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Why is maternal mortality a problem in India? It's all in the numbers.
PITHAKHAITI, India — Growing up in a small village in northeastern India, Hasina Khatun spent her days helping her aunt around the house and playing with her siblings. She did not drop out of school; she never started. Hasina began menstruating at the age of 13 and soon after her aunt, who raised her after her mother died, told her it was time to get married. Hasina did not understand what her aunt meant, or that her life was about to change dramatically.
“I thought marriage was a game,” Hasina says as she sits in a bamboo home in her husband’s village. She fidgets with her orange, black and green sari that covers her head and falls over her breasts, unusually big for her tiny frame. Hasina is now 15 and five months pregnant.
Nearly half of girls in India are married before they turn 18, according to the International Center for Research on Women, making India home to a third of the world’s child brides. In India, there is often social pressure on women to give birth soon after marriage to prove their fertility. Child brides like Hasina — even though their bodies are often too small and undeveloped to handle the burden of a pregnancy — are no exception.
Child marriage increases the chances of a maternal death due to an increase in the likelihood of pregnancy complications combined with lack of knowledge about maternal health, lack of control over medical decisions and lack of access to timely and adequate health care. A girl who gives birth under the age of 15 is five times more likely to die in pregnancy or childbirth than a woman in her 20s, according to the United Nations Population Fund. Girls 15 to 19 are twice as likely to die.
After decades of neglect, the Indian government began to prioritize maternal health in 2005 and embarked on an effort to reduce its maternal mortality rate through its National Rural Health Mission. India contributes almost a quarter of the world’s maternal deaths, at least 70,000 deaths each year. A commitment to reduce the number of women and girls who die from pregnancy, labor or post-pregnancy causes comes as countries face growing pressure to meet the Millennium Development Goals set by the international community. Improving women’s reproductive health and reducing maternal mortality is one of eight goals U.N. member states including India have agreed to achieve by 2015.
Nationwide, India’s maternal mortality rate has dropped from 677 deaths per 100,000 live births in 1980 to 254 in 2008, according to a study published in the British medical journal The Lancet in April.
However, despite improvements among some segments of the population, there are great disparities within the country. Factors related to education, caste, religion, income and geographic region reflect the nation’s socio-economic diversity and lead to differences in the status of maternal health.
Assam, where Hasina lives, has been plagued by decades of underdevelopment, unrest and corruption and has the country’s highest rate of maternal mortality at 480 deaths per 100,000 live births, according to government statistics.
While India has made progress with maternal health targets that are more easily achievable, like in encouraging more women to give birth in medical facilities, its biggest challenge now is to address the difficult cases. And of these, mothers like Hasina are among the hardest to reach and help.
When Hasina was 13 her aunt told her she would marry Islam Ali, a young man who also never went to school. As a teenager, Islam worked as a day laborer on other people’s fields in Dibrugarh, a district in upper Assam known for its beautiful tea plantations.
When Islam was 19, his mother fell sick, he says through a translator as he sits inside a one-room bamboo home in his village. A farming hoe leans against a wall near the door, and a collection of men’s pants and women’s saris rest on a wooden rod. Islam speaks in Bengali, and his words are translated into Assamese and then English.
With his mother unable to perform her household duties, Islam’s father decided his son should move back to their village and get a wife to look after the family. Islam’s father worked out with Hasina’s family the deals of the marriage.
Hasina’s aunt then explained to the 13-year-old that she would have to leave her family and friends and move to her new husband’s village, which is on an island on the Brahmaputra River in lower Assam.
About 3 million people live in villages on these islands, most of which have no electricity, roads, secondary schools or just about any public services. The people live on the islands because they rely on the river for their fishing and farming. In a state with close to 30 million people and a growing shortage of land, the island dwellers also have nowhere else to go.
In communities like Islam’s, many of the villagers originally moved to Assam as migrant workers or refugees from Bangladesh. While some have now lived in India for generations, most still speak Bengali and practice a more conservative form of Islam than the Assamese Muslims. Many indigenous Assamese resent them for what they see as encroachment upon their land. The Assamese fear their numbers will outpace their own population and view them as a threat to Assamese culture and way of life.
Islam’s village, Pithakhaiti No. 2, is about 25 kilometers and a two- to three-hour boat ride away from Hasina’s family on the mainland. It has a population of 886.
Hasina did not want to move to her in-laws’ village, but she had no option.
Three days after getting married, Islam told Hasina they would have sex. Hasina said no. But like every other decision in her life, the 13-year-old did not have a choice.
Islam, a muscular young man who towers over Hasina, forced himself on her. Her body pulsated in pain, and Hasina sobbed.
