India is home to one-fourth of the world’s poor. Credit: Neeta Lal/IPS

By Neeta Lal
NEW DELHI, Feb 14 2015 (IPS)

Despite being one of the world’s fastest expanding economies, projected to clock seven-percent GDP growth in 2017, India – a nation of 1.2 billion – is trailing behind on many vital social development indices while also hosting one-fourth of the world’s poor.

While the United Nations prepares to wrap up a decade-and-a-half of poverty alleviation efforts, framed through the lens of the Millennium Development Goals (MDGs), by the end of this year, the international community has its eyes on the future.

"A focus on accelerating sustainable, inclusive and balanced growth is key to poverty eradication." -- Ranjana Kumari, director of the Delhi-based non-profit Centre for Social Research (CSR)
The coming development era will be centred on sustainability, driven by targets set out in the Sustainable Development Goals (SDGs). Home to one-sixth of the world’s population, India’s actions will determine to a great extent global efforts to lift millions out of destitution in the coming years.

Experts say its patchy progress on the MDGs offers some insights into how the country will both assist and hold back global development efforts in the post-2015 era.

Earlier this month the U.N. released a report lauding India’s efforts to half the number of poor people living within its borders to the current 270 million since the country joined hands with 189 U.N. member states to draft the MDGs 15 years ago.

While making strides in poverty reduction, India is also on track to achieve gender parity at the primary, secondary and tertiary levels on the education front by the year’s end though it lags significantly on the goal of empowering its women.

“The proportion of women working in decent jobs outside agriculture remains low; their participation in the overall labour force is also low and declining in rural areas; women in farming are constrained by lack of land ownership; and women are poorly represented in parliament,” the U.N. report stated.

The report recommends a continued emphasis on increasing both growth and social spending. However, experts point out this will be a significant challenge against the backdrop of India’s new Hindu nationalist government slashing social sector spending by about 30 percent in the supplementary budget.

Wretched poverty persists

The allocation for the National Rural Employment Guarantee Act (NREGA), an initiative to provide employment to all adult members of poor Indian families for five dollars per day, is now the lowest it has been in five years.

Despite robust economic growth, scenes of destitution are visible all throughout India, a nation of 1.2 billion people. Credit: Neeta Lal/IPS

By the end of last year, state governments had reported a drop of 45-percent in funds allocated by the Centre, from 240 billion to 130 billion rupees (3.8 million to 2.1 million dollars) – the sharpest decline since the scheme’s inception in 2005.

India needs to balance its economic growth while tackling poverty as the latter can considerably erode the progress achieved from high GDP numbers, say economists.

“Removing poverty is clearly the most important of the goals as it has clear linkages to the other MDGs,” Delhi-based economist Parvati Singhal, a visiting professor at Jawaharlal Nehru University, told IPS.

“It needs to be central to the post-2015 development agenda. Higher income resulting from growth is the best panacea for poverty […],” Singhal elaborated.

According to Sabyasachi Kar, associate professor at the Institute of Economic Growth, with the University of Delhi, a major reason for continuing poverty in India is the country’s below-par industrial growth, which scuppers job creation.

“Programmes like NREGA and food-for-work programmes are at best safety nets that will keep people from starving. We need robust growth in the industrial and manufacturing sectors to generate employment and alleviate poverty while raising incomes permanently.

“Effective domestic resource mobilisation and incentivising the private sector to invest in sustainable green technologies will also help to tackle poverty,” the economist added.

Though Asia’s third largest economy has shown good progress in achieving its poverty reduction target, the malaise has ironically become more visible.

The sight of homeless construction workers, beggars, rag pickers, child labourers – the ensemble cast of India’s apparently prospering megacities – reflects its harsh underbelly.

According to a report entitled ‘Effects of Poverty in India: Between Injustice and Exclusion’, “The spectacular growth of cities has made poverty in India more visible and palpable through its famous slums.”

U.N. data shows that 93 million people in India live in slums, including 50 percent of the population in its capital, New Delhi.

Meanwhile, the megacity of Mumbai, home to 19 million, hosts nine millions slum-dwellers, up from six million just 10 years ago.

Dharavi, the second largest slum in Asia, is located in central Mumbai and is home to between 800,000 and one million people, crammed into just 2.39 square kilometres of space.

Investing in women and children: crucial for development

Public health in India is also an area of concern, with the country trailing in the realms of infant and child mortality as well as maternal health.

According to the World Bank India accounts for 21 percent of deaths among children below five years of age. Its maternal mortality ratio (MMR) – the number of women who die during pregnancy, delivery or in the first 42 hours of a termination per 100,000 live births – is 190. Countries like Ecuador and Guatemala fare better than India, with MMRs of 87 and 140 respectively.

Addressing these issues will be a considerable challenge as India is home to 472 million children or about 20 percent of the world’s child population, while nearly 50 percent of its population is comprised of women.

Health activists are advocating for greater capital investment in public health. India currently spends an abysmal one percent of its GDP on health, half the sum allocated by neighbouring China.

