I spent the last four days observing a training program for Ekjut’s newest participatory meeting cycle. This cycle addresses malnutrition among newborns and infants in the surrounding rural communities and encourages mothers to put aside special food to supplement their child’s nutrition. Dr. Nirmala Nair, Ekjut’s* co-founder, told me this action is sometimes misunderstood by other family members who believe the mother is hoarding food for herself.** This hit me like a truck. These women never stop fighting.
In these rural communities, many women are married well before the age of 18 and give birth within a year. Prenatal care is minimal and often low-quality. Frequently, there are delays in seeking care and arranging transport to local health centers, which may not even be equipped to address problems. Consequently, women may be referred to another hospital, causing additional delays and increasing risk.***
Those who cannot afford hospital care give birth in their village often at the hands of an untrained service provider lacking sterilized instruments. If the mother and child survive that trauma – in Jharkhand, maternal and infant mortality rates are some of the worst in the country (World Bank, Jharkhand 2007) – then they have to battle to feed themselves and their children so they can stave off undernutrition and disease. (World Bank, Jharkhand 2007). Most women repeat this cycle two, three, four times, because contraceptive use is estimated around 25 percent in Jharkhand (World Bank, Jharkhand 2007). This means women spend almost their entire reproductive life fighting to live. Exhausted yet?
As I mentioned in my first post, my work here is focused on family planning. The benefits are multifold. Contraceptives give women the ability to delay motherhood, avoid unintended pregnancies and often unsafe abortions and control the spacing of their children. Not only do each one of these factors play a role in a mother and child’s chance for survival, but family planning can contribute to reducing poverty and hunger and promote gender equality. Family planning also fosters social and economic development within the family, community and country levels, and can even address environmental issues (Guttmacher, 2008).
Internationally, family planning is a salient health issue. For instance, this past July, the London Summit on Family Planning secured $4.6 billion in financial commitments to reduce the unmet need for family planning services, including nearly $2 billion from developing countries alone. Never before has this issue been so widely supported.
For many countries, simple access to contraceptives is enough. However, in the rural, marginalized communities, such as those in which I work, merely handing someone a pill is insufficient. This top down, centralized approach ignores the most important issue: the women. Often, their voices are silenced by multiple attitudes and systems, which treat them as second-class citizens, too ignorant to understand and solve problems facing their own communities. My work in India has made it crystal-clear that these women do have a deep understanding of the root causes of suffering in their communities. They can articulate their understanding quite elegantly, if only we took a moment to stand back and listen – in effect to become their students.
As far as I am concerned, family planning and the choice to control reproductive health is a woman’s right. In order to make an informed choice, women’s education and empowerment should be a priority, coupled with regular and predictable service delivery and access to contraceptives.
There is growing evidence that community participation can be a cost-effective tool to address these issues by empowering communities and improving health outcomes. Participatory learning and action (PLA) models employ strategies of participation, mobilization and empowerment—separate but closely related concepts that build on one another. Guided by local facilitators nominated by the community, individuals come together to actively engage in decisions that affect both their own health and the health of their communities. Consequently, individuals and communities gain control over their own health decisions, while enhancing self-confidence and leadership skills.
During my time in India, it is my hope to utilize this method to address family planning and the unmet need for contraceptives in these marginalized communities. However, while I bring specific skills from my public health training and experience to this effort, the chances of effective change in communities are at their highest when the knowledge and strategies are applied in a collaborative manner, which supports and encourages the ideas and assets of the community.
* Ekjut is an Indian-run NGO that focuses on reducing infant and maternal mortality through participatory learning and action cycle. They are advising me on my Fulbright program. For more information please visit their website at: www.ekjutindia.org.
** As with all stories, the context is critically important. The communities here are traditionally communitarian: everything that the family has is shared between its members. As mothers are learning about the special nutritional needs of their children, seniors remain wedded to status quo. To compound matters, deforestation, droughts and the frequent failing of crops have changed the situation, thus increasing the tension between family members. Participatory methods that build a commonality of understanding between generations can be a solid platform to address these issues.
*** The Indian Government has attempted to address these issues by implementing the National Rural Health Mission (NRHM). While progress has been made, there still are difficulties in reaching the most marginalized of communities.