Good food, extra rest: Little attention on special needs of pregnancy in rural India

Excerpts from the Jaccha Baccha-Survey (JABS) of pregnant and nursing women in rural India conducted in June 2019, coordinated by Jean Drèze, Reetika Khera and Anmol Somanchi:

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The Jaccha-Baccha Survey (JABS), conducted by student volunteers in June 2019, took place in six states: Chhattisgarh, Himachal Pradesh, Jharkhand, Madhya Pradesh, Odisha and Uttar Pradesh. In each state, the survey teams visited 10 to 12 randomly-selected anganwadis (spread over two blocks, in the same district) and interviewed as many as possible of the pregnant and nursing women (women who delivered a baby during the six months preceding the survey) registered at those anganwadis: 342 and 364 respondents, respectively.

Special Needs Ignored

We were shocked to find how little attention was paid, in the sample households, to the special needs of pregnancy – good food, extra rest and health care. Often, family members or even women themselves had little awareness of these special needs. For instance, 48% of pregnant women and 39% of nursing women in UP had no idea whether or not they had gained weight during pregnancy. Similarly, there was little awareness of the need for extra rest during and after pregnancy.

Frugal Diets

Among other neglected needs is the need for nutritious food. Only 22% of the nursing women reported that they had been eating more than usual during their pregnancy, and just 31% said that they had been eating more nutritious food than usual. The main reason for not eating more is that many pregnant women feel unwell or lose appetite. The proportion of nursing women who reported eating nutritious food (e.g. eggs, fish, milk) “regularly” during pregnancy was less than half in the sample as a whole, and just 12% in UP.

Low Weight Gain

Poor diets lead to low weight gain during pregnancy. Compared with a norm of 13-18 kg for women with low BMI, the average weight gain in the sample was barely 7 kg (in UP, just 4 kg). Even these figures are likely to be overestimates, as they exclude women who did not know their weight gain at all. Some women were so light to start with that they weighed less than 40 kg at the end of their pregnancy.

Lack of Rest

Rest is another unmet need of pregnant women. Almost all the respondents had done household work regularly during their last pregnancy. A significant minority (21%) of nursing women said that no-one (not even a grown-up child) was available to help them with household work during pregnancy. Almost two thirds (63%) said that they had been working right until the day of delivery.

Weakness and Exhaustion

Due to lack of food and rest, most of the respondents had felt tired or exhausted during pregnancy. As many as 49% reported at least one symptom of weakness, such as swelling of feet (41%), impairment of daylight vision (17%) or convulsions (9%).

Dismal Health Services

Pregnant and nursing women are acutely deprived of quality health care. Many of them receive some basic services (e.g. tetanus injections and iron tablets) at the local anganwadi or health centre, but they get very little beyond the basics. Small ailments easily become a major burden, in terms of pain or expenses or both. At the time of delivery, women are often sent to private hospitals when there are complications.
A significant minority also report rude, hostile or even brutal treatment in the labour room. There is an urgent need for radical expansion of quality health care close to home. Two signs of hope here: high rates of institutional delivery and widespread use of public ambulance services.

Delivery as an Economic Contingency

Institutional deliveries are supposed to be available free of cost to all women in public health centres. In practice, we found that nursing women had spent close to ₹ 6,500, on average, on their last delivery. This amounts to more than a month’s wages for a casual labourer, in the survey areas. One third of these women’s households had to borrow or sell assets to meet the costs. The economic risks associated with pregnancy and delivery adds to other arguments for universal maternity entitlements.