Even Russia and Brazil, two other nations in the BRICS association of emerging economies of which India is a part, invest 3.5 percent of their respective GDPs on health.

“A focus on accelerating sustainable, inclusive and balanced growth is key to poverty eradication,” Ranjana Kumari, director of the Delhi-based non-profit Centre for Social Research (CSR), told IPS.

The activist feels that growth and development should not only be measured in GDP terms but also in terms of per capita income and per capita spending.

“Right now, there is inequitable distribution of wealth in India. Money is concentrated in the hands of a few while the masses struggle to get two square meals a day. This inequity needs to be addressed as there’s no conflict in the growth of social justice and GDP growth; both ought to work in tandem for success.”

Speaking at the launch of the U.N. report on India last week, Shamshad Akhtar, under-secretary-general of the U.N., advocated for a new sustainable agriculture-based green revolution, which could contribute to ending hunger not only in India but across South Asia at large.

With eight percent of India’s population engaged in agriculture, amounting to some 95.8 million people, sustainable development will be impossible without lifting India’s farmers out of poverty, researchers contend.

Edited by Kanya D’Almeida

Scenes like this are not uncommon at relief camps inhabited by the Bodo community. Many families have accepted that they will have a long wait before returning to their homes, or before their children resume schooling. Credit: Priyanka Borpujari/IPS

By Priyanka Borpujari
KOKRAJHAR, India, Feb 3 2015 (IPS)

The tarpaulin sheet, when stretched and tied to bamboo poles, is about the length and breadth of a large SUV. Yet, about 25 women and children have been sleeping beneath these makeshift shelters at several relief camps across Kokrajhar, a district in the north-eastern Indian state of Assam.

The inhabitants of these camps – about 240,000 of them across three other districts of Assam – fled from their homes after 81 people were killed in what now seems like a well-planned attack.

The Asian Centre for Human Rights says the situation is reaching a full-blown humanitarian crisis, representing one of the largest conflict-related waves of displacement in India.

It has turned a mirror on India’s inability to meet the Millennium Development Goals (MDGs), and suggests that continued violence across the country will pose a major challenge to meeting the basic development needs of a massive population.

Edited by Kanya D’Almeida

In Serfanguri relief camp in Kokrajhar, several tents were erected, but they were inadequate to properly house the roughly 2,000 people who had arrived there on Dec. 23, 2014. This single tent houses 25 women and children. Credit: Priyanka Borpujari/IPS

By Priyanka Borpujari
KOKRAJHAR, India, Jan 29 2015 (IPS)

The tarpaulin sheet, when stretched and tied to bamboo poles, is about the length and breadth of a large SUV. Yet, about 25 women and children have been sleeping beneath these makeshift shelters at several relief camps across Kokrajhar, a district in the north-eastern Indian state of Assam.

The inhabitants of these camps – about 240,000 of them across three other districts of Assam – fled from their homes after 81 people were killed in what now seems like a well-planned attack.

The Asian Centre for Human Rights says the situation is reaching a full-blown humanitarian crisis, representing one of the largest conflict-related waves of displacement in India.

It has turned a mirror on India’s inability to meet the Millennium Development Goals (MDGs), and suggests that continued violence across the country will pose a major challenge to meeting the basic development needs of a massive population.

Hunger is constant in the refugee camps, with meagre rations of rice, lentils, cooking oil and salt falling short of most families’ basic needs. Women are forced to walk long distances to fetch firewood for woodstoves. Credit: Priyanka Borpujari/IPS

Appalling conditions

On the evening of Dec. 23, several villages inhabited by the Adivasi community were allegedly attacked by the armed Songbijit faction of the National Democratic Front of Bodoland (NDFB), which has been seeking an independent state for the Bodo people in Assam.

The attacks took place in areas already marked out as Bodoland Territorial Authority Districts (BTAD), governed by the Bodoland Territorial Council (BTC).

But the Adivasi community that resides here comprises several indigenous groups who came to Assam from central India, back in 150 AD, while hundreds were also forcibly brought to the state by the British to work in tea gardens.

Clashes between the Adivasi and Bodo communities in 1996 and 1998 – during which an estimated 100 to 200 people were killed – still bring up nightmares for those who survived.

This child, a resident of the Serfanguri camp, is suffering from a skin infection. His mother says they are yet to receive medicines from the National Rural Health Mission (NRHM). Credit: Priyanka Borpujari/IPS

It explains why the majority of those displaced and taking shelter in some 118 camps are unwilling to return to their homes.

But while the tent cities might seem like a safer option in the short term, conditions here are deplorable, and the government is keen to relocate the temporary refugees to a more permanent location soon.

The relief camp set up at Serfanguri village in Kokrajhar lacks all basic water and sanitation facilities deemed necessary for survival. A single tent in such a camp houses 25 women and children.

“The men sleep in another tent, or stay awake at night in turns, to guard us. It is only because of the cold that we somehow manage to pull through the night in such a crowded space,” explains Maino Soren from Ulghutu village, where four houses were burned to the ground, forcing residents to run for their lives carrying whatever they could on their backs.

