About the Book:
Consider the following: Eleven out of twelve abortions in India are illegal. The 2001 Census showed a decline in the number of females per thousand males in the most literate and prosperous states, especially in the 0-5 age group. The private sector has more doctors and fewer beds than government hospitals, thereby emphasizing out-patient care. And while Indian traditions sanctify fertility and motherhood, government policies and health care services are focused on controlling fertility.
These are some of the paradoxes of India's health care system Mrinal Pande encountered when she set out on her journey across several states to put together information on the health of Indian women. She soon realized it could not be a mere documentation of the history of reproductive health in India and the state of India's public health care system. Though listening to women's perspectives on their bodies when they came for treatment and conversation with dedicated health workers, she gained an insight into larger realities. The result is a patchwork quilt of narratives about women's lives - how they are affected by their environment, their perspectives on male and female sexuality, the mystery of pregnancy, the joy of birth, the fear of infertility, the pain of backroom abortions and the often bleak world of adolescent girls.
Mrinal Pande also discusses important issues like the population policies followed by the government over half a century and the consequences of a welfare state abdicating its obligation to provide basic health care for all in its pursuit of globalization and market economics. Through it all she reveals enormous faith in the role of non-governmental organizations in providing better health care services - the dedicated doctors and attendants who are making a difference, helping women step out from the dark bylanes and silence of their lives to create a socio-cultural milieu which restores their basic dignity and rights.
Mrinal Pande is the group editor of the Hindi publication of the Hindustan Times house: the daily Hindustan, a monthly digest Kadambini and a magazine for children, Nandan. She also been the editor of verma and Saptahik Hindustane, executive editor of a Hindustan Dainik, senior editorial adviser to NDTV and has anchored the Hindi news for Doordarshan. The first Indian woman to be editor-in-chief of a multi-edition national daily newspaper, she is the founder president of the Indian Woman's Press Crops. Mrinal has written extensively in Hindi and english, including novales, short stories and essays, has written a column for the Hindu. She has previously published Daughter's and Devi: Tales of the Goddness in Our Time, and a noval, My own Withness.
Half a century after the makers of lndia’s constitution opted for a socialist welfare state and limited laissez-faire economics at the national level, a new globalized system is emerging. It decrees that in the twenty-first century volatile market forces shall be the locomotive of growth. And elected governments and the people must learn to live with invisible hands. It is not difficult to see how this model relies a lot on both the state and the markets behaving rationally in the pursuit of their legitimate interests. But what happens if behaviour is not always rational? What about socio- cultural practices that time and again get in the way when calculating the utility of children and the need for population control?
It would be deterministic to say that all Indians or some states in India are programmed for population proliferation. Also, it is not at all clear that the two great priorities of our democratic capitalism—economic integration and political self-determination- will complement each other in the twenty—first century, as they have not in the last decade of the twentieth century Historic evidence shows that the desire to procreate is deeply embedded in human nature, and matrimony and childbirth have always been treated as holy and ennobling experiences by all communities and castes in India. If the state refuses to accept and endorse this view and opts for blind coercion, individually or culturally sanctioned procreative activity may start giving subtle encouragement to people to ignore all appeals for planned families. As the scientists tell us, under certain circumstances, even inanimate objects such as molecules may reveal a capacity for self—organization.
The new economy India has opted for is distributing wealth in an unprecedentedly unequal manner today. Everywhere you travel in India, you see two kinds of life, two kinds of growth. On the one hand, there are gigantic shopping malls, from Ahmedabad, Allahabad, Guwahati and Kottayam to Amritsar and Chennai. One is struck by the richness and variety of goods displayed there, as also by the number of rich urban and rural customers they attract through the year. At the same time, the numbers of our poor and their miserable unauthorized colonies are also growing. Theirs is a lean and disempowered weld, furnished with objects of the most elementary kind, overflowing with hoards of malnourished children. Life here has come to be entirely sustained by symbolic values and meanings that the poor will impart to the most mundane things in the face of total neglect by the state. Here a pubescent girl being fed with rotis from five homes becomes a symbol of nascent and holy fertility that creates life. A smudge of black kohl or honey on a child’s tongue shall become a shield that will protect him from all illnesses. A smear of red on a new mother’s forehead shall anoint her as Laxmi, the fertile creator of wealth and life, in the midst of poverty and death.