Hasina, suddenly living in a new village without her family or friends, did not tell anyone about her first sexual experience. The first time she talks about it is with me.
As she tells me what happened, she does not shed a tear or show grief. She talks in a matter-of-fact style, answering most questions with hei (yes) or na (no). And while she has never told anyone about Islam forcing himself on her, she does not act like it is a big secret. Rather, it is simply the life she knows.
As we chat, children, men and women from the village repeatedly gather at the door to get a view of the action. The translators and I ask them to leave, over and over. We cannot shut the door because the home does not have electricity, and we depend on the natural light to see each other.
Islam also tries to stand by the door and watch. We ask him to leave, and he does. In a world where the men make the decisions, if he had wanted to stop the interview or insist on being in the room, he could have. But he allows his young wife to talk to us. We are therefore able to talk to Hasina and Islam separately.
Islam says that even though Hasina told him she was not interested in having sex, he pursued it because that is what married couples do.
“Since we’re married, we will live together in good times and hard times, so we have to go for it,” he says.
Islam says Hasina had problems during intercourse, but that when she felt discomfort, he stopped.
Hasina’s story differs. She says that despite her evident pain, Islam continued.
The teenager clutches a piece of her sari in her hand as she talks. After the first time having sex, she says, Islam forced himself on her once a week. Hasina keeps her eyes focused on the dirt floor and pulls her sari up to her face, resting it against her cheek. She says she did not once enjoy the sex, but she felt like it was her responsibility to her husband.
Asked if Islam ever used protection, she says she does not know.
Islam says there were problems early in the marriage related to Hasina’s young age.
“Because she was a small girl,” he says as he chews on a piece of grass, “she wouldn’t listen to me.” He would tell Hasina to get him a glass of water or do chores for him, and she would refuse. The community got involved and taught Hasina what it meant in their village to be a wife.
“My parents, neighbors and sisters told her, ‘He’s your husband, you have to listen to him,’” he says.
Islam has a strong jaw line and deep dark eyes. Light coming through holes in the home’s tin roof reflects on his full head of black hair, which he wears stylishly long in the front and brushed to one side. After the first year of marriage, he says, Hasina got better at following directions and doing what she was told.
It has been about two years since they got married and had their first sexual encounter, and a bump is evident under Hasina’s sari. The 15-year-old with a heart-shaped, delicate face who walks around her village barefoot like the other children says she was happy to get pregnant. She thought it would make her an adult.
“When women bear a child they get respect,” she says.
After chatting with us, Hasina goes to a small clinic set up in the village by the Centre for North East Studies and Policy Research. The organization, which receives support from the government, sends boats equipped with doctors, nurses and medical supplies to villages on the Brahmaputra to provide basic medical care. For many of the villagers — including Hasina — the boats provide them their first ever health care.
A nurse sits on a plastic chair in front of a bamboo home and asks Hasina questions about her background and pregnancy as children from the village gather around to watch. The antenatal checkup is Hasina’s first visit with a medical professional. The boats had come a month earlier, but Hasina had not come to the clinic because her in-law’s thatch-roof home is across a small stream, three kilometers away. Hasina says she has a government-sponsored community health volunteer, called an Accredited Social Health Activist (ASHA), but the ASHA worker had not told her about the boat clinic.
The nurse examines Hasina and discovers that the girl, like 73 percent of pregnant women in Assam, is anemic. Her hemoglobin level, which should be at least 11 grams per deciliter, is 6.4. Such severe anemia is a result of chronic malnutrition, say doctors from the boat clinic. The nurse gives her extra iron and folic acid tablets.
When pregnant women are anemic, they are at greater risk of premature delivery, having a low-weight baby, falling sick from infectious disease and dying during childbirth. If anemic women or girls like Hasina have a complication such as a hemorrhage and do not have access to emergency obstetric care, they face the threat of bleeding to death.
Hasina says that when she goes into labor, she will stay home rather than give birth in a medical facility. She knows she would receive 1,400 rupees ($30) from the government to give birth in an institution, but she says it would cost about 1,500 rupees to take a boat and then public transportation to get to the primary health center on the mainland plus to pay for some of the medications. The government’s National Rural Health Mission helps defray some of the costs of transportation, but Hasina says its not enough to make the trip worth it for her.
She also does not want to go to a health center because she does not want to be seen naked by male doctors, she says.
And finally and perhaps most importantly, Hasina says Islam wants her to give birth at home.
“Home is better,” she says.
The nurse scolds Hasina like a parent, asking her what will happen if she has a medical complication and she is in a tiny hut on an island far from any trained medical professionals.
Hasina shrugs and says, “If I die, I die.”
To this young girl, that is life.
This reporting was sponsored by a grant from the Pulitzer Center on Crisis Reporting.