Thursday, 13 November 2014

Concentration of Neonatal Deaths and Role of Community Newborn Care Practices

Neonatal Mortality and its Concentration in India

Every year about 0.76 million neonatal deaths (death within one month of the birth) occur in India, which accounts for 28 percent of such death in the world, the greatest for any country. About two-thirds of infant deaths and half of under-five child deaths are during the neonatal period.  India’s Neonatal Mortality Rate (NMR) stands at 29 deaths per 1000 live birth, and the states at high risk include Madhya Pradesh (39), Odhisa (39), Uttar Pradesh (37), Rajasthan (35) and Chhattisgarh (31).  Though the Neonatal Mortality Rate (NMR) has declined from 52 per 1000 live births in 1990 to 29 per 1000 live births in 2012 (SRS 2012) the declining rate has been very slow as compared to many other developing countries and emerging economic states.

A latest report ‘State of India’s Newborn 2014’ released by Public Health Foundation of India (PHFI) reveals the health disparities among newborns of various communities in India. According to the report, health outcomes are shaped not just by biological factors but also by the social, economic, and cultural environment. Social hierarchies and inequitable distribution of resources produce significant inequalities in the health and well being of people.

Considering the health inequality and social inequality interface, the poorest and most disadvantaged have a higher risk for diseases. This includes the urban and rural poor, female children, specially-abled persons, and traditionally marginalized and excluded communities like Scheduled Tribes (STs), Scheduled Castes (SCs), and ethnic and religious minorities. They also have a higher probability of being excluded from the health services. The PHFI report states that the newborn in these populations are expected to be the most vulnerable to morbidity and mortality. It is evident from the empirical data on Indian neonatal and child mortality that mortality is high among children of these socially disadvantaged and economically deprived communities. The report by Public Health Foundation of India has also emphasized on identifying such communities. The report says that doing this will help in identifying entry points for action and setting priorities for long-term improvement in neonatal survival.

High Risk Communities

High Risk Communities
Status of Neonatal Deaths
Rural Population
In rural areas, neonates are at two times more risk of dying, as compared to their urban counterparts. Data has recorded Neonatal Mortality Rate as high as 33 deaths per 1000 live birth in rural India as compared to 16 for urban areas.
Source: SRS
As children get older, probability of female mortality becomes higher than the males. Females have 36 percent higher mortality than males in the post neonatal period, but a 61 percent higher mortality than males at age 1-4 years.
Source: NFHS-3
Dalits and Adivasis
Child born in a SC family has 13 per cent higher risk of dying in the neonatal period and 18 percent higher risk of dying in the post-neonatal period, as compared to others. Similarly, a child born in a ST family has 19 per cent higher risk of dying in the neonatal period and 54 percent risk of dying in the post neonatal period. 
Source: UNICEF
Educationally Disadvantage Section
Children born to a mother with at least eight years of schooling have 32 percent lesser chance of dying in neonatal period and 52 per cent lesser chances in the postnatal period, as compared to illiterate mothers.
Source: UNICEF

Newborn Care Practices among High-risk Communities

Given the diversity of India, each community and region have their own local newborn care practices. Most of these practices are strong and legitimate, since they originate from local culture, environment and religion. Some of them are also based on traditional medical knowledge of the community regarding pregnancy and neonatal care. Traditional Birth Attendants (TBAs) are the key stakeholders in practicing and delivering traditional neonatal for the disadvantaged population in villages, slums, tribal areas etc. Various studies on this issue have identified many practices that are healthy for the survival and growth of the newborn. However, studies also identify a number of hazardous practices that leads to many prevalent causes of neonatal death such as sepsis, pneumonia, birth asphyxia, injuries, tetanus and diarrhea. The lack of institutional care system and prevalence of such harmful neonatal care practices are correlated to the higher concentration of neonatal death in villages, slums and traditional communities. Some of these practices are described here briefly to understand their impact.