Denial of Maternity Benefits

Under the National Food Security Act 2013 (NFSA), all pregnant women are entitled to maternity benefits of Rs 6,000, unless they already receive benefits as formal-sector employees. The central government ignored this for more than three years, before launching the Pradhan Mantri Matru Vandana Yojana (PMMVY) in 2017.
In flagrant violation of the Act, PMMVY restricts benefits to one child per woman – the “first living child”. Further, benefits have been arbitrarily reduced from Rs 6,000 to Rs 5,000 per child. Even these meagre benefits are elusive. Among nursing women eligible for PMMVY, only 39% had received the first instalment. The government’s own data show that PMMVY covers less than one fourth of all births as things stand.
India’s population is estimated at 1,339 million in 2017. With a birth rate of 20.2 per thousand (2017 estimate), this implies 270.5 lakh births per year. As against this, the number of women who received any maternity benefits (even just one instalment) under PMMVY in 2017-18 was just 60 lakh or so, i.e. just 22 per cent of the total number of births.

How did this happen? The JABS survey sheds some light on this issue. Briefly, women’s rights have been denied in three steps.
Step 1: Restriction of entitlements: In flagrant violation of the Act, PMMVY restricts benefits to one child per woman – the “first living child”. Further, benefits have been arbitrarily reduced from Rs 6,000 to Rs 5,000 per child.
Step 2: Cumbersome application process: To receive these meagre benefits, eligible women need to fill a long form for each of the three instalments. They also have to produce their “mother-child protection card”, Aadhaar card, husband’s Aadhaar card, and bank passbook, aside from linking their bank account with Aadhaar. Further, they depend on the goodwill of the Anganwadi worker and CDPO to ensure that the application is filed on-line. This entire process is challenging, especially for women with little education. Many are not even aware of PMMVY benefits.
Step 3: Unreliable payments: On-line applications are often rejected, delayed, or returned with error messages for a series of reasons that are familiar from studies of Aadhaar-enabled payments of welfare benefits in other contexts (e.g. pensions and NREGA). Examples include: (1) incomplete information, (2) inconsistencies between Aadhaar card and bank passbook; (3) diversion of payment to a wrong person’s account. In cases of unsuccessful application, there is no provision for informing the concerned women and explaining to them what needs to be done.
Bottom line: a promising scheme has been ruined by stinginess and technocracy. Aside from undermining women’s rights, this is a major loss for Indian children.

Aadhaar Spanner in PMMVY Wheel

The PMMVY application process is complicated to start with. The imposition of Aadhaar has created further complications. One-fifth of the respondents who had applied for PMMVY reported experiencing Aadhaar-related problems. In addition to this, there are Aadhaar-related problems at the payment stage (e.g. when payments are made using the Aadhaar Payment Bridge System), which women were mostly unaware of. Some of them were reported by Anganwadi workers (AWWs) who take care of application formalities on behalf of the women.
One third of AWWs reported general Aadhaar-related issues, and 15% reported bank-related issues. Remember, these are young women in their sasural, either carrying a baby or nursing an infant, who are in need of rest. Instead, they are constrained to spend time and money on fixing errors that have crept in for no fault of their own – with no guarantee that the issues will be resolved. Here is a brief recap of the Aadhaar-related issues we encountered during the survey.

1. Aadhaar is the only acceptable ID document for PMMVY: The requirement of an ID while applying for government benefits is understandable. For PMMVY benefits, however, the only acceptable ID is the Aadhaar card, even if women do not have one, or they have lost it, or there are errors in their Aadhaar records, etc. This makes the application process costlier and more cumbersome. Some women had to pay anything between Rs 50-200 to enrol for Aadhaar. When Sushman Devi (from Sonebhadhra, UP) was trying to make corrections in her Aadhaar records, local officials kept delaying the matter. Ultimately she had to borrow money to go to the Block headquarters to get the corrections made. She borrowed Rs 2,000 from her sister to get corrections made to her and her husband’s Aadhaar card.
2. Linking the benefits of PMMVY with the husband: In contrast with Odisha’s Mamata scheme, PMMVY benefits require identification documents of the husband. There were cases where women had not been able to apply, or the application had been delayed, because of failure to produce the husband’s Aadhaar card. Some husbands did not have Aadhaar cards, some women were living with men to whom they were not married, or were single mothers. There were several cases where applications had been delayed or stalled because Aadhaar cards with the father’s name or address were not accepted. Pooja is from Uttar Pradesh and married to someone in Surguja, but she had no way of providing a proof of address for her new address. The Aadhaar enrolment centre advised her to get a certificate from the sarpanch. It was rejected. Many women such as Krishna Baiga and Sunita in Umaria (Madhya Pradesh) tried to have the address changed but failed. When Dinesh Mehta (in HP) went to get her address updated, the machine did not work. Some women in Odisha reported being able to get their Mamata benefits in spite of this issue. 
   