Now, she tells IPS, there is a serious lack of basic necessities like blankets to help them weather the winter.

Missing MDG targets

In a country that is home to 1.2 billion people, accounting for 17 percent of the world’s population, recurring violence and subsequent displacement put a huge strain on limited state resources.

Time after time both the local and the central government find themselves confronted with refugee populations that point to gaping holes in the country’s development track record.

With food in limited supply and fish being a staple part of the Assamese diet, it is common to see women and even children fishing in the marshy swamps that line the edge of the refugee camps, no matter how muddy or dirty the water might be. Credit: Priyanka Borpujari/IPS

Outside their hastily erected tents in Kokrajhar, underweight and visibly undernourished children trade biscuits for balls of ‘jaggery’ (palm sugar) and rice.

Girls as young as seven years old carry pots of water on their heads from tube wells to their camps, staggering under the weight of the containers. Others lend a hand to their mothers washing pots and pans.

The scenes testify to India’s stunted progress towards meeting the MDGs, a set of poverty eradication targets set by the United Nations, whose timeframe expires this year.

One of the goals – that India would reduce its portion of underweight children to 26 percent by 2015 – is unlikely to be reached. The most recent available data, gathered in 2005-2006, found the number of underweight children to be 40 percent of the child population.

Similarly, while the District Information System on Education (DISE) data shows that the country has achieved nearly 100 percent primary education for children aged six to ten years, events like the ones in Assam prevent children from continuing education, even if they might be enrolled in schools.

According to Anjuman Ara Begum, a social activist who has studied conditions in relief camps all across the country and contributed to reports by the Internal Displacement Monitoring Centre (IDMC), “Children from relief camps are allowed to take new admission into nearby public schools, but there is no provision to feed the extra mouths during the mid-day meals. So children drop out from schools altogether and their education is impacted.”

Furthermore, in the Balagaon and Jolaisuri villages, where camps have been set up to provide relief to Adivasi and Bodo people respectively, there were reports of the deaths of a few infants upon arrival.

Most people attributed their deaths to the cold, but it was clear upon visiting the camps that no special nutritional care for lactating mothers and pregnant women was available.

This little boy is one of hundreds whose schooling has been interrupted due to violence. The local administration is attempting to evict refugees from the camps, most of which are housed in school compounds, but little is being done to ensure the educational rights of displaced children. Credit: Priyanka Borpujari/IPS

Bleak forecast for maternal and child health

Such a scenario is not specific to Assam. All over India, violence and conflict seriously compromise maternal and child health, issues that are high on the agenda of the MDGs.

In central and eastern India alone, some 22 million women reside in conflict-prone areas, where access to health facilities is compounded by the presence of armed groups and security personnel.

This is turn complicates India’s efforts to reduce the maternal mortality ratio from 230 deaths per 100,000 live births to its target of 100 deaths per 100,000 births.

It also means that India is likely to miss the target of lowering the infant mortality rate (IMR) by 13 points, and the under-five mortality rate by five points by 2015.

Scenes like this are not uncommon at relief camps inhabited by the Bodo community. Many families have accepted that they will have a long wait before returning to their homes, or before their children resume schooling. Credit: Priyanka Borpujari/IPS

According to a recent report by Save the Children, ‘State of the World’s Mothers 2014’, India is one of the worst performers in South Asia, reporting the world’s highest number of under-five deaths in 2012, and counting some 1.4 million deaths of under-five children.

Nutrition plays a major role in the mortality rate, a fact that gets thrown into high relief at times of violence and displacement.

IDPs from the latest wave of conflict in Assam are struggling to make do with the minimal provisions offered to them by the state.

“While only rice, lentils, cooking oil and salt are provided, there is no provision for firewood or utensils, and hence the burden of keeping the family alive falls on the woman,” says Begum, adding that women often face multiple hurdles in situations of displacement.

With an average of just four small structures with black tarpaulin sheets erected as toilets in the periphery of relief camps that house hundreds of people, the basic act of relieving oneself becomes a matter of great concern for the women.

“Men can go anywhere, any time, with just a mug of water. But for us women, it means that we have to plan ahead when we have to relieve ourselves,” said one woman at a camp in Lalachor village.

It is a microcosmic reflection of the troubles faced by 636 million people across India who lack access to toilets, despite numerous commitments on paper to improve the sanitation situation in the country.

As the international community moves towards an era of sustainable development, India will need to lay plans for tackling ethnic violence that threatens to destabilize its hard-won development gains.

Edited by Kanya D’Almeida

Only 65 percent of Senegalese women give birth in the presence of a skilled attendant. Credit: Travis Lupick/IPS

By Doreen Akiyo Yomoah
DAKAR, Sep 24 2014 (IPS)

Diouma Tine is a 50-year-old vegetable seller and a mother of six boys. In her native Senegal, she tells IPS, motherhood isn’t a choice. “If you’re married, then you must have children. If you don’t, then you don’t get to stay in your husband’s house, and no one will respect you.”