There is nothing here. No money no nutrition or sterilized water, not even medicines of the most basic kind. Only a few coins, a small dish with vermilion, jaggery and wild flowers, a coconut shell with a few teaspoons of oil, and a gourd with rice liquor. And yet those who are gathered around the objects look wildly excited and proud. The young woman, by giving birth, has attained a great honour, and her new baby is deemed an honoured addition to the community.
CEHAT, one of the Mumbai—based groups that I interacted with during the course of my travels for this book, had in 2001 filed a writ petition in the Supreme Court of India alleging that, laws notwithstanding, large—scale illegal sex determination and subsequent aborting of female foetuses were still going on in no less than eleven states of India. These are ironically some of the richer states that according to the latest census reports have registered a worrisome decline in their girl child population in the 0-6 age group. Piqued by the refusal of several state governments to curb private clinics that use ultrasonic techniques and amniocentesis to check out the gender of the unborn foetus, and help abort the unwanted female, the Supreme Court of India summoned their health secretaries. The court severely indicted the state governments for not complying with its earlier orders for registration of all ultrasound clinics and prosecution of those who resorted to illegal sex determination of the unborn foetus. And it also ruled that it would be desirable for the Government of India to frame appropriate rules with regard to sale of such (ultrasound) machines to unregistered clinics.
India’s supreme court may or may not favour privatization of medical and health services, but its recent ruling reveals that it definitely expects them to be monitored and supervised strictly by a national (read governmental) authority It is notable too that privately run hospitals and clinics may be critical of the state—run health care system, but they also look to the state for the order within which legal contracts can be enforced and commerce can flourish. (There is no rush these days, for example, to open branches of leading private hospital chains in militancy—infested areas, where the rule of law is shaky.)
But what is it like for a woman living below the poverty line in the India of today to be a client of the governmental and non- governmental health care systems? Can the comfortingly simple categories of good and evil, guilty and innocent that we take for granted be applied to those who live in extreme deprivation? How should we view a woman’s silence? While she quietly accepts what is given, is there a whole angry debate running inside her head? If yes, how does this anger manifest itself? Does it taint her relationship with her own children, especially her daughters? These are some of the questions that have haunted my mind whenever I have travelled as a journalist gathering stories about women’s lives and their state and status at the workplace, which exposes them to tremendous health hazards.
The door to finding satisfactory answers to these questions was first opened for me in 1998 by Carmen Barroso, Director, Population and Reproductive Health Area, and Poonam Muthreja, Country Coordinator, India, of the john D. and Catherine T. { McArthur Foundation. They suggested that I put together the, not-inconsiderable information available on the subject of Indian women’s reproductive health and update and strengthen it with 1 travels to various parts of India. They inspired me further by providing lists of NGOs working in remote areas in the field of health care, and helped me contact them and prepare a travel itinerary In 1999, Vasudha Dhagamwar, Director and founder of Multiple Action Research Group (MARG), hired me to pursue I the project. The support and patience I have received from these three extraordinary women has been the mainstay of this book.
The social and health workers and women from urban slums A and rural communities that I met and interviewed during the course of my travels all agreed that if India’s population policies are to succeed, it is necessary that women have real control over both their productive and reproductive lives. It is senseless to pour an inordinate amount of energy and resources into controlling l female fertility while neglecting a genuine socio-political agenda A towards restoring the basic dignity and human rights for all women. Our population problem can and must be tackled in the overall context of democracy, not demography.
Under the circumstances, the NGOs’ template for better reproductive and child health care with its sensible and sensitive support for local customs and culture, and their tendency to consult I with those for whom the family welfare programmes are meant, seems a much better model than the one created by our policy makers who seem to nurse an arrogant, unilateral disdain for the human rights of the poor. One wonders, however, if the old-timers on the national government’s huge population policy team will be willing to humbly learn from the non-governmental sector. Will the financial advisers to various governments at the Centre be more willing to allocate larger funds for health care? Will an administration, filled with promoters eager to increase the pace of privatization, be willing to put the necessary pressure for cross- subsidies for public health insurance, better monitoring of private clinics, and allocation of a compulsory apprenticeship in the public sector health care system for all students of medicine? And, above all, will we, the Indian public, have the patience, the sophistication and the fortitude to do some soul searching on the matter and become more engaged with health care issues?