Harmful Local Neonatal Care Practices
Health Consequences
Home Delivery by Untrained Individual
More than one third of deliveries in the rural areas are conducted outside health institutions. One in every four deliveries is conducted by untrained individual/person in the villages.
The unsafe places of deliveries and untrained person conducting deliveries cannot handle complicated cases. This increases probability of health complications in mother and neonatal care.
Thermal Care
Common practices in slums and rural areas identified by number of studies reveals that most of the newborn were given a bath immediately after birth.
Bathing immediately after birth causes hypothermia and may lead to death
Delay in Breastfeeding
According to the latest SRS data, during 2012-13 as high as 3.72 million newborns in India were not breastfed within one hour of the birth
The delay in breastfeeding and feeding baby with any liquid and solid food other than mother’s milk before the age of six month is a harmful practice for health and survival of the newborn.
Asphysia Care
To clean the airway of secretion, the newborn needs to be held upside down and the back slapped immediately after birth. Many studies found that there is a lack of knowledge about asphyxia in communities across the country and also amongst traditional birth attendants.
Asphyxia is one of the major causes of the neonatal death in India. Common community practices such as holding the baby upside down and patting or massaging it, blowing in the ears, sprinkling and dipping it in water and making loud noises are harmful for the newborn
Postpartum Hygiene
Umbilical cord care is a big issue in villages, tribal areas and in the slums.
Cord cutting and tying practices in rural India is one among high risk factors for neonatal infections. The blade is commonly used to cut off the umbilical cord in rural and geographically difficult areas but following the steps of clean cord care remain a problem. Most people lack knowledge about sterilization of the blade and after care.

Policy Responses and Way Forward

The entire cycle of reproduction and local cultural practices are intertwining. There are number of good neonatal care practices but we have also witnessed a number of harmful practices that fuel mortality of newborns. It shows us that the issue is not just medical but also has social dimensions. Indian Maternal and Child health policies have always addressed social aspect in various ways. In the last decade, National Rural Health Mission promoted community level interventions through ASHAs. However, TBAs remain the main source for delivering both good and bad community practices. The Indian policies never took TBAs seriously to involve them in health system other than providing them some skill trainings. There were no serious efforts to exchange knowledge between TBAs and modern medical professionals. Health system needs to accommodate TBAs and consider their community influence, traditional knowledge and skills along with knowledge gap to promote better neonatal care in the country.

Jeet Singh and Shriyam Gupta

Tuesday, 4 November 2014

Creating Social Change to End Manual Scavenging

Source: UN Women
Manual Scavenging-The dirty truth
“Hundreds of thousands of impoverished "low caste" Indians are being forced to clean human excreta from dry toilets and open drains, despite a ban on the discriminatory and undignified practice”, reports Human Rights Watch (HRW) in its recent publication in August 2014. It is a shameful truth that reflects the discrimination practised by society and the state towards one of the most vulnerable sections of the population, the Dalits.

Manual Scavenging is not only dehumanising but also dangerous. According to the Tata Institute of Social Sciences, 80 per cent of the manual scavengers die before they turn 60 because of health problems and accidents. In the last decade, 98 manual scavengers have died in Gujarat. This figure was gathered by Safai Kamdar Vikas Nigam, in reply to an RTI query and was published by the Times Of India in April 2014.

Despite legislations prohibiting employment of manual scavengers and demolition of dry toilets, the 'Houselisting and Housing Census 2011' data in March, 2012 shows a bleak picture. Its estimation of insanitary or dry latrines in the country is close to 26 lakhs. Though there is no credible data on the exact count of manual scavengers in the country, various surveys and sources have suggested that there are approximately 11 lakhs manual scavengers in India.  

Legislations banning the practice alone cannot change the social realities. There are number of legislations to eliminate manual scavenging like The Civil Rights Act, 1955; the Construction of Dry Latrines and Employment of Manual Scavengers (Prohibition) Act, 1993 and the recently enacted Prohibition of Employment as Manual Scavengers and their Rehabilitation Act, 2013. However, the twin evils of insanitary latrines and manual scavenging persist.

Our society has to challenge and break free from the internalised caste hierarchy, empower the minds of the manual scavengers and change the attitude of the state.

Attitude of the society
Manual scavenging is a manifestation of the rigid caste system in India. Manual scavengers belong to one of the Dalit sub-castes and are considered lowest in the caste hierarchy. The society, time and again has treated Dalits as untouchables and reserved the humiliating job of cleaning excreta only for them thus reinforcing the idea of untouchability based on occupation. A child born into a family of manual scavengers is denied the basic rights guaranteed under the constitution. Manual scavenging as an occupation is passed on from one generation to another.
 In the rare occasion when a manual scavenger challenges the social structure and his position in it; s/he is threatened by members of higher castes, and ostracized to the extent that s/he is denied food entry to communal land to feed their livestock, and other facilities necessary for his survival. The community in which the manual scavenger lives does not allow them to break free from their caste based roles.

Lack of political will of the State
Government institutions like municipal corporations, village councils, railways and defence are the largest violators of the law and perpetuate the problem by continuing to recruit manual scavengers and failing to demolish dry toilets.