Despite this prevailing cultural outlook, becoming a mother here is neither easy, nor safe, with only 65 percent of Senegalese women giving birth in the presence of a skilled attendant.

According to available data, 54 percent of Senegal’s 13.7 million people live in rural areas. Of these, some 3.3 million are women of reproductive age, an estimated 85 percent of who live about 45 minutes from a health facility.

The country has a worryingly high maternal mortality rate (MMR). The last government survey taken in 2005 found that 41 women died per 1,000 live births, giving the country a ranking of 144 out of 181.

“In some regions, like the Kolda and Tamba Regions, you can find up to 1,000 deaths per 100,000 live births [since] some women are denied the ability to make decisions about when to go to hospital, [and] sometimes when roads are bad it’s difficult for them to get to a health centre.” -- Gacko Ndèye Ndiaye, coordinator of the gender cell at the Ministère de la Santé et Action Sociale (Ministry of Health and Social Action)
Between 2005 and 2010, the MMR in Senegal fell from 401 to 392 deaths per 100,000 live births, representing some progress but hinting at the scale of unmet need around the country.

One of the Millennium Development Goals (MDGs) is to achieve universal access to reproductive healthcare by 2015, but it is increasingly clear to health workers and policy makers that Senegal will not reach this target.

This year’s State of the World’s Midwifery Report produced by the United Nations Population Fund (UNFPA) projected that Senegal’s population was set to increase by 59 percent to 21.9 million by 2030.

“To achieve universal access to sexual, reproductive, maternal and newborn care, midwifery services must respond to one million pregnancies per annum by 2030, 53 percent of these in rural settings,” the report stated, adding that the health system must be configured to cover some 66 million antenatal visits, 11.7 million births, and 46.7 million post-partum and postnatal visit from 2012 to 2030.

This past May, on the International Day of the Midwife, former Prime Minister Aminata Touré called attention to a gap of 1,336 midwives in the country, setting in motion a government-sponsored recruitment drive to rapidly increase the number of trained birth attendants.

The midwife shortage is felt most severely in rural areas: the Matam region in eastern Senegal, for instance, has only 14 midwives for a population of nearly 590,000, while Tambacounda, to the south of Matam, has only 38 for a population of about 670,000.

Senegal has both ‘sage-femmes’ (fully trained midwives), and ‘matrones’, direct-entry midwives who deliver the vast majority of babies in Senegal but lack proper education, and often learn their trade on site, sometimes spending less than six months in a clinical training setting before being taking up posts in rural areas.

“There is kind of a crisis in education,” Kaya Skye, executive director of the African Birth Collective, tells IPS.

“Matrones learn how to take blood pressure, but they don’t understand what that means. [With matrones] there is an urgency to get the baby out as soon as possible [and] an overuse of drugs, which is […] another cause of mortality,” she explained.

In fact, Touré stated during a speech on May 12 that 60 percent of maternal deaths in the country could have been avoided with “sufficient personnel, a suitable medical platform, [and] democratic access to women’s health services, notably the disadvantaged in remote areas.”

Gacko Ndèye Ndiaye, coordinator of the gender cell at the Ministère de la Santé et Action Sociale (Ministry of Health and Social Action), and a midwife by trade, tells IPS that numbers alone don’t tell the whole story.

“There are disparities between different areas,” she asserted. “In some regions, like the Kolda and Tamba Regions, you can find up to 1,000 deaths per 100,000 live births [since] some women are denied the ability to make decisions about when to go to hospital, [and] sometimes when roads are bad it’s difficult for them to get to a health centre.”

The National Agency of Statistics and Demography’s 2011 health indicators report found that over 90 percent of urban births are assisted by a trained assistant, but that number falls to just half for rural births.

Skye’s African Birth Collective works to fill these gaps, and recently built the Kassoumai Birth Centre in the Kabar village of the southern Casamance region to meet the needs of mothers and midwives.

According to Skye, “Traditional midwives said they wanted their own place to practice; that they didn’t feel welcome in government clinics. There was nothing in Kabar for women – they were giving birth in the showers behind their houses.”

Although the government does provide training for midwives, building this centre was “about creating infrastructure that is outside of government protocols and facilitating that dialogue where the traditional midwives can say ‘We do it this way’,” Skye says.

A long colonial history and post-colonial education in Senegal has meant that the Western obstetric model has been dominant.

Grassroots efforts, including the work of ENDA Santé, the health division of an international NGO called Environmental Development Action in the Third World, are helping to foster a better balance between Westernised birthing techniques and traditional methods.

The African Birth Collective and ENDA Santé have translated the educational manual ‘A Book for Midwives’ into French, giving birth attendants in Francophone West Africa access to crucial information, such as the case for non-supine positions, and inverted resuscitation methods.

For women like Tine, the pride that comes from being a mother will always outweigh the dangers and complications of pregnancy and childbirth.

