Samvarthana – Perspectives of various mothers

By: Bennett Cook, Interpreter: Sumati, Inteview date: June 16, 2016

Abstract:

Pramathi is a 23 year old mother living at her mother’s house in the village of Golur in Nanjangud taluk, Mysore district, which has a population of 3402 according to the government’s 2011 census. She is seven months pregnant with her second child. She has only completed school up to 9th grade and her husband, while helpful to her, is illiterate. She was initially very shy and hesitant to answer questions, but with some encouragement from the mother we were able to gain more information. Her first child died early in life due to supposed “cardio” issues, although this is not clear. The interview showed that she lacked education on many facets of infant and maternal care, and was scared she was going to lose her second child. She is very adherent to traditional beliefs, some of which are detrimental to the child. She represents more of a baseline or typical case rather than one of positive deviance.

Case Report:

Background Information: This interview took place at 1:00 PM to 2:30 PM on June 16, 2016. The interview took place in Golur, a small village south of Mysore in the Nanjangud taluk in Mysuru district. The town has approximately 3402 residents (as of 2011). The subjects house was made of cement and clean. She had electricity, but no functioning toilet. In Karnataka 48.8% of homes do not have toilets, this is lower than the national average in India. The household we conducted the interview in belonged to her mother (she had come for the delivery of the baby), and had five members living there. This is consistent with the Karnataka and India average household size (4.6 members and 4.8 members). The subject are her family are members of the Adi-Karnataka caste (a scheduled caste or SC), which in 2011 made up 12.76% of the population of Golur.The family is primarily an agricultural one, with the husband providing most of the families income. In 2011, jobs such as cultivation or agricultural labor constituted approximately a third of total workforce.

Subject Information: The subjects name is Pramathi. She is 23 years old and is currently unemployed. She usually lives at her mother in law’s house, but is currently staying at her mother’s house until delivery of the child and a few months after, after which she will return to her normal residence. She has been living here for three months. She got married at the age of 16 to her current husband via an arranged marriage. Her husband does agricultural work and is illiterate, despite completing up to the 7th grade in education. This places Pramathi in the majority demographic for the village, and her husband in the minority, as the male literacy rate is 66.34% for men and 51.36% for women. The average recorded literacy rate for Karnataka is 75.60% making it the state with the 23rd highest literacy rate, and above the national average in India. Pramathi has completed her education up to the 9th grade, at which point she got married and could not continue. She has no further plans to continue her education.

She is seven months pregnant with her second child. The first child died in early infancy at four months old, she was 21 at the time (she did not know about the importance delaying another pregnancy). The mortality rate in Karnataka was 31 in 2009, nine points below the national average. The child had signs of jaundice, according to her mother in law, and was undergoing unspecified traditional medicine treatments to manage it, all of which were unsuccessful. The jaundice persisted from birth for the first three months. Then during the fourth month the baby began to vomit often. Again, rather than going to a doctor she sought the help of the village elders, who unsuccessfully attempted to treat the child using unspecified traditional methods. The child’s condition grew worse as time went on and at the end of four months the child’s breathing was labored. After this persisted for a very short time she took it to the local government hospital. The hospital ran tests on the child and said that he was sick, but would not specify the specific problem. It is unclear if Pramathi did not understand the doctors or if they actually did not tell her the problem at all. Based on other information from a case study in the same village it is certainly a likely possibility that they did not tell her. Another possibility is that they genuinely may not have possessed the equipment or training to actually understand the problem, thus they did not actually know. The local hospital then suggested she take the child to Mysore general hospital. They went by local transport to the hospital but experienced a similar situation in Mysore. They were admitted but the hospital staff and doctors again would not tell them the problem. They were then referred to a Bangalore hospital. However, by this point it was too late. Shortly after being admitted in the Bangalore hospital the child passed away. The cause of death was unclear to Pramathi, but the consensus seems to be unspecified cardiac complications. When asked why she did not pursue the issue further, she claimed she was too tired from grief and travelling and wanted to return home. After this experience she said she would always trust traditional medicine more than doctors, which seemed to infer she thought that the hospital’s negligence was responsible for the death of her child, despite the traditional methods having not worked before.

Health Information and Access: Pramathi claims she has “little or no access” to health information, despite ASHAs conducting regular visits every 15 days. She says the ASHAs, ANMs, and AWWs never mentioned things such as anemia, but did tell her to eat greens and vegetables regularly, advice which she has not followed for reasons she would not explain. When asked why she simply stated “I wish they provided more information”. She claims she has a monthly visit with her doctor about nutrition and danger signs during pregnancy, but not other issues.Her husband provides her transport to the doctor, who is three kilometers away, and he frequently reminds her of the child’s check up dates, which she has attended. She has never been screened for any diseases and is unaware of diseases such as HIV and other STIs. This is a common problem in Karnataka, where female HIV awareness is only 66% for women, making it the 14th highest state in HIV awareness among women. For men in Karnataka, 85% know about HIV but she claims it is unlikely that her husband knows if she does not know.

Her knowledge of postnatal care is extremely limited. She is not aware of the symptoms of sickness or dehydration in infants beyond a fever. She is also unaware that she is supposed to introduce complementary food to the infant only after six months. Oddly, she is aware that she is supposed to breastfeed the child exclusively for six months, but says she is not sure if she wants to do it with this child. When asked why this was she was unresponsive. Her mother in law, who Pramathi claims has a great deal of say in family decisions, has advised her to seek medical advice from a doctor but she has not done this for unspecified reasons. She expressed explicit interest in learning more about health, which is odd, as she seems to be not seeking or applying it to her life. She even hears medical advice on TV, but thinks that “that information isn’t for me, it’s for other people”. It is unclear whether she owns a television, but she has access to one. Karnataka ranks seventh in media access for women in India, with 81% having access to media such as television. Despite the doctors, ASHAs, ANMs, AWWs, and media available, she still says she desperately needs access to proper information. In one comment she did mention not asking doctors for information because she did not want to be in the way, but it was only brought up briefly, so its significance is unknown. She also mentioned that it is a common belief that if a doctor does not explicitly say what is wrong with you, then there probably is not anything wrong.

Pregnancy and Health Practices: At first when we asked Pramathi if she was prepared for the birth of her second child, she seemed tentatively sure that she was. Her mother is set to accompany her, and she plans to accompany her to Mysore if there are problems with the local hospital. She said she had packed clothes and arranged transport and that she had money set aside for the hospital in case of emergencies and other expenses. Upon further questioning however, she admitted the money she saved was mostly to be given to the elders of the village to perform purity rituals upon the child and that a very meager amount was for the hospital. The elders bathe the baby as soon after birth as possible (a practice that is highly advised against), and clean the baby’s diapers. She claimed she had never heard of delaying the bathing of a newborn, and she thought it should be done right away. The elders also remove mucous from the child’s throat via an unknown method. The elders also teach some practices which are beneficial or harmless, such as getting a lot of rest during pregnancy, and not eating oily foods. Alarmingly, she says it is common practice to wipe away the colostrum after birth and then begin feeding the baby, she says she practiced this with her first child. She has no additional money saved for vaccinations or medical services. Later in the interview, somewhat contradictory she said that if her new child is sick she will only attempt traditional remedies for two days before taking him to a hospital. When asked what these practices entailed, she gave a few examples, like putting ash on the throat to prevent cough. For fever in the child, coconut oil is applied to the forehead. She has received two TT shot vaccinations, but is unsure if she wants to have her next child vaccinated, she would not say why. Paradoxically, she said her first child had not been vaccinated although she thinks it might have saved him. Her first child would have been in the minority of people in Karnataka who have been vaccinated. In 2011 63.4% of people were vaccinated, which is almost 10% higher than the national average for India.

Pramathi did not appear to be in the best health. She was very thin are during our conversation about anemia, it was brought up she had many signs, particularly the characteristic yellowing of the eyes. During this pregnancy she has not increased her diet and eats mostly grains. She ate exclusively rice until the third month of pregnancy. She eats vegetables only once every three days, if that often. She eliminated all dairy from her diet as she believes it may cause a cough in the child. She has taken all the iron tablets given to her by the government, but has not done anything special with her diet to reduce anemia. She also seems unaware of the effect anemia has on unborn children, which may have contributed to the death of her child, among other complications.

Discussion:

Pramathi presents a case that is seemingly common in rural India. She follows traditional ways closely, despite the obvious detrimental effects. The most unusual factor in this case was that she seemed very eager to learn new health information because she wants to save her new baby, but claims she has no access to information despite a myriad of options available to her. There is clearly an underlying issue with obtaining and following health recommendations. It is possible she partially does not understand what she is hearing if it has been too technical, but the ASHAs information should be easy to understand. Furthermore, it is odd that even when she hears the correct information, she does not implement it into her lifestyle, despite many suggestions having no conflict with traditional beliefs or being simple lifestyle changes. There is clearly a large unknown factor in play here, but her shyness, or reluctance to answer many probing questions made identifying whatever the factor may be difficult. Even her mother in law’s advice to seek medical advice from a doctor was ignored, even though she allegedly has the highest say in decision making in her family and life. If she does not make changes soon, losing her next child is a very real possibility, especially if undiagnosed and untreated anemia is present. Pramathi’s case represents almost no examples of positive deviance from the baseline population and a health intervention is crucial if the other members of Golur are similar to her case, which is what her mother thought to be the case.