Over the course of a couple of years, I travelled to five states—West Bengal, Tamil Nadu, Maharashtra, Gujarat and Rajasthan——to gather information (apart from Delhi). I visited the projects of a number of NGOs, including CINI, SEARCH, MASUM, SEWA and ARTH. My first-hand experiences and what I learnt from those whom I interacted with forms the basis of this book. Occasionally, I have provided relevant state-level and all—India data on the issue being discussed to better inform the understanding of the larger picture for the reader. But as it has finally shaped up, the book must remain a kind of a patchwork quilt of wo1nen’s narratives about their lives. And in the manner of all quilting activity, the stories will often allow key characters, incidents, statistics and themes to criss—cross each other, across the boundaries of various states.
At the end of my travels I realized that for women, who form half of India’s population, democracy can have no joy unless it is also accompanied by freedom and dignity There is hope yet for women, provided the welfare state does not abdicate its basic obligation of providing health care and education for all. This, incidentally is also the only guarantee we have that the democratic state will not give way once again to aggressive and violent medieval empires.
While writing this book, many people—friends, family, interviewers—asked me what the book was about. I was reluctant to give them a precise answer then. On its completion, I can say the book is variously about women’s health, about how their lives are affected by the environment they live in, about the pain of infertility about the joy and mystery of pregnancy and birth, about the fear and pain of unwanted pregnancies and back room abortions, about the sometimes radiant and oftentimes bleak world of adolescent girls, and last, but not least, about male and female sexuality.
Ultimately I hope my readers will see the book not as an academic exercise but as an intellectual journey and (hopefully) a sustained exploration of the relationship between social power and political power in a democracy such as ours. I, too, like most of my readers, had started by assuming that sex is basically biological, whereas gender is a social construct. The women I met in the rural areas and urban slums of India made me realize painfully how amidst inequality an Indian woman’s sexuality often acquires social overtones and determines her social destiny This book thus recognizes and upholds the power of the democratic Indian state and the power that our law has to confer legitimacy to a woman’s search for equality—both political and social—in the face of tremendous odds. Democracy may be the truth, or as Nietzsche said (about Christianity), it may be a ‘fruitful lie’, but it is the only form of governance that women can be comfortable with in their endeavour to step out and gain equality.
Imagine a spectrum, at one end of which is a mud and straw hut in Rajasthan, where an undernourished, anaemic nineteen-year-old mother of three is expecting her fourth child. Married at fourteen, she became a mother at fifteen, and has since been pregnant most of the time. She knows about the need for rest and nutrition and the existence of a primary health centre (PHC). But for her to get to the nearest one for care and counselling would entail an hour's walk and then a two-hour ride in a bus. Before she embarks on her journey, she must take permission from the family, do all the household chores, feed everyone, hastily swallow the leftovers, arrange for her older children to be looked after by friends, carry her youngest on her hip, and make sure that she gets home to cook the evening meal before her husband gets back from the fields. When she finally makes it to the dispensary, she could be told by the 'nurse bai' that she is late and the visiting doctor has left; if she is willing to get herself sterilized after this pregnancy, she could contact the nurse when she goes into labour, and they will then see what they can do.
At the other end of the same spectrum is an air-conditioned ultrasound clinic-cum-abortion centre in a big city. Here the immensely cheerful and friendly doctors, for a fee varying from Rs 300 to Rs 3000, will carry out sophisticated tests and reveal the sex of the unborn to the client. If it is a female foetus and the family wishes to have it aborted, they will tell them, 'You only have to shell out a further sum of Rs 2000 or so and we shall clean it out. Spend five thousand now, save five laky (in dowry) later.' The case will, of course, not be recorded in the register.
Neither of these images is an exaggeration.
