NUH, HARYANA: At Al Afia Civil Hospital popularly known as Mandikhera Civil Hospital, the gynecology department is a hive of activity. An average of 250 babies enter the world each month within the walls of this hospital. Many mothers have already delivered 3-7 children earlier. On-duty medical staff reveal a common occurrence: deliveries with alarmingly low hemoglobin levels in mothers. “Mothers endure childbirth even with hemoglobin levels as low as 2g/dl. Typically, we confront an average of 7g/dl, significantly below the healthy threshold of 12,” shares a seasoned nurse who has been working here for a decade now. Over 60 per cent of women in reproductive age are anaemic, an underestimation claim doctors and health workers. The result? Underweight infants who barely meet WHO’s criterion of 2500 grams. 

“Children just about meet the 2500 grams threshold. Limited education among women and multiple pregnancies contribute to prevalent anemia. The key lies in optimizing maternal health; a well-cared-for mother ensures that the child is not stunted.  Our Asha workers play a vital role, urging families to prioritize four prenatal check-ups. This proactive approach helps detect and address any maternal deficiencies, contributing to improved outcomes,” explains Dr. Asish Singla, Deputy CMO at Mandikhera hospital. 

(Table sourced from Healthcare Status and Medical Facility Feasibility Report – Field Report, Nov 2023)

Infant mortality rate in Mewat is 32 per 1000 births, while that of the rest of Haryana is 28. While 76.4 per cent children in the age group of 6-59 months are anaemic.

High Fertility Rate and  geographical isolation

The fertility rate of Mewat’s women is 4.9 children as against the national and state average of 2.1.  Mewat is one of the 25 districts in India that experienced an increase in fertility rates from 2001 to 2011. Total Fertility Rate (TFR) represents the estimated number of children a woman would have, given the current age-specific fertility rates, if she were to live from birth until the end of her reproductive years.

In a report titled “Fertility at District Level in India: Lessons from the 2011 Census” by S. Irudaya Rajan, the rise in fertility in Mewat from 2001 to 2011 is attributed to its unique formation in 2005. The district was carved out in a manner that isolated the underdeveloped rural areas of Gurgaon and Faridabad, predominantly populated by the underprivileged Muslim Meo community. “As expected, fertility rates are significantly higher among the Meo community than the middle classes in Gurgaon or Faridabad,” says the report.  In 2016, Mewat was renamed Nuh to separate it from its cultural region of Mewat stretched across Rajasthan and Uttar Pradesh. As per the 2011 census, Mewat region has a Muslim population of 79.2 percent. 

Compromised reproductive health and lack of health access

Early marriage, unprotected sex, frequent pregnancies often compromises the general reproductive health of women. Women frequently present with Pelvic Inflammatory Disorder (PID), says trainee Dr Sakshi at the gynae department at Mandikhera Civil Hospital. PIDs occur when one or more upper reproductive organs, such as the uterus, fallopian tubes, and ovaries, become infected. If left untreated, PID can lead to the formation of scar tissue and the development of pockets of infected fluid (abscesses) in the reproductive tract, resulting in potential permanent damage.

Outside the gynae ward, we meet  Shehnaaz, accompanied by her towering husband Salamuddin, a JCB contractor who chauffeured the family in their private car from the nearby Padla Shahpuri village. In his imposing presence, Shehnaaz, demure and feeble, fades into the background. Perched in her arms is a toddler, while a 5-year-old clings to her fragile finger.

Shehnaaz with husband Salamuddin, and children. Photo credit: Akshay Razdan/HoA

At 25, Shehnaaz has already birthed four children. Her husband tells us that she has been experiencing excessive period bleeding and secretion of white discharge, and they are seeking their first consultation. Prematurely aged and visibly weakened, Shehnaaz shies away from discussing her condition in detail. Her husband evades further questions. The weight of unspoken words on the underlying reasons lingers in the air.

Dr Md. Arshad Ghayas, a Unani doctor at a Wellness Center in Nagina gets several women patients in a day who present with similar problems. “A large number of my patients are women and they show up with problems of weakness and excessive white discharge (Likoria/Leucorrhoea ),” he says. Abnormal discharge of Leucorrhoea can be a symptom of an underlying issue, such as an infection, hormonal imbalance, or other gynecological conditions. 

Unani, a part of Ayush,  is quite popular among women of Mewat. Perhaps due the school of medicine’s historical association with Muslim medics and societies. Dr Ghayas says he sees several women during his duty hours at the wellness center, formerly known as PH. “Women often aren’t given the right diet. They themselves are quite careless about their dietary choices, making them weak and anemic. Lack of family planning and frequent pregnancies contributes to their bad health but there is a gradual change. Now, women are getting educated here and families have warmed up to the idea of adopting family planning measures,” he added. 

However, Unani doctors have their limitations in the range of medical care they can provide. Additionally, when women need to travel from the village to the city for medical facilities, male family members must accompany them, resulting in work disruptions and impeding women’s access to quality healthcare. That 89 per cent of Mewat’s populations lives in villages calls for better health accessibility within the villages.

“In Ferozepur Jhirka block only 29 villages out of 145 villages have health subcentres. Lack of transport facilities and social restrictions reduces women’s mobility making them depended on male counterpart. Due to shyness and logistical inconvenience women tend to neglect their health issues particularly reproductive health,” writes Shiraz Sheikh of Human Welfare Foundation, in his Healthcare Status Report.

Trust deficit 

Mewat earned the unfortunate distinction of being labeled the most backward district in India according to Niti Aayog’s 2018 rankings. The present condition of Mewat can be partially traced back to the mass migration of a significant number of educated and wealthy families to Pakistan during the Partition in 1947.  

Every Mewati fondly remembers December 19, 1947, when Mahatma Gandhi intervened to prevent the Meo Muslims from leaving India during the chaos of partition. Gandhi famously referred to the Meos as “the backbone of the country.” Mewat also boasts a significant contribution to India’s freedom struggle. Ethnically the Muslims of Mewat belong to Meo Cast, a variant of Rajput martial race, which explains their turbulent relations with conquerers and colonisers – be it the Mughals or the British.  

The Meos are unique in their Islamic past. In an article in Scroll, journalist Saba Naqvi writes, “These Muslims profess Islam but follow a fascinating composite culture that accommodates many Hindu customs. They trace their origins to Hindu figures such as Rama, Krishna and Arjuna and celebrate many Hindu festivals like Diwali, Dussehra and Holi.” 

Over the years, the influence of Tablighi Jamaat, a global movement that encourages Muslims to “return” to the way of life as professed by Prophet Mohammad, has diluted the syncretic nature of Meo Muslims.  Nonetheless, to this day, the region retains fleeting echoes of romanticized ideals of communal harmony. It isn’t uncommon for Muslim to offer namaaz inside the houses of their Hindu friends, as we witnessed. 

In Adber village, Hindu and Muslim female friends pass wintry afternoons engaging in heartfelt conversations/ Photo: Akshay Razdan/HoA

Yet, the repercussions of heightened cow vigilantism and the Muslim-VHP clash on July 31st last year, resulting in extensive rioting that extended to nearby Gurugram, with six fatalities and 70 injuries, are palpable. The consequences go far beyond and deeper than Biryani sellers shutting shop. 

Public funded health programs have experienced a setback. The trust deficit has heightened reluctance towards immunization and institutional deliveries, even though over the years institutional deliveries have gone up bringing down maternal mortality rate to some extent. 

“Due to circumstances not under our control, immunization numbers went down drastically. But in the last few months we have done special immunization weeks under Mission Indradhanush to bring the numbers up to 70 per cent,” says Dr Singla.  

The programme provides vaccination against eight life-threatening diseases (diphtheria, whooping cough, Haemophilus influenzae type B (Hib) causing pneumonia and meningitis, tetanus, polio, tuberculosis, measles and hepatitis B) in the entire country. 

Historically, the immunization numbers in Mewat have been abysmally low. According to a paper in the Journal of Family Medicine and Primary Care, despite ongoing government initiatives, vaccination coverage in Mewat district is significantly lower, ranging from 20.8% to 27%, in stark contrast to the coverage observed in the rest of Haryana (77%).

“Often the women tell us that Modi has tampered with the vaccines to sterilize them, or that some spurious substance has been added to it,” says Jyoti, an ASHA worker from Adber village. “We tell them that our kids have also been administered the same vaccines, as a counter,” she adds. 

This trust deficit is being exploited by private players to deter the community from having institutional deliveries in government hospitals. “Midwives in the village receive commissions from private hospitals to dissuade families from opting for government facilities during deliveries,” reveals Sashi, a 30-year-old Asha worker.

Even though institutional deliveries have increased over the years, the district still lags behind the rest of the state.

Institutional deliveries in Mewat – 74.6

On-duty staff in Mandikhera civil hospital confirm that in instances when the gynaec suggests the need for a c-section, families panic and take away the patient (mostly to a private institute). “They often come back with severe post-delivery complications,” says a doctor, who didn’t want to be named. 

Dr. Singla highlights that to bridge this trust deficit ASHA workers are tasked with cultivating personal connections with the beneficiaries of health schemes. At the same time religious leaders are being roped in to make announcements during Friday prayers in order to dispel any misinformation about government schemes. “No technical terms are used; the clerics use their language to convey the significance of these programs to the community,” he says. 

Zayed Hussain, the Mufti of the main mosque in Nuh, says, “As religious guides, we address concerns within our community regarding government schemes. We assure them that there is no misalignment between the government schemes and our religious principles. We impart a positive message, emphasizing that good health is essential even for the worship of Allah.”

The lethal grip of patriarchy

Meo Muslims of Mewat are a pastoral community who are heavily dependent on  agriculture and animal rearing for their livelihood. While the men mostly have taken to driving and leveling and cutting of hilly roads with JCB, women are left behind to do the back breaking agriculture work in the water deficient region. 

Being pregnant or a new mother doesn’t bring any respite. 27- year old Ayesha, an ASHA worker from Andhaka village says, “Women have to work in the field and look after the animals. So, mothers are hesitant to get their children vaccinated as it results in fever. If the baby falls ill, who will do the household and field work, they ask us. Our job is to prepare them for the side-effects. We give them medicines to control the fever and make them aware about it.”

 “The biggest problem in Mewat is that the women are too dependent on the male members of the family to take even the smallest decisions. It is a humongous task to take them to the local PHC for their prenatal tests or encourage them to bring their children for immunization. They hide their pregnancy till the last moment. All government interventions fail if they keep their pregnancy hidden,” says Ritu, another ASHA worker from Adber village. 

It is almost impossible to get the women of Mewat to speak about their own health problems. Only men are allowed to give opinions on women’s health, which are often ill-informed and counter-productive. The refusal among men to acknowledge the actual reasons behind the poor health of women in the region is deeply troubling.

Asha workers share the challenges they face on the ground in raising awareness among women about health seeking behaviour. Photo: Akshay Razdan/ HoA

Abdul Haziz, 70, exemplifies this sentiment, stating, “Women are simply ignorant. Their weakness is due to their own negligence – they don’t drink water, eat fruits, or salad.”

 When asked why they are not being given food, he simply blames women again  – “They are illiterate.”  Female literacy in Mewat stands at 36 percent as against the state average of  65.94 percent. 

Muslim clerics, tactfully skirt the matter of frequent pregnancies leading to anemia, invoking Islamic tenets. “According to Sunnat (the way of life of the prophet), couples should exercise caution during the period of breastfeeding. In Islam, the recommended duration of breastfeeding is 2 years. Our elders consistently advise couples to prioritize the nutritional care of the child in their lap and refrain from conceiving another. The well-being of the existing child must be the primary focus,” they emphasize. A woman’s health is never seen de-hyphenated from her child-bearing capabilities among the community leaders. 

***

At PHC Nagina, Muskan attends her first prenatal visit accompanied by her mother-in-law and sister-in-law. Meanwhile, her husband and another male family member sit outside, huddled in the sunlight.  Her family claims she is 20. Muskan, pregnant with her first child, is in her first trimester. We try to strike a conversation with her. How does she spend her days? What does she like to eat? If she watches television or has a phone and if she is looking forward to this new phase of life. She stares blankly.

Muskan at PHC Nagina / Photo: Akshay Razdan/HoA

In the depths of Muskan’s gaze, one discerns a profound melancholy, a quiet resignation towards the small pleasures of life. She understands well her first pregnancy is a mere prelude to the inescapable cycle of perpetual childbirth.

She doesn’t mind being photographed. But she refuses to let go of the sadness laced with a tinge of hurt and anger.  When asked if she has thought of a name for the child, she makes an unusual request to the writer – “You can name it whatever you want”. As if she couldn’t care less. 

(With inputs from Md Imran)