But if the government of Senegal scales up its efforts to improve health services, it can remove the fear factor altogether, and make a strong contribution towards global efforts to ensure the health and safety of every mother.

This story originally appeared in a special edition TerraViva, ‘ICPD@20: Tracking Progress, Exploring Potential for Post-2015’, published with the support of UNFPA, the United Nations Population Fund. The contents are the independent work of reporters and authors.

Edited by Kanya D’Almeida

Teen mothers give birth to 81 out of every 1,000 children in Nepal. Credit: Mallika Aryal/IPS

By Mallika Aryal
CHAMPI, Nepal, Jul 11 2013 (IPS)

Radhika Thapa was just 16 years old when she married a 21-year-old boy three years ago. Now, she is expecting a baby and is well into the last months of her pregnancy. This is not the first time she has been with child – her first two pregnancies ended in miscarriages.

“The first time I conceived I was just 16, I didn’t know much about having babies, nobody told me what to do,” Thapa tells IPS in between assisting customers at the vegetable store she runs with her husband in the small town of Champi, some 12 km from Nepal’s capital, Kathmandu.

"When girls get pregnant their education stops, which means a lack of employment opportunities and poverty." -- Bhogedra Raj Dotel
“The second time I wasn’t ready either, but my husband wanted a baby so I gave in,” she admitted.

After the second miscarriage, Thapa’s doctors urged her to wait a few years before trying again, but she was under immense pressure from her in-laws, who threatened to “find another woman for her husband if she kept losing her babies”.

What might seem like a horror story to some has become an accepted state of affairs in Nepal, the country with the highest child marriage rate in the world.

On average, two out of five girls are married before their 18^th birthday. The legal age for marriage in Nepal is 18 years with parental consent, and 20 without, a law that is seldom observed, least of all in rural parts of the country.

Studies show that child marriages occur most frequently among the least educated, poorest girls living out in the countryside.

According to the 2011 Nepal Demographic and Health Survey (NDHS), 17 percent of married adolescent girls between 15 and 19 years are either pregnant or are mothers already. In fact, research shows that adolescent mothers give birth to 81 out of every 1,000 children in Nepal.

The survey also shows that 86 percent of married adolescents do not use any form of contraception, meaning that few girls are able to space their births.

Disturbed by trends in countries like Nepal, the UNFPA spotlighted teen pregnancy as the theme for this year’s World Population Day, observed annually on Jul. 11.

“Globally there are 16 million girls aged 15-19 who give birth each year – they never had the opportunity to plan their pregnancy. It is a developmental issue that goes beyond health,” Vallese stressed.

In reality, teen pregnancy can be a matter of life and death. Adolescent girls under the age of 15 are up to five times more likely to die during childbirth than women in their 20s.

The number one cause of death among girls aged 15-19 relates to complications in childbirth. Young mothers are at a high risk of suffering from complications such as obstetric fistula and uterine prolapse.

Furthermore, “the first child born to a mother aged 12-20 is at greater risk of being stunted or underweight, suffering from anaemia or even of dying before the age of five,” says Vallese.

Less visible, but equally troubling, is the host of social complications that teen mothers must navigate.

“When girls get pregnant their education stops, which means a lack of employment opportunities and poverty,” says Bhogedra Raj Dotel of the government’s family planning and adolescent sexual reproductive health division.

According to the UNFPA, 37 percent of married adolescent girls are not working and 76 percent of those who are employed are not paid in cash or kind for the work they do.

Menuka Bista, 35, is a local female community health volunteer in Champi, assisting about 55 households in her area. Bista has been advising Thapa, to ensure that the girl has a safe pregnancy.

“Radhika (Thapa) is educated, she knows she needs to go to the doctor and eat nutritious food for her baby to be safe, but she doesn’t make decisions about her body: her husband and in-laws do,” Bista told IPS.

This observation finds echo in research carried out by various experts: according to Dotel, husbands and in-laws make all the major decisions about a woman’s reproductive health, from what hospital she visits to where she will deliver her child.

For this reason, Vallese believes it is important to train husbands and family members on reproductive health and rights.

Another problem, experts say, is that almost all national policies have been designed with the assumption that adolescent pregnancies affect only married women, with little acknowledgement of the fact that unmarried teenaged girls also engage in sexual activities, said Vallese.

The penetration of the Internet and mobile phones into every aspect of daily life, coupled with a massive wave of migration of young rural men into urban areas, has created “a significant teenage population that engages in pre-martial sex,” she stressed.

Whether the teenaged girls are married or unmarried, sex education plays a major role in decreasing the number of pregnancies.

Sex education is a part of the national school curriculum from Grade 6 upwards, but teachers are not trained, and are uncomfortable talking about it. When the subject comes up in a classroom, most teachers simply skip that chapter, or defer to a health worker to explain the process of reproduction.

“There’s a general (perception) that teaching about sexual health makes girls promiscuous, but we have found it to be exactly the opposite,” says Shova KC, chair of a local cooperative that works with women in Champi.