3. Inconsistencies of demographic information between Aadhaar and other databases: Demographic data glitches (e.g. typos in Aadhaar number, misspelling of names, wrong date of birth on Aadhaar, mismatch between Aadhaar card and other records, etc.) can all lead to the PMMVY application getting rejected or delayed. In Odisha, Rani Gope had to get multiple corrections made to her date of birth; Hulari Munda has three IDs each of which shows a different date of birth. Marcilin Munda’s Aadhaar card overstates her age by 10 years (1980 instead of 1990). In most cases, these errors crept in for no fault of the women who were applying for PMMVY, but they are paying the price for it. Further, the processes for making these corrections are not clearly laid out or communicated. For instance, we came across several women who were told that a “No objection certificate” was required from the sarpanch, but when they got it, it was rejected. We also met women who came back with new errors when they went to correct an earlier mistake in their Aadhaar records. In what will likely make matters worse, a recent central-government circular (dated 14 October 2019, available on request) restricts the number of changes of demographic information in the Aadhaar card to once in a lifetime for gender and date of birth, and twice in a lifetime for name. 
4. Problems arising from the requirement to link bank accounts with Aadhaar: Women such as Sukiya Baiga (in MP) could not open a bank account because she did not have Aadhaar; others faced difficulties because their bank account was not linked to Aadhaar (despite repeated attempts in some cases). Sadhna has an account and an Aadhaar card, but linking is creating difficulties. Others, such as Santoshi (in HP), find that their Aadhaar is linked to an account different from the one they submitted when applying. Resolving these issues is cumbersome, time-consuming and uncertain. 
5. Other Aadhaar related issues: There were other unspecified issues – cases where even the Anganwadi worker and/or bank official are unable to figure out what the problem is. Laxmi, a Dalit woman in HP, was told that there’s an “Aadhaar card problem” with her application. Some women are asked for a bribe by ASHA or AWW when there were Aadhaar issues (to bypass the issues). For instance, the ASHA worker in Parvati’s natal village in UP told her that she could get the PMMVY form filled without the presence of her husband for a charge of ₹ 500. The costs associated with photocopying Aadhaar for submission with their PMMVY application form was also mentioned by many respondents. 

CASE STUDIES

Renu Raidas (Umaria, MP)

Renu Raidas went to the Umaria district hospital three days before the delivery. The staff was illmannered. She was given sleeping pills when she was in pain. Even though she wanted a normal delivery, she was advised a C-section. On the third day, the nurses started pushing her stomach vigorously – one nurse on each side. She shouted at them and they moved away, but after that denied her care. Her father had to bribe them to get them to look after her. The child was born stiff and could not move its body. Here, at the hospital, they spent Rs. 5000. From there, they went to a private hospital in Katni and spent three days there. They had to spend another Rs. 35,000 at this hospital. In spite of this, her child was not fully cured. She blames the nurses for the child’s deformity. The family had to borrow Rs. 40,000 from a moneylender at Pipariya at an interest rate of 5% per month. During her pregnancy, a family member advised her to eat less.

Kunta Kol (Umaria, MP)

Kunta Kol is a young Adivasi with no formal education. The village is situated close to a reservoir, and this family’s land remains mostly submerged. She was pregnant with her third child when we met her. She is among the few women who did not have a “jachha-baccha card” (mother and child card). Quite likely, she did not receive much by way of ante-natal care. She had a premature delivery, in her 8th month. She managed to get an ambulance to take her to the hospital (it seems they were trying for a while, and it was delayed), but the child was born at the doorstep of the hospital, in the ambulance at about 9pm. A doctor was present at the time of her delivery, and left soon after. When the doctor returned at 8am, the child was dead. She said that she had to pay Rs. 500 to the doctor, Rs. 400-500 to the nurse, Rs. 200 for the sweeper and Rs. 500 for the ambulance.

Alia Naz (Sundergarh, Odisha)

Alia Naz delivered her child in the dead of the night at 3am. There was no doctor to attend to her. The nurses who looked after her delivered without anaesthesia or hot water. The nurses demanded Rs. 1500. Two days after being discharged from Birsa Hospital, the child stopped drinking milk and on being taken to the hospital, it was found that she was suffering some infection. She was admitted to the ICU in Rourkela government hospital. The family rented a room in a lodge nearby. A week later, the child was discharged. The doctor was of the opinion that this was because of unhygienic conditions at the time of delivery.

Rani Gope (Sundergarh, Odisha)

Rani Gope delivered her child at the Birsa Hospital. She is weak and has low blood pressure – five months after her delivery, she loses consciousness from time to time. She is advised by her family to eat less. The child did not cry after being born, so they carried her to Rourkela government hospital. There they were referred to a private hospital (“Aastha”). This was very expensive – the child was kept in ICU for five days. They had to mortgage their land (for a loan of Rs. 50,000) and borrowed from relatives as well (another Rs. 50,000). After a few days, they had exhausted all their cash reserves and Briefing Note 7 2 moved back to Rourkela government hospital where they got affordable care. The child continues to be unwell – does not sleep comfortably, there’s swelling in the head, they have been consulting a doctor (each session costs Rs. 700), but there’s no clear diagnosis yet.

Kunti Nagesh (Sarguja, Chhattisgarh)

Kunti Nagesh delivered her child at the government hospital in Ambikapur. She had to have a C-section. She faced a lot of financial difficulties because the child had to be kept in ICU for 15 days. Though they were not charged for the ICU, they spent Rs. 12,000 on four units of blood. She said they did not receive proper attention from the nurses. Because of the improper dressing of the caesarean wound, a lot of pus developed in the wound. Yet, the doctors paid no attention. She was forced to leave the hospital without getting officially discharged. In her village, she took the help of a quack. The family spent Rs. 15,000 in all. The family met these expenses by taking a loan from a shop (it was repaid by selling grain) and by selling tomatoes harvested at the time of the baby’s birth.

Sangeeta (Sonebhadra, UP)

Sangeeta lives with her five children in a miserable hut on the edge of their small plot of land. Her husband works in Bhabani and other places from time to time as a casual labourer. Sangeeta’s situation looks very difficult (she had eight children, of whom three died) but she does not seem to think that her last pregnancy and delivery was a big deal. She said that she rested for six days after her delivery – more because in their community women who have delivered are not supposed to touch any vessels, as they are considered untouchable at the time. If she had worked, she would have been ostracized, she said. She does not report any special problem though she would have liked to eat better food. She used to work in NREGA but not recently.

Sarita (Sonebhadra, UP)

Sarita is a Dalit woman. When she reached the hospital for delivery, she found it closed. The doctors, it seems, had taken a day off. So she had to deliver her baby in the verandah with the help of her badi saas, chhoti saas and chhoti bua. When she applied for Janani Suraksha Yojana, she was denied the money as they were not sure if the baby was born in this hospital as it happened in the absence of hospital staff, on a “self-declared holiday”.

Rita Devi (Kullu, HP)

Rita Devi, childless, was currently pregnant but could not get PMMNY benefits because she had to abort her previous pregnancy. According to the Anganwadi worker, the child was aborted in the fourth month, after the pregnancy had been registered. As a result, it counts as the first child and she cannot get PMMVY benefits. The AWW consulted the CDPO on this, who said nothing could be done.

Hima Devi (Kullu, HP)

Hima Devi is a shy young mother, whose first child was born premature at home. The AWW tells her that she cannot get PMMVY benefits because the child was born prematurely (possibly because it was not an institutional birth).

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