By Abha Rao

Near the end of the epic poem Ramayana, a pregnant Sita is banished to the forest by Rama. She seeks refuge in the sage Valmiki’s ashram, and shortly thereafter, gives birth to twin boys. For at least one young feminist (me!), this familiar story aroused both anger about the gendered unfairness of Sita’s abandonment and concern about her labour and delivery deep in the forest. These apprehensions were not unfounded, as it reflects the experiences of not only mythological characters but of many Adivasi women across India even today. 

Between 2014 and 2018, I worked on several projects in the Chamarajnagar district in southern Karnataka, an area that has a significant Adivasi population. In those years, I visited anganwadis across the district, met with district and taluk level health officials and anganwadi workers, and interviewed many women of reproductive age. Two issues cropped up regularly – the prevalence of anemia, and the barriers to women seeking healthcare. One is a medical issue and the other a structural and social issue, and both contribute significantly to a bigger problem: complicated pregnancies and maternal deaths.     

India’s Maternal Mortality Rate (MMR) has dropped considerably over the decades and is currently about 113 deaths per 100,000 births. There is a great deal of variation within the country, ranging from a low of 43 in Kerala to a high of 215 in Assam; only a few states in the country currently meet the Sustainable Development Goal (SDG) of less than 70 deaths per 100,000 births. The MMR of Adivasi women is currently not known, although evidence from field research suggests that their rate disproportionately exceeds that of non-Adivasi women. But MMR is just one statistic – one that represents a string of maternal health failures along the way. Several studies conducted across a range of tribal communities, from the Sugali in Rayalaseema (Andhra Pradesh) and the Kondh in Rayagada (Odisha) to the Gonds and other communities in Bastar (Chhattisgarh) and Soliga in BR Hills (Karnataka), all tell the same story: Adivasi women’s health is severely compromised by limited contact with mainstream health services during their reproductive years.

Many Adivasi women have indicators that increase the risk of poor maternal health outcomes, including menstrual problems, high rates of anaemia and undernutrition, early childbearing, and having more than four children. Despite the gender egalitarianism prevalent in Adivasi culture, women still have limited control over their bodies and ability to seek healthcare services, especially during their reproductive years. The communities are often poor and live in remote, hard-to-access areas, which may lack healthcare facilities. Even if such facilities exist, they are often inadequately staffed and poorly resourced. As a result, Adivasi women are less likely to receive antenatal care, deliver in a health facility, or have postnatal check-ups compared with non-Adivasi women.     

While some of this lack of access is due to logistical barriers, many tribal women report being discriminated against in their interactions with health services. This is evident in the lack of responsiveness to their needs, dismissal of traditional Adivasi beliefs and practices related to pregnancy, labour, delivery, and postnatal care, and the exclusion of traditional midwives and other birth attendants. These negative experiences have led to a distrust of the health system and a disincentive to interact with health workers or visit facilities. 

In more recent years, I have spent time in temporary migrant settlements interviewing women, many of them Adivasis from northern Karnataka, working mainly as construction labourers in Bangalore. While the challenges of physical access are mitigated by urban living, the reluctance to visit mainstream health facilities remains, due to repeated experiences of being neglected or treated poorly by medical providers on account of their poverty.

Sita was a goddess and the safe birth of her sons was likely overseen by the will of divine beings. But Adivasi women have no such guarantees. In order to ensure their well-being, maternal health interventions for this population need to involve the community and be culturally and linguistically appropriate. Healthcare providers need to be held accountable with respect to providing care that is non-discriminatory and respectful of traditional beliefs and practices.

Abha Rao is a public health researcher with training in family studies, human development and medical anthropology, with an interest in sexual, reproductive, and maternal health issues.  

Abha Rao

Research Scientist & Assistant Professor

Ramalingaswami Centre on Equity & Social Determinants of Health

Public Health Foundation of India

References

Chauhan, P., Chauhan, V. K. S., & Shrivastava, P. (2012). Maternal mortality among tribal women at a tertiary level of care in Bastar, Chhattisgarh. Global journal of health science, 4(2), 132.

Contractor, S. Q., Das, A., Dasgupta, J., & Van Belle, S. (2018). Beyond the template: the needs of tribal women and their experiences with maternity services in Odisha, India. International journal for equity in health, 17(1), 1-13.

Geetha, P., Chenchuprasad, C., Sathyavathi, R. B., Reddy, K. S., & Reddy, K. K. (2015). Reproductive Health Status of Sugali Tribal Women: A Field Based Study. Studies of Tribes and Tribals, 13(1), 73-78.

Ministry of Health & Family Welfare and Ministry of Tribal Affairs (2018). Report of the expert committee on tribal health, tribal health in India: Bridging the gap and roadmap for the future-Policy brief. Available at: http://nhsrcindia.org/news/report-expert-committee-tribal-health.

Sengupta, A. (2019). Maternal health in underserved tribal India. Sexual and reproductive health matters, 27(1), 304-306.

Sample Registration System, Office of the Registrar General, India (2020). Special Bulletin on Maternal Mortality in India, 2016-2018. Available at: https://censusindia.gov.in/vital_statistics/SRS_Bulletins/MMR%20Bulletin%202016-18.pdf. 

Zilla Budakattu Girijana Abhivrudhhi Sangha (2016). Maternal health of tribal communities in Chamarajanagar district, Karnataka: A community’s reflection on their access to maternal health services. A report submitted to the Implementation Research Platform, WHO Alliance for Health Policy and Systems Research.