I travelled around the country for a little over two years, gathering pain. Whenever opportunity arose, I visited NGOs working in remote rural areas and urban slums. I avoided any structured agenda, official invitations or routes, important local personages and high-level politicians. Instead, I hitched rides with health workers and sat in their offices and clinics chatting with them, or just watched as women came in to be checked, counselled and treated.
Genuine compassion is rare in the lives of the poor. And women of all ages, classes and castes let their lives unfurl under the kind gaze of these doctors and their attendants who fit Camus' definition of heroism: ordinary human beings doing extraordinary things out of simple decency. As they all talked, I tried to piece together women's impressions about their productive and reproductive lives from their monologues. Ordinary women in India are like those bejewelled court-wives and lowly maids on the wall paintings at Ajanta and 'Ellora, They have quietly watched the spectacle of a male dominant, authoritarian power unfold all around them. They are seldom included in the power equation. More often than not, it generates endless conflict and inequalities in their productive and reproductive lives by depriving them of basic decision-making powers, choices and actions in the name of tradition and security. There is a certain irony in a woman's own frank perspective of her body and her health that steps away from conventional socio- political discourse on these matters. In her heart, one can see, each woman resists easy labels and generalizations. She has her own way of describing her life although she is seldom, if ever, asked to describe her impressions. As she introspects, it takes her time to find the right words, but when she does, her tale gushes out in staccato outbursts. Sometimes she will use only her eyes, at others, her whole body, to drive home a certain point and to explain the moral dilemmas and ironies of her life. The result is a staggering and vivid sketch of a unique human existence where the reproductive life of an ordinary woman can reveal a whole constellation of extraordinary memories and experiences.
When I was growing up, the world seemed divided in two groups: the mothers and the rest of us. And there were two kinds of mothers-those of sons and those of daughters.
On 26 November 2000, a mother who had given birth in a government hospital in Warangal (Andhra Pradesh) charged the hospital with having replaced her newborn son with a daughter, and demanded that her son be restored to her. The police sent the couple and the baby to Hyderabad for a DNA test. The blood samples of the couple matched perfectly with those of the girl. The parents then confessed that the woman had staged the entire drama. She had wanted to destigmatize herself for having given birth to a girl and to take home a male child, She had been under great pressure from her in-laws to produce a son, and feared she would be thrown out of the house if she went back without a son.
lt is not only the poor and the powerless who hanker for sons. One rupee and one son are never enough, the chief minister of one of India's most populous states once told me. One must have at least two sons, he said, lest one turns out to be a dud. He himself had sired eleven children to have the two mandatory sons. Another chief minister's housel1'old erupted into wild celebrations when his daughter-in-law gave birth to a boy after several daughters. 'Sons,' wrote one party sycophant in his letter, 'are like dry fruits. May God give them to everyone?' The unfortunate fact is that the number of female babies in this chief minister's state has been steadily dipping. Demographers suspect sex-selective abortions to be the cause.
Slowly, as I witnessed and wrote about all this, another worldview began to emerge. I began to see how often well- intentioned moves for women's empowerment, such as access to contraception, could and did turn abusive. That if a woman was poor and lived in an urban slum or a backward rural area and did not speak English, the state and the policy makers might be prone to viewing her as less worthy of attention. The system, of which I too was a peripheral part, told her that as a poor, illiterate woman she could not be trusted to make an intelligent choice, so the choices had to be made for her. And when a morally and politically complex issue such as that of accessing safe and legal abortion arose, low class and caste could make a difference to even the most shared basic experience among women.
I must confess, I found it very difficult to express an undistorted account of poor women's frank criticism of privileged women without stepping on an anti-feminist minefield. But I realize that feminist rights debate in India has so far mostly been centered on the urban middle class, upper caste women. To that extent, this narrative may be quite vulnerable to certain kinds of critical probing. But my ultimate query always has been: How do women who have not been included in the feminist debate on rights view the whole scenario of their reproductive health?
such a deeply flawed attitude towards women's reproductive health is not limited merely to women. Men share it too, and since most policy makers and researchers are men, this mindset inhibits serious, in-depth research.
India constituted its first official family planning programme way back in 1950. It was renamed the Family Welfare Programme in the 1970s, and Reproductive and Child Health (RCH) Services in the 1990s. Given the above mindset, it has basically remained a programme to control and reduce fertility. That sexually active - men and women may have asymmetrical roles in childbearing and rearing, that the young wife may have much less of a say in fertility control than her mother-in-law, or adolescents too may have urgent needs for counselling and treatment in this area, are realities mostly not accounted for in this system. The government's efforts to promote acceptance of the small family norm among the poor and the underprivileged have remained some:vhat unrewarded. Since Independence, we have had two National Family Health Surveys (NFHS). These surveys are ajointventure of the Government of India and the International Institute for Population Studies. According to these surveys, the material mortality ratio (MMR)l is on the rise, i.e., more mothers are dying during childbirth today than they did earlier. In 1992-93, the number was 424 deaths per 100,000 live births; in 1998-99 it had gone up to 540! The mortality rates are especially high in states such as Uttar Pradesh, Bihar, Orissa, Rajasthan and the North East, particularly in areas where the number of tribals and lower castes is higher, health services are underdeveloped and hard to reach, most births take place at home and not in hospitals, and where births are not attended by trained personnel.
Fertility in India, a report by the Voluntary Health Association of India (VHAI), has been a demographer's delight and a policy maker's nightmare. As per the report, the total fertility rate (TFR),2 of an average urban woman stands at 3.5. For her rural counterpart the rate is 3.7. Eighty per cent of the births in urban areas and 75 per cent in rural areas take place between the ages of twenty and thirty. Delay in having the first child, all sources testify, is extremely rare, primarily because social pressures on young couples to procreate soon are still intense.
Since Sanjay Gandhi's time, the issue of birth control for men has become such a hot potato that it is almost totally ignored. In
1. Maternal mortality ratio is the number of deaths of females during pregnancy or within forty-two days of termination of pregnancy from any cause related to pregnancy and childbirth per 100,000 births in a given year.
2. Total fertility rate is the average number of children that would be born to a woman if she maintains the current fertility rate all through her reproductive span (15-49 years).
fact, in April 1996, the government announced a shift in policy by abolishing targets and the method-specific approach. A close examination, however, reveals that allover India instead of men the meeker sex, i.e., women, are still being targeted and chased relentlessly for sterilization. Government health functionaries in rural areas are still largely preoccupied with distributing condoms to men and meeting targets for sterilization among women!
Some years ago, the national goal of achieving a birth rate3 of twenty-five per 1000 was translated into targets for different kinds of contraceptive services. But by the time the central government ordered the state governments, who then allocated the targets to the village-level health functionaries, the pursuit of targets was almost totally bereft of the 'cafeteria approach' (that promised women a wide choice of contraceptives) and turned into what one may call a 'ration-shop' attitude ('This is what we have been given, this is all we have. Take it or leave it at your own peril').
Dr Amar Jesani, that tireless data gatherer from CEHAT, told me it is a chicken-and-egg situation. The policy makers have paid more attention to controlling fertility and very little to gearing the system for generating consistent and reliable research-based data. due to a lack of comprehensive data, good sustainable policies are impossible to formulate. Data culled variously by CEHAT, a non- governmental research body, the NFHS and the census reports reveal that there has been an increase in both short- and long-term Illnesses III women, especially before, during and immediately after childbirth. For every one woman who dies due to childbirth- related causes, twenty times ( or more) women suffer from various maternity-related illnesses. These may include short-term illnesses, like white discharge or septic nipples, or long-term morbidities, such as uterine prolapse or recto-vaginal fistulas. Yet, very little reliable research data is available.
The Registrar General of India's surveys are one of the few reliable sources of information about the causes of maternal deaths.
3. Birth rate is the number of births per 1000 population in a. given year.
According to these surveys, in 1993, an overwhelming number (71.2 per cent) of maternal deaths occurred directly due to childbirth; another 12.8 per cent were indirectly related to childbirth.