Indian Railways
Approximately 43,000 railway coaches are engaged in the passenger service, and there are about 1, 72,000 insanitary toilets which discharge the human excreta on the railway tracks that require the services of manual scavengers. Intrigued, the high court ordered an inspection of bio-toilets led by a team of senior advocates P S Narasimha and Rajiv Nanda. In their status report to the court, the advocates described work on bio-toilet installation as being extremely slow and criticised the Ministry of Railway’s timid target of installing only 500 bio-toilets.

Municipal Corporations
A recent survey report by Manav Garima, a community based organisation fighting against dry toilets and practice of manual scavenging have brought to light the existence of dysfunctional toilets under the aegis of Ahmedabad Municipal Corporation (AMC). Located in slums, these toilets do not have proper sewerage system, water facility etc.  Also, not every household has a separate toilet. People are forced to defecate in the open. The survey which looked at few sample areas found out that there were 126 areas where manual scavenging was practised and there were 188 dry latrines. To make the situation worse, AMC built 30 new dry toilets in the Nagorivad area of Ahmedabad.

A survey conducted in a few villages of Dhule in Maharashtra, by the Rashtriya Garima Abhiyan showed that 162 women and 90 men were hired by panchayats and municipal corporations to manually clean toilets and open defecation areas.

Challenges faced by people and breaking the silence
People who continue cleaning human excreta do it involuntarily under great social pressure, poverty, illiteracy and often because of the extreme atrocities they experience when they seek alternative job opportunities.

As reported in the Human Rights Watch publication, the manual scavengers face resistance not only from the members of higher castes but often from local officials like Pradhans who refuse to give manual scavengers any in

formation or assistance in getting a job card. As a result, manual scavengers are deprived of work opportunities provided by MNREGA.

The fear of demanding a new life and accepting the humiliation as fate is the greatest challenge. There are many schemes and legislations to provide education, alternative job opportunities, trainings to manual scavengers, but these benefits and opportunities alone cannot change their situation unless every single manual scavenger refuses to clean other’s excreta. Until then, when a manuals scavenger denies cleaning the dirt, there is another manual scavenger ready to do his work.  Hence, it is crucial to make manual scavengers aware that such dehumanising work is illegal and by mobilising them their voice can be made to be heard not as an individual but as a group.

Role of Social Movements towards defending the right’s of manual scavengers
In contrast to constitutional safeguards, some civil society movements have been able to bring to the forefront the massive discrimination faced by manual scavengers in India.

Safai Karamchari Andolan
Safai Karmachari Andolan (SKA) is a national movement working towards eradicating manual scavenging, by organising and mobilising the community around the issues of dignity and rights, accompanied by strategic advocacy and legal interventions. SKA’s efforts helped to uncover the fact that government departments including Railways, Defence, Judiciary and Education are violators of the Manual Scavenging Prohibition Act. A Public Interest Litigation (PIL) was filed in the Supreme Court by SKA and 18 other civil society organisations in 2003. As a result, the Supreme Court gave strict orders to all the states and central ministries to address the issue of manual scavenging. In 2010, for the first time 23 hearings were conducted in the state of Haryana and the act was enforced and 16 members were taken into custody for violating the law and employing manual scavengers.

Rashtriya Garima Abhiyan
Launched by Jan Sahas Development Society, the “Rashtriya Garima Abhiyan” is a national campaign for dignity and elimination of manual scavenging. The Abhiyan has liberated 11,000 manual scavengers in Madhya Pradesh. By organising sanghatans or community-based organisations, it has mobilised manual scavengers and empowered them to oppose all kinds of discrimination. Liberated and empowered, manual scavengers have taken the lead in putting an end to this practice. The campaign has been taken to other villages and states. In December 2012, the Rashtriya Garima Abhiyan, also organised a two-month long march ‘The Maila Mukti Yatra’ across 18 Indian states that liberated thousands of manual scavengers.

Similar success stories have been showcased by other national and local level movements which have successfully spread awareness and empowered manual scavengers and helped them fight against their own fears and challenge the rigid social structure and government institutions that are responsible for depriving them of their rights to live in dignity.

Journey towards changing mindsets
Manual scavenging is “shame of the nation” said Mahatma Gandhi.  The fight to end manual scavenging is more than one individual’s struggle; it is a struggle of the nation. Social movements have shown positive change by bringing people together. For a change to happen at a large scale, it is important for all the segments of the society, including civil society organisations and the state, to join hands and fight against the violation of human dignity.

Legislations and schemes prohibiting manual scavenging, as modernising India’s sanitation, are important. But for effective implementation of these, mindsets of people, society and state needs to undergo change. Synergised efforts towards challenging the caste structure, changing the mindsets of people involved in scavenging and people employing them as scavengers can make a significant positive difference.

By Abhishikta Roy