of health innovation covers her traditional headscarf and bold sari, red with gold embroidery. Doors are waiting.