Infertility is another vital subject that health policy makers have left untouched. It is estimated that between 5 and 10 per cent of all couples in India are infertile, with causes ranging from sexually transmitted diseases (STD) to genital abnormalities and harmful toxins. But given our national obsession with fertility control, the pain and needs of infertile couples are not even recognized. According to the NFHS, women totally incapable of bearing children constitute a small portion (2 per cent) of all women of childbearing age. But translate this into real numbers and you will be astounded. Around 7 per cent of such women have been diagnosed with primary (total) and secondary (inability to carry a pregnancy to full term) sterility. Some reports from Haryana also suggest that twice as many women conceive but are unable to carry a child to full term. The reasons for such miscarriages may range from complications of obstetric and gynaecological procedures, STD and post-abortion infections to pelvic inflammatory diseases that could have been treated but were left unattended for too long.
Findings from studies about utilization of various kinds of health care services show that by and large both the rich and the poor prefer to go to private health care providers and all of them, especially the poor, are spending a large proportion of their incomes on health care. In Andhra Pradesh, Bihar and Uttar Pradesh, according to NFHS, 63 to 81 per cent of health care seekers go to private practitioners. Public facilities are used by the poor only in cases requiring prolonged hospitalization, where cost considerations are an important factor.
Why is this so? Because no matter how good they sound in theory, our population policies are driven by fear and based mostly on stereotypes. They seek to preach and control, not to listen and guide. And women have had enough of it. When you actually go and talk to rural women, their stories about the attitudes of trained government health workers surprise you as much as the widespread desire for fertility control among the women themselves. By indiscriminate administering of birth control pills without prior medical screening, by ignoring male responsibility for birth control and by focusing mainly on irreversible sterilization as the only method 'fit' for the poor, time and again our government health care givers have denied women real control over their own wombs. And women are understandably angry and intrigued by this attitude which reduces them to human guinea pigs.
Such attitudes are not limited to rural health workers alone. One also encounters them among our highly educated and otherwise socially savvy urbane middle classes, as I did
One of the first encounters I had was with a town planner. 'I hear you are writing a book about women and fertility. My field is aesthetics, and I feel that all methods for controlling fertility and demolishing those ugly jhuggi clusters are justified. Ugly sterilized colonies of these Biharis and Bangladeshis are breeding criminals like flies, and destroying the beauty of Delhi.
A friend looks at the TV screen, where one can see the debris from a hill that has collapsed suddenly, killing many hapless dwellers of a shanty town in Mumbai. 'If they do not force such people to be sterilized, how are our cities going to cope with the population explosion and environmental pollution?'
My gynaecologist friend of thirty years peers quizzically at me through her glasses. 'What are you talking about?' she says. 'Sex- selective abortions can revolutionize our family planning programmes. No one, nearly no one, even among my rich clients, wants more than one daughter. They have large families because they want more sons. If I can guarantee them a male child and help abort a female foetus they definitely do not want, what is wrong? She is not going to be a welcome addition to the family, and anyway abortion is legal. So?'
Chase stories about government-controlled contraceptive services in the media and you will uncover facts that will make you laugh till you cry. A visit to Varanasi's famous silk weavers revealed to a journalist friend the astounding fact that some of the weavers were using lubricated condoms for polishing their dharkis (bobbins) so as to speed up the spinning process of the silk saris even when the yarn was weak. According to senior weavers, as free condoms are available at all government-run hospitals, they are thus guaranteed an uninterrupted supply. They even told the reporter that it takes fourteen condoms to produce one sari, and after the lubricants are exhausted, the condoms make good balloons for the child labourers to play with. According to the report, even the local Bunkar Bachao Andolan (Save the Weavers Movement) activists support this novel use of condoms.
In Shamirpet PHC in Andhra Pradesh in November 1998, two years after the new 'non-target' approach had been announced, 676 vasectomies were performed during an intensive 'vasectomy' drive. The target was 300. The reason for such a success for a fertility control programme was the incentive given for vasectomy: Rs 1000 and 100 square yards of land for building a house, plus part payment for its construction. But even here there was a gender bias at work. Women complained that when tubectomies were performed on them by the auxiliary nurse midwife (ANM), she only attended on them till the stitches were removed. After that nobody bothered about what happened to them and their men confiscated their 'incentives' no sooner had they received them!
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