Public health experts, meanwhile, have criticised the government for not implementing existing policies that could spare thousands of young girls from the trauma of complicated pregnancies so early on in life.

For instance, “more than 500 youth friendly service centers have been set up but progress is about more than just ticking boxes,” UNFPA Assistant Representative Latika Maskey Pradhan, told IPS.

In the future, she said, advocates must keep a close eye not only on how policies are designed but also on how they are implemented.

Shirin Aktar, a young girl who resisted child marriage, poses with her mother outside their home in northern Bangladesh. Credit: Naimul Haq/IPS

By Naimul Haq
RANGPUR, Bangladesh, Jul 5 2013 (IPS)

Shirin Aktar was just 13 years old when her parents decided it was time for her to get married.

The eldest girl in a poor, conservative family hailing from the Rangpur district in northern Bangladesh, Shirin had few opportunities open to her: with no formal education or job prospects, marrying her 31-year-old cousin seemed her best bet to avoid a life of abject poverty.

The soft-spoken girl told IPS her parents never consulted her about their decision. Her father lacked a steady job, and the family had no home to call their own. Accepting the proposal of a relatively well-off businessman seemed to them the obvious choice for their daughter.

Unbeknownst to her family, Shirin had other plans. Determined to fulfil her dream of studying and going to college, the girl enlisted the help of her fellow members of ‘Child Journalists’, a group of local boys and girls who “oppose social injustice and raise awareness on children’s rights,” she said.

Sitting in her home in the village of Arajemon, located some 370 km northwest of the capital Dhaka, Shirin, who just turned 18, confessed that she had seen one too many female friends and relatives suffer dearly as a result of early marriage, experiencing everything from domestic violence at the hands of in-laws, to heavy loads of housework.

Shirin knew she could not go down the same path.

But standing up to her parents was not easy – it required courage, and massive peer support.

Reza, leader of Child Journalists, told IPS that despite being cognisant of the “consequences of meddling in adults’ affairs, we felt Shirin’s parents were doing her an injustice – we had to resist.”

The resourceful youngsters approached village elders, religious leaders, influential academics and local business-owners who agreed to talk to Shirin’s parents.

Still, this near unanimous support among community members would not have gone far without a boost from the Kishori Abhijan, or the Adolescent Empowerment project, an initiative of the United Nations Children’s Fund (UNICEF) in Bangladesh that works to equip young girls with the tools they need to make their own life choices.

First piloted in 2001, the programme arose in response to the staggering number of child marriages in this South Asian country of 150 million people. Over half a decade later, the need for such a service is – sadly – greater than ever.

With roughly one-third of the population living on less than a dollar a day, it is small wonder that families turn to marriage as a means of social mobility and an escape from a life of gruelling labour: finding a husband for a daughter means one less mouth to feed and the possibility of financial supplements from the spouse.

Despite progress in girls’ school enrolment rates, a substantial decline in fertility rates and greater freedom for young women to demand their rights, many still find their lives constrained by the custom of child marriage: according to recent research, 68 percent of women aged 20–24 were married before reaching the legal minimum age of 18, while other studies indicate that a vast majority of these girls were actually married off before their 16^th birthday.

Government data suggests that over 50 percent of the estimated 13.7 million adolescent girls in Bangladesh will be mothers by the age of 19.

In rural Bangladesh, where poverty is even more widespread than it is in the cities, girls from poor families are considered eligible for marriage at the onset of puberty – meaning children as young as 13 and 14 years old often become wives.

Partly in an effort to bargain down dowry prices, partly to “protect” their children against sexual harassment, impoverished families seldom think twice before handing their girls off to husbands who are often much older.

Child rights activists say the practice is not only socially damaging but also hazardous to girls’ health: in a country where 80 percent of all births happen in the home without a skilled medical attendant present, young mothers and their children are vulnerable to complications during pregnancy and a range of associated conditions such as pneumonia and low birth weight.

Early child marriages no doubt contribute to the country’s high maternal mortality rate of 320 deaths per 100,000 live births, compared to 21 deaths per 100,000 live births in countries like the United States.

Now, a major push by locals together with international organisations seems to be bearing fruit.

Self-help groups known as ‘kishori clubs’ bring together about 30 peers every fortnight to discuss everything from reproductive health and nutrition to gender roles and violence against women.

Group leaders trained by UNICEF help facilitate the acquisition of life skills such as stitching, pottery making, or learning how to rear poultry, which improve young women’s chances of securing a livelihood.

Kishori clubs work with affiliated grassroots organisations like the Centre for Mass Education in Science (CMES), which operate in hundreds of sub-districts around the country and have proven invaluable in providing basic training in computer literacy and carpentry, among others.

The youth collectives also act as coordinating bodies for awareness campaigns that include spreading information about child marriage among their peers and throughout the broader community.

Shirin’s story is a testament to the power of these local groups: when her father first approached the local marriage registrar, he refused to register the union before first checking the girl’s birth certificate, signaling a turning point from the days when officials would not blink an eye at the sight of a teenaged bride.

But advocates are aware that education alone will not change the mindset that perpetuates this practice. In order to put a complete cap on child marriage, it will be necessary to change the economic circumstances of impoverished families.

Rose-Anne Papavero, UNICEF chief of child protection in Bangladesh, told IPS that the agency is working with the government to “provide conditional cash transfers (of 472 dollars per year) to poor families… if they agree not to marry off their (underage) daughters, not to use child labour, and not to practice corporal punishment.”

The positive impacts are evident: the 2007 Bangladesh Demographic and Health Survey (BDHS) reported that there has been a slow but steady increase over the past 25 years in the average marriage age, from 14 years for women in their late 40s to 16.4 years for those in their early 20s.

Every year, thousands of Afghan women cross the border into Pakistan in search of medical treatment. Credit: Ashfaq Yusufzai/IPS

By Ashfaq Yusufzai
PESHAWAR, Pakistan, Jun 3 2013 (IPS)

Muzaffar Shah, a shopkeeper from Kabul, sits in a hospital waiting room, desperate for news. He has travelled nearly 300 km to get to the Khyber Teaching Hospital in Peshawar, capital of northern Pakistan’s Khyber Pakhtunkhwa (KP) province, where his wife is now in intensive care.

Just a few days ago, she delivered a baby boy who died within minutes. Shortly after, she started to experience severe vaginal bleeding.

“She was initially admitted to the Indira Gandhi Children’s Hospital in Kabul, where there was only an occasional supply of electricity and where a lack of water badly hampered patients’ treatment,” Shah told IPS.

“After two days my wife showed no signs of improvement so we rushed her here.”

Now his wife is receiving three pints of blood daily and her chances of survival have increased, but she is not yet fully recovered, most likely because she did not receive immediate medical attention during the birth process.

According to Dr. Muhammad Shaukat, a representative of the Khyber Pakhtunkhwa Health Directorate, doctors in the KP province are more than used to receiving desperate patients from across the border, particularly those seeking emergency obstetric care.

“Three teaching hospitals in this border town receive at least 1,000 Afghan patients every month, mostly those suffering from maternal and childhood diseases, from cities like Kabul and provinces like Jalalabad, Kunar and others, due to a lack of specialised medical facilities there,” he told IPS.

Most hospitals in Afghanistan are rudimentary and understaffed, while a shortage of life-saving drugs has fuelled the health crisis.

Afghan patients now occupy 10 percent of the beds in Peshawar’s hospitals. “They are becoming a burden…but we cannot deny them admission, so we treat them on humanitarian grounds,” Shaukat added.

Last year, teaching hospitals in the northern province treated approximately 34,888 Afghan patients. This year the number is likely to increase, with 20,000 Afghans having already received treatment as of May 20.

Meanwhile, facilities like the government-run Hayatabad Medical Complex (HMC) in Peshawar admitted 3,456 Afghan patients, mostly women and children, in 2012, Dr Hakimullah Khan told IPS.

“This year, we have already hospitalised about 3,000 patients,” the HMC specialist said, adding the influx will not slow down any time soon.

Dr. Sardar Ali, Pakistan field officer for the World Health Organisation, told IPS most Afghans seek treatment here due to a dearth of health facilities in their home, which is evident in Afghanistan’s maternal mortality rate of 500 deaths per 100,000 live births, as opposed to 250 deaths per 100,000 live births in Pakistan.

In comparison, the maternal mortality rate in the United States is seven deaths per 100,000 births, he said.

The infant mortality rate in Afghanistan is also a reflection of the near total lack of infrastructure, services and trained professionals like midwives and female nurses: over 152 infants die per 1,000 live births, since only eight percent of all deliveries are handled by skilled birth attendants. In Pakistan, trained attendants handle 35 percent of births.

Some experts blame the abysmal health situation on political instability.

Ahmed Jamal, a doctor from the eastern Afghan city of Jalalabad, told IPS that ever since U.S. troops deposed the Taliban government in 2001, the country has been almost entirely reliant on international funding for its health needs, with 70 percent of the population relying on health facilities set up by aid agencies like the WHO, the United Nations Children’s Fund (UNICEF) and the International Committee of the Red Cross (ICRC).

Since 2002 Afghanistan has received about 60 billion dollars in aid, much of which has gone towards improving basic infrastructure like schools and hospitals. But despite generous foreign donations, nearly 40 percent of the country’s 25 million people do not have access to health facilities.

Some sources estimate that the decade since the U.S. invasion has seen the child mortality rate drop by 50 percent. But 20 percent of newborns continue to suffer from low birth weight and acute malnutrition.

The WHO says Kabul, a city of 3.2 million people, has an estimated 1.28 hospital beds per 1,000 people, while other provinces have even fewer, with roughly two beds for every 10,000 people.

The few hospitals that exist often lack electricity and running water, and equipment is poorly maintained. As a result, the limited facilities are under-utilised, with an average occupancy rate of less than 50 percent.

Although the northwestern provinces of Pakistan provide an attractive option for well-heeled Afghans, not everyone can avail themselves of the services just across the border.

Aziz Ahmed, an automobile dealer in Kabul whose ailing father is now recovering in a private Peshawar hospital after an operation to remove a kidney stone, says that while he managed to scrape together the money to come here, “most of my countrymen cannot.”

In addition to hospital fees, anyone wishing to cross the border in search of medical treatment must pay about 200 dollars to rent a vehicle, and endure numerous checkpoints before entering Peshawar on rough and bumpy roads that doctors have described as “hazardous” to those already in precarious medical situations.

He said many people in Afghanistan blame the situation on 35 years of conflict, which has caused massive brain drain from the country, leaving the population without access to specialised services.

Dr. Abdul Shakoor at the Institute of Radiotherapy and Nuclear Medicines in Peshawar tells IPS that 15 percent of cancer patients treated in Pakistan come from Afghanistan, which does not have a single cancer treatment centre.

“Last year, we provided treatment to 3,000 patients from Afghanistan,” he said. This year, the KP provincial government registered 189 Afghan nationals for a free cancer treatment programme.

Afghans living with HIV/AIDS also receive free treatment at an antiretroviral therapy centre in Peshawar, which has “been providing treatment and counselling facilities to 250 patients from different parts of Afghanistan,” Dr Akhtar Nabi, a staff member at the centre, told IPS, adding that the centre also treats 600 Pakistanis.

The situation has bred resentment among communities in the northern provinces, which also host two of three million Afghan refugees currently living in Pakistan. Most locals look down on refugees, especially on those with whom they are forced to share the country’s limited medical resources.

Laxmi Yarragantla, a 20-year-old mother of three, lives in the Warangal district, where over 50 percent of girls are married before they reach 18 years. Credit: Stella Paul

By Stella Paul
HALDIYAGANJ, India, May 28 2013 (IPS)

In the small village of Haldiyaganj in the northeastern Indian state of Meghalaya, 17-year old Injuara Begum is nursing her son who was born right here on the floor of her home three years ago.

She has never heard of Janani Suraksha Yojana (JSY), a government health scheme that provides free medicine, midwife assistance and 30 dollars in cash to all pregnant women who deliver at a government hospital.

“In marginalised communities, early marriage is the only way to…ensure a girl’s physical safety.” -- Mamatha Raghuveer
Nor is she aware that marriage before 18 years of age is illegal and punishable by law. “My parents arranged my marriage when I was fourteen,” she tells IPS in a whisper – a result of shyness coupled with intense fatigue that has plagued her ever since giving birth.

Injuara comes from a poor Muslim family that migrated to India from Bangladesh in 1980. Her father, a brick kiln worker, says the early marriage was intended to “protect his daughter’s future” in this volatile border village where there are few opportunities for women beyond motherhood.

Injuara’s story is indicative of a worrying trend in India, where, according to a 2012 study by the United Nations Children’s Fund (UNICEF), 22 percent of women become mothers before the age of eighteen.

Research indicates that over 70 percent of these child mothers are from marginalised groups like the Scheduled Caste (Dalits) and other tribal communities, who comprise 24 percent of the country’s total population of 1.24 billion people, or refugees who have few economic opportunities.

Experts say lack of access to, and awareness of, health services compounds the problem.

Severe health repercussions

The exclusion of marginalised women from health services is holding India back from achieving the Millennium Development Goals, which set the target of reducing maternal mortality and achieving universal access to reproductive healthcare by 2015.

According to the UNFPA, 25 percent of the 56,000 maternal deaths in India in 2010 occurred within marginalised communities.

D C Sarkar, head of the Haldiyaganj Public Health Centre, tells IPS that most first-time mothers here are below 18 years. “Almost 70 percent of them suffer from low haemoglobin levels and weakness,” he said, which results in premature deliveries and miscarriages.

Since his own centre is ill equipped to deal with pregnancy-related complications, he often refers his patients to the district hospital. But it is an exercise in futility, since none of the village’s residents can afford to pay hospital fees.

Sunil Dhar, one of the leading gynaecologists in the northeastern region, says over 70 percent of his patients are from minority communities, while most are below the age of 20.

Drawing on his 50 years of medical experience in the border state of Tripura, Dhar told IPS, “Over 50 percent of my patients are as young as 14 and 15. Elderly female relatives, who want to know the health of the foetus, usually accompany the young girls who come here – but one look at the expecting mother tells me she is the one in need of treatment,” for conditions like jaundice, or swollen ankles.

He links poor health and early marriages to the socio-economic status of refugee communities in these northern border regions, where over two million people fleeing the bloody Liberation War in Bangladesh arrived in 1970.

The 1990s also saw an influx of refugees from Myanmar (formerly Burma) and the Chittagong Hill districts of Bangladesh. Still living in abject poverty in informal camp settlements, these communities “can’t be expected to go to the hospitals – the hospitals must come to them,” according to Dhar.

Further south, in the central Indian state of Chattisgarh, a Gