Toward Better Reproductive
Health Care in India
by Lakshmi Salgame
The big gathering of women in the middle of a Bangalore street is not an impromptu one. It is the result of several weeks of interaction with Suraksha's ("to protect") Outreach Educators. In a country where discussion on sexuality and reproductive health is taboo, these women have taken a big step forward.
But one can't fail but notice the tinge of bashfulness that is still there in most of them. In a social context where childless women are perceived with scorn, no woman wants to admit to any dysfunction (read: abnormality) concerning her reproductive health.
Suraksha meeting led by Harini Kakkeri (left)
A reluctance to speak, arising from the fear of being typecast, is what most women are experiencing at this afternoon gathering. Suraksha volunteers soon take charge and Harini Kakkeri works skillfully at transforming the mood.
One by one, every woman is prompted, if not to understand, at least to acknowledge, that her reproductive health is her own concern. If she doesn't talk or do anything about it, nobody else will.
Suraksha works in the slums and poor neighborhoods of Bangalore city. It has the indomitable plan to educate every vulnerable woman about her reproductive health. It highlights the fact that women in the Indian context have always lived with vulnerability in respect to their own bodies.
Ignorance, cultural stereotyping, gender-biased attitudes of medical practitioners, and the absence of appropriate and affordable diagnostic/clinical facilities reflect the inadequacies concerning women's reproductive health in the Indian health care system. Kakkeri, who is the director of Suraksha, aims to build a healthier work force of women for the country by addressing these inadequacies. Arising from her own need to bear healthy children, her relentless efforts through Suraksha have made a difference to thousands of Indian women.
In a context where daughters-in-law are often judged on their child breeding capabilities, Kakkeri found it hard to cope with society's expectations of her. "What's happened to her, she's so healthy and yet can't bear a healthy child?" were abuses that poured in from within the family and beyond. Medical advice on reproductive health was scarce and unaffordable for a middle class family like hers.
Societal Norms: Frustration and Agony
"I felt sheer helplessness," recounts Kakkeri. "And I thought, if I could feel so helpless, what about similar women like me?" Building on this urge to help women deal with reproductive problems, Kakkeri's efforts took shape in Suraksha.
She was joined by the like-minded, and today Suraksha has more than 15 full-time staff and more than four
clinics in the poorer slums of Bangalore city. In 1998, Kakkeri was awarded the Ashoka fellowship for her pioneering work in addressing women's reproductive health issues. Her particular strategy involved devising a comprehensive and cost-effective method aimed at strengthening the existing healthcare delivery system in India by integrating reproductive health care.
In many parts of India, childlessness is an undesirable situation for a woman. In a society where the family
is all-important, not being able to make a family of one's own leads to jibes that stem partly from concern as well as from spite. Women who have children feel cocooned in the knowledge that they have borne the next generation.
Over the years, societal norms have penetrated the psyche of the childless woman so much, that she suffers immense frustration and agony at her "barren" condition. Such women often seldom consider themselves worth attention and end up neglecting themselves, with health taking a back seat.
The supreme irony is that reproductive health is not even considered for such women, even though it is often the very cause of their lowered social status.
On the medical downside, in Indian slums, sexually-transmitted and reproductive tract infections are extremely common among women of all ages. In a recent study by Suraksha in the Bapujinagar slum in Bangalore, 26 percent of women surveyed tested positive for the Chlamydia test, i.e., they had contracted sexually-transmitted infections.
Worse – not even a single woman was aware that she was infected. As many as 60 percent of sexually transmitted diseases in women produce no symptoms until complications arise, which could include infertility, tubal pregnancy and the highly incapacitating pelvic inflammatory disease.
Reproductive Health: Reinventing the Wheel
Most women are shy and adhere by the social norm that decrees that sexuality is taboo. Feelings of guilt are not uncommon and they are hesitant to talk about their gynecological problems for fear of being blamed for it. Though their problems may range from painful menstrual cycles to sexually-transmitted diseases and infertility, women are not always aware that the symptoms are medically treatable.
Government machinery too is ill-equipped to handle the various issues that constitute women's reproductive health. The health and family welfare department takes a narrow view and limits their definition to childbirth. This includes only "problems" – stillbirths, infant mortality, abortion, low birth weight, etc.
The general reproductive health status of women is not understood nor is it a priority. For the bureaucracy, women's general reproductive health includes family planning measures and is often clubbed with child health. Scant attention is paid to sexual health, while the sexual and reproductive rights of women do not even enter the picture. Even sexually-transmitted and reproductive tract infections fail to get priority status.
Counseling session with Harini Kakkeri
"When all players concerned – the women themselves, the government agencies, and society at large – gave least priority to women's reproductive health, we had to start by inventing the wheel of thought," Kakkeri said. "We had to highlight that reproductive health is a must for a woman's general well being and contributes immensely to her productivity."
Kakkeri offers her definition of reproductive health as "a state of complete physical, mental and social well being – and not merely the absence of disease or infirmity – in all matters relating to the reproductive system and to its functions and processes."
Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in the last condition are the rights of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, as well as other methods that they may elect for regulating fertility. Also implicit is the right of access to appropriate healthcare services that will enable women to go safely through pregnancy and childbirth and provide couples the best chance of having a healthy infant.
Suraksha works to create a society where reproductive health services as prescribed above are accessible easily. "Though the concept of reproductive health applies to both sexes, it has a far greater impact on women and preferential allocation of resources for their health is essential," says Annapoorna Venkatesh, coordinator for Suraksha.
Demystifying Reproduction
However, for women to receive health care, they need to come out with their problems. Comments Dr. Veda Zachariah, a medical practitioner, and board member of Suraksha: "Harini's biggest strength has been her ability to make people talk about such a personal and sensitive issue. This is not something everybody can freely mention in our society."
To gain people's trust, Suraksha demystifies the process of reproduction with simple charts and displays. "We work with an illiterate or barely-literate population," Kakkeri said. "Their minds are filled with myths and superstitions. We educate them about the human body, the reproductive system, the menstrual cycle, safe sex, contraception, infertility, family planning, reproductive tract and sexually transmitted infections, menopause, etc."
In her view, family planning should be an integral part of family welfare and cannot be dealt in isolation. "A woman should feel the need to plan her family and realize that this is essential for her family's welfare."
While this remains the theory base and what Suraksha advocates, how do they go about implementing their ideologies?
Along with a team of gynecologists and counselors, pilot Well Woman Clinics (WWC) have been set up, housed close to the slums in which Suraksha works, to cater comprehensively to women's reproductive health. The clinics operate in the afternoons when women find it convenient to attend without their absence being noticed in the family.
Harini Kakkeri counsels a woman at a WWC preceding treatment
At WWC, confidentiality is paramount, and the friendly atmosphere conducive for women who would normally feel inhibited to share such intimate information for fear of being revealed to the community. Not only that, counseling is offered prior to medical diagnosis and treatment, to ally fears and to lend support.
To counteract the high cost of gynecological diagnosis and treatment, Suraksha has set up a successful system of referrals. Diagnostic centers and laboratories were approached and many now treat WWC referrals at minimal cost.
Respect, Love and Care
Care has been taken to project the clinics more as a home for women to come in whenever they wish. "Our most popular service is the counseling," says Manjula Raju, a staff member at Suraksha's first independent WWC. The clinics provide education, screening and treatment of reproductive tract infections and gynecological problems resulting from sexuality, age, multiple births and birth trauma. It also counsels on sexuality, contraception, abortion, infertility prevention and treatment.
The various contraceptive methods are explained, with attention to contraceptive safety. Safe menstrual regulation and abortion for contraceptive failure or non-use, prenatal care, supervised delivery and postpartum care, infant and child services are some of the other services offered by a WWC.
"Here, we are not seen only as patients; treatment is given with love and care. The respect we get despite whatever problems we have makes me very happy," says Rajamma, who has benefited immensely from the clinic.
In 1997, Suraksha approached the government with a plan to integrate the protocols of the WWCs with the World Bank-funded Indian Population Project VIII which had set up Urban Family Welfare Centers in five major Indian cities. Harini's idea was to utilize the existing government machinery to take her ideas to scale, and quickly. In Bangalore itself, 90 centers had been instituted, each reaching out to over 50,000 people.
The broad objectives of the government-WB project are focused at family welfare, and maternal and child health care services for the urban poor. This was to be done by improving the quality of existing services; expanding the coverage of urban poor by establishing new facilities and providing these almost on their doorsteps; and female education and employment. The active involvement of community leaders, CSOs, and medical practitioners are key to the project.
However, Kakkeri questioned the success and impact of this initiative. With reproductive tract infections and sexually-transmitted diseases not being included in their mandate, she found the program incomplete. Coupled with the alarming rise of HIV/AIDS, she felt this aspect needed to be tackled urgently.
But, any inroad in this area had to involve a subtle approach considering how orthodox Indian society generally is. Intensive staff training was required to foster a non-judgmental understanding of the issue so that they could, in turn, pass on the same values to the community. Kakkeri was prepared to take on this role.
Sensitizing Men
Kakkeri was granted one center to experiment with and set up a WWC within it. She realized that to create awareness, community intervention was necessary. Her group targeted corporation-supported tailoring centers, mahila sanghas (women's groups), anganwadis (preschools), etc., to reach out to the community.
Presentations were made on the socio-cultural aspects of a woman's life, gender discrimination, nutrition for women, and the importance of economic sustainability for women. Through these interactions, women were motivated to visit the local WWC.
The experiment was a huge success, with the attendance figures being a sure-shot indicator of this. More than 1,500 women visited the clinic and received treatment in just one year. With this success behind her, Kakkeri was able to convince the health ministry to integrate women's reproductive health care with the services at the Urban Family Welfare Centers across Bangalore.
News spreads fast, and the Suraksha team was invited by the people of Kamalanagar to set up a WWC in the area. Even with a population of 185,000, not a single government-supported Primary Health Care Center existed for them.
Kakkeri singled out ten volunteers from within the community who were trained to be Outreach Educators. Inspite of being barely-literate, they were chosen because of their aptitude to deal with people and their current social status within the community. Popular leaders were preferred. Today, five men and five women are Suraksha spokespersons who spread the word about the WWC in the locality.
This was the first time that Kakkeri's program included men: "I believe in sensitizing men to the plight of their women. After all, it is they who need to take the initiative and use a condom. So, we're making them aware about their reproductive health as well!"
However, without a strategy involving men, the decision-makers in India's largely patriarchal society, it is not possible to propagate women's reproductive health.
Protecting the Male Ego; Straight Talk
"It is harder for us men to talk about sexual health," says Harish Srikantaiah, an outreach educator with Suraksha. "We need to very careful not to hurt the male ego." With men, the program focuses on analyzing love and family life, sexual attitudes, responsible sexual behavior and behavior change communication.
Initially, local youths are involved in developing and staging street plays, a popular folk medium for social communication, especially in low-income communities. Methodology is through participative interactions, by using appropriate visual aids.
In Chandranagar slum, a group of women are engaged in serious discussion. The topic is rather sensitive – the interrelation between sexual health and family planning. "I've had the 'family planning operation' (vasectomy), why does my husband still need to use the condom?" shoots middle-aged Sakamma. Annapoorna Venkatesh, a Suraksha coordinator, clarifies that condoms are more than mere contraceptive devises.
The group moves on to discuss the pros and cons of family planning. "Why do you think you need to plan your family at all?" questions Annapoorna.
Community meeting
After ten minutes of brain storming, an elderly lady sums it up: "If we want a healthy family, we should plan well in advance. What's the point in having so many children when none have enough to eat?"
These women are participating in a Forum meeting at a WWC. The atmosphere is casual, yet there is subtle apprehension too. Suraksha has guided the local women to organize themselves into a Forum that meets every month to discuss topics related to women's reproductive health. Their agenda is also to devise strategies to bring other community women in contact with Suraksha's program on this issue.
Each topic is deliberately chosen by Suraksha as a vehicle to educate them, and may cover anything from misconceptions about white discharges to family planning or infertility. At the end of each year, the Forum women are equipped with considerable knowledge and are set to replicate and lead Forum's in their own areas.
Genius: Leveraging Government Resources
Kakkeri has reached a stage where replicating the WWC is a logical step to creating greater visibility for her work. But the paucity of funds has been a nagging hindrance. As a nonprofit organization, Suraksha does not have any source of self-finance. Although a minimum of Rs.20 (less than 50 cents) is charged for registering at a Well Woman Clinic, these funds are inadequate.
To get around the financial crunch, Kakkeri solicits services at minimum cost and has spread her net wide. Other CSOs have helped Suraksha sustain itself and have provided facilities such as medical aid at a minimal cost.
The genius of her idea however, lies in identifying the government as an important partner. "We don't need to work parallel to the government: it has all the necessary infrastructure to reach reproductive health services to more and more women," Kakkeri says. She is currently garnering support to convince the government to give women's reproductive health top billing.
Harini Kakkeri
Kakkeri's approach to reproductive health seeks to provide comprehensive services, and emphasizes on high quality care. It is premised on fully-informed choices and builds on the already-established government-run family planning and maternal and child health programs. She is seeking modifications in these programs to make women's well being and reproductive choices the central objectives. Demographic goals are important, but they are not primary.
"If all goes well, we should be able to replicate and have a Well Woman Clinic in every slum of Bangalore City," she predicts.
India women are faced with numerous health challenges. With HIV/AIDS figures horrifically high in India, women's sexual and reproductive health demand immediate attention. Time is running out – we can't afford to wait for the volcano to erupt into an epidemic. They say minutes count, but for Harini Kakkeri, every second makes a difference.
Needs:
Suraksha is in need of funds. It also implores more doctors to join it's efforts, particularly volunteer gynecologists. Any number of general volunteers are always welcome to join hands with Suraksha.
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