Patna/New Delhi- Leela Devi, 32, experienced six consecutive miscarriages from four to eight months into her pregnancy. A resident of Sirsia village in Bihar’s Darbhanga district, she has not been able to give birth to a child even once in the past 12 years since she got married.
“I don’t have enough money to go for further treatment. I consulted a doctor and even spent Rs 9,500 on treatment, but to no avail,” said the Dalit woman who belongs to the extremely marginalized Musahar community.
Muntarni Devi, also from the same village, has hearing loss. The mother of four fails to control her emotions when one mentions an unwanted pregnancy termination. Years after her marriage, she had her first successful delivery after six miscarriages and stillbirths.
“Due to financial limitations and the lack of a healthcare system, I was unable to receive care following the initial fetal loss,” she told The Mooknayak, adding that she suffered the next five miscarriages.
After the first loss of a fetus, she did not get the mandatory medical care — which involved treatment for problems resulting from miscarriage or induced abortion.
Manju Devi, a mother of two, lost her first pregnancy due to miscarriage. Despite having given birth later, two of her children died of pneumonia during floods. Following a bout of high temperature, she lost another child as well.
Aarti got married four years ago. She was expecting her first child in 2019, but the fetus could not survive after six months of gestation. When conceiving, she was under the supervision of a doctor at her nearest public health centre (PHC).
The doctor tried his best but failed to save the fetus because the woman was too weak to become a mother owing to the absence of access to required nutritious food and proper healthcare.
Women belonging to the Scheduled Caste (SC) community in various villages of the state have been experiencing repeated miscarriages in the first, second, or even third trimester of their pregnancies for a number of years.
The reason behind fetal loss on such a large scale is almost common for all of them: abject poverty, illiteracy, ignorance, lack of exposure to the outside world, and most importantly, lack access to the bare minimum of food. Here, supplementing with fortified food is a pipe dream. Fortified food supplementation is a far-fetched dream here.
“All these women are victims of the state’s criminal negligence,” asserted Nand Kishor Pandey of the Mithila Gram Vikas Parishad (MGVP), a non-governmental organization — which assists marginalized and underprivileged rural communities.
Because of their social exclusion, these Dalits live in ghettos close to the Kosi River, which is also referred to as the “Sorrow of Bihar” because of its destructive yearly flooding. Water contamination is a significant concern in such areas since these hamlets are submerged in water for almost half of the year.
Their primary sources of income used to be agriculture and animal husbandry. However, the vast majority of people lost their land after the 2010 floods. As a result, men migrated in significant numbers, and they are currently employed in agricultural fields in Haryana and Punjab.
Even though they work hard away from their families, they are unable to do much for their families with their earnings because most of them borrow from local moneylenders to bear their travel costs and leave a small part of the fund behind for expenses at home.
Since the women also work in the fields to supplement their families’ meager income, they cannot afford to take recommended rest during the first trimester of their pregnancy. Such settlements, especially in north Bihar, have a high rate of stillbirths due to hard physical labor and lack of access to nutrient-rich foods.
Leela’s husband, Chhabbu Sada, works in Haryana as an agricultural laborer. The money he earns is disbursed to moneylenders in the form of convenient monthly payments (EMIs).
“He had taken out a loan to meet his travel and other expenses. He is currently paying off the debt. He is left with no additional funds for us. We don’t have any source of income,” she said.
When asked if she had the Pradhan Mantri Jan Arogya Yojana (PM-JAY) card, which entitles her to a health assurance of Rs 5 lakh annually from the National Health Authority (NHA), she said that she had just received it. But using it is a challenge for her because she cannot even afford to travel for adequate medical care to the district headquarters of Darbhanga — which is merely 30-40 km from her village and the transportation cost generally settles somewhere near Rs 100.
“I did not have the card when I suffered fetal loss. I have received it recently. To use it, I would need to go to nearest towns — which have multi-speciality medical facilities. Although the card ensures free treatments, going there would require funds — which my financial condition does not allow me to bear. You won’t understand in which circumstances we are surviving,” she narrated the ordeal.
Asked about the diet they take, she said they eat what the poor people eat — rice and khesari dal (grass-pea or chickling-pea).
“We get it for free (from the government under the public distribution system). We cannot afford green vegetables, milk, and other nutritious food because of high inflation. Sometimes, we eat bread with salt and chilli paste. This is our food,” she narrated.
Notably, grass-pea has been banned in India since 1961 due to allegations that its plant contained a neurotoxin that might paralyze lower limbs. However, because it is inexpensive, the impoverished consume it a lot.
Leela claimed community health workers — also known as Accredited Social Health Activists or ASHAs — do not often visit them as SCs are considered “untouchables”. Even if they come, they allegedly maintain a physical distance from the women of the caste.
“No ASHA worker ever visited me when I needed them the most,” she claimed.
Appointed by the Union Ministry of Health and Family Welfare (MoHFW) as part of the National Rural Health Mission (NRHM), the ASHA workers are expected to be a driving force behind community involvement in public health initiatives in their respective villages. They are equipped with the necessary knowledge and a medication kit to provide first-contact healthcare.
Rukni Devi from a neighboring village in the same subdivision explained what she considers are the reasons behind the cases of fetal losses in their ghettos and surrounding areas.
“We lack access to wholesome food as a result of poverty. When survival is a challenge, thinking about nutritious food is a luxury. When doctors recommend bed rest (up to 12 weeks of pregnancy), we work in the fields to support our family income. We don’t have enough funds to pay for better medical care. We eat grass-peas, which the government provides for free, to survive. Vegetable prices are so high that we cannot afford,” she described.
People in these hamlets are daily wagers. They are able to have food when they get work. “We often have to go hungry when there is no work. We had spent Rs 10,000 – 12,000 on wheat crops, but the unseasonal rains accompanied with hail storms and strong wind ruined the yield.
Some of them were engaged in contract farming, but that too got destroyed because of nature’s fury.
“Medical care is not always free; even in government facilities, we have to purchase most of the medicines from outside,” she noted.
There is no multi-speciality or super-speciality hospital with specialized doctors nearby. The DMCH (Darbhanga Medical College and Hospital) is the only option in case of complications.
“But going there is not everyone’s cup of tea given the acute financial crisis and lack of resources such as vehicles and roads. Apart from medicines, we also have to get several diagnostic examinations done from private labs — which charge exorbitantly,” she added.
Manju did not have money when her now-deceased children fell ill. She said though her husband works as a farm laborer in Punjab, he was unemployed at that time.
Aarti’s husband was also unemployed and at home when she lost her first pregnancy after six months of gestation.
“We did not have money at all even to think about consulting a gynecologist at a hospital,” she said.
At the PHC, she had dilation and curettage (D&C) — a surgical procedure, but she had to bear the cost of medicines as it was not available in the government facility. “The hospital did not have the necessary medicines, so we had to buy them from outside,” she said.
Now, her husband is working in an agricultural field in Punjab.
According to Pandey of the MGVP — the NGO that operates a dispensary in Tarwada village where the poor receive free medical care, the cases are not restricted to one village only.
“About 60% SC families scattered in different villages in the district have two to three cases of fetal losses on average. The reasons are malnutrition among women, abject poverty, unhygienic living conditions, lack of awareness, and a poor healthcare system,” he claimed.
He added these cases are unfortunately neither reported in the government records nor in the media.
Asked about the government’s steps to ensure proper nutrition and medical assistance to these marginalized people, he alleged that Anganwadi centers and ASHAs have been left “to God’s mercy”.
“In the majority of villages, their efforts appear to be half-hearted or restricted to records only. Even the ANM (Auxiliary Nursing cum Midwife) who go to these villages for vaccination and other medical interventions don’t screen the women properly for pallor, undernourishment, or abnormal blood pressure,” he alleged.
The Mooknayak visited PHCs in the district and surrounding regions and spoke to doctors posted there. They acknowledged the problem and said malnutrition among women and children is the big killer. In addition, they said, the IFA (iron-folic acid) tablets, which are distributed to pregnant women in the villages, are not consumed by them because of misinformation coupled with lack of awareness.
“We try our best to undo the misinformation and convince them to have it. A good section of women now takes the tablets as prescribed, resulting in a fall in the number of miscarriages that used to occur earlier. But still 40% of women from these villages don’t take it regularly. When they come here with a variety of complaints, we find low hemoglobin. On inquiry, they reveal that they did not take the tablets given to them,” almost all of them said, without wishing to be named.
Talking about possible reasons behind fetal losses, they pointed out, “Most of the women have low hemoglobin. They are prone to several infections as they fail to maintain hygiene. Because of annual floods, water contamination also contributes to the problem. Groundwater here has excessive amounts of iron, which is harmful.”
Asked about awareness campaigns, they said, “We regularly counsel pregnant women; we also educate them on the importance of adhering with daily intake of one IFA tablet for six months. They are also advised on preventive measures such as sanitation and footwear. We keep holding meetings with ASHAs to take their feedback and give them guidelines from time to time to tackle the situation. We also hold them accountable if we find growth in IDA (iron deficiency anemia) in their areas. Situation will improve with time.”
With regard to the shortage of doctors and paramedics, they said their PHCs have a severe lack of doctors. Many of them have only one MBBS doctor against the sanctioned strength of six.
“Unfortunately, at present, there is only one MBBS doctor, who is me. There are two Ayush doctors. Earlier, there were three doctors in addition to me. But two of them retired and the third, who was on contract, was regularized and transferred to another district. Of the six doctors appointed this year, three were relieved to pursue higher education soon after their postings and the rest three never joined — perhaps due to the poor infrastructure of the area,” one of them said.
The PHC at Kirathpur has six beds, which continue to remain occupied throughout the year. When this correspondent visited the PHC’s indoor department, each bed had two occupants.
“There is a high footfall every day in the OPD as well as indoors. And therefore, you can see two patients on every bed. We never deny admission to those who need hospitalization on account of the dearth of beds. We have to accommodate them somehow in this limited capacity,” he said, adding that ideally, there should be one PHC for a population of 1 lakh, but the hospital also caters to patients from neighboring districts for whom this PHC is closer than the government health facility in the district.
Sanjay Kumar Paswan, manager of the PHC, said the facility has five health sub-centers (HSCs). Against the sanctioned 38 posts of ANM, he said, there are only 12 ANMs posted in the hospital.
He further said the area has two additional PHCs — one in Jamalpur and the other in Rasiyari villages — which should have one MBBS doctor each. “But these two facilities are being run by one Ayush doctor each in place of MBBS doctors. Two MBBS doctors had recently joined there but they were relieved for higher studies on the same day they joined the additional PHCs,” he added.
Darbhanga Civil Surgeon Anil Kumar Sinha too acknowledged the shortage of medical professionals adding that “it is something the government should look into”. “We are highly understaffed, but we cannot do anything as appointments are not in our hands. The government must look into it,” he added.
When asked about the high incidences of miscarriages, he said he is unaware of it. “I don’t have any such information. If it is happening, it should have been brought to my notice by the officials concerned. I would personally look into this matter,” he assured.
Bihar’s health secretary could not be reached for comments.
Just 3.97 lakh pregnant women in Bihar received benefits of the Pradhan Mantri Matru Vandana Yojana (a central government’s maternity benefit scheme) in 2021–2022, against the total 15.01 lakh institutional deliveries, Newslaundry reported — citing a date provided by the state’s Women and Child Development Department.
Only about 35–50% of the total applications were accepted, while the rest were rejected.
Launched in 2017, the PMMVY offers monetary support to compensate for lost wages during the non-working days of expectant mothers. It is particularly important for protecting women’s financial stability and addressing maternal and child health problems in low-income states like Bihar.
According to the NFHS-5, the state has the lowest percentage of pregnant women who undergo four or more prenatal care check-ups (25.2% of all pregnant women for 2019–2020), partly owing to a lack of financial aid among other issues. The World Health Organization (WHO) advises getting at least four prenatal examinations.
Pregnant women in the state received prenatal care at a rate of 52.9% in the first trimester, far less than the national average of 70%. Conversely, just 47.6% of women used public health facilities for institutional deliveries.
Furthermore, just 9.3% of all pregnant women in Bihar took iron folic acid for 180 days, despite the fact that 89.5% of registered pregnant women received the Mother and Child Protection Card, which tracks the health of each mother and child.
With 118 deaths per 100,000 live births in 2018–2020 and 47 deaths before the age of one year per 1,000 live births in 2019–2021, this translates to one of the state’s worst healthcare indices for mothers and children.
All expectant and lactating mothers are eligible to receive Rs 5,000 as financial assistance under the PMMVY. This aid is sent directly to their bank accounts in two installments: one after the pregnant woman’s required registration and the other after the child’s registration.
Pregnant women receive a total of Rs 6,000 in addition to the benefits under the Janani Suraksha Yojana, which aims to reduce maternal and newborn mortality by boosting hospital delivery.
If the second child is a female, starting from the fiscal year 2022, the PMMVY will cover two children. In an effort to deter female foeticide, the mother of the girl child receives Rs 6,000 as one-time payment after the birth.
Women who experience a stillbirth or miscarriage can reapply for the benefit as new beneficiaries if they become pregnant again.
In addition to improving a pregnant woman’s approach and access to healthcare, the monetary incentive guarantees that she gets enough sleep both before and after giving birth to her first child. To enhance mother and child health, however, in addition to financial support, health infrastructure and procedures must be strengthened.
“Maternal health is also impacted by social determinants such as gender discrimination, poverty, asset limitations, low levels of education, and cultural norms, as well as a lack of women’s involvement in reproductive decision-making,” argued Ujala Kumari, a policy analyst at the Center for Budget and Governance Accountability, in her article published on the website.
Both the Central as well as state governments provide funding for the PMMVY. Nonetheless, the program is frequently criticized for having gaps in its implementation and insufficient funding.
“The fund availability under the scheme appears to be inadequate going by the number of applications received,” she said, stating that the number of applications and enrolled beneficiaries were at their peak during the pandemic, according to a review of fund allocation and usage from 2019 to 2021, and payments were constantly received.
“This might be the result of laborers migrating back home during the pandemic, from urban to rural areas,” she added.
The registration process’s intricacies are a major contributing factor to the low PMMVY enrollment rate. This further feeds the vicious cycle of declining prenatal care visits and delivery registration.
“The requirement for the woman’s husband’s Aadhar card, a workforce devoid of tech know-how, and inadequate network connectivity in remote areas are among the registration hurdles,” she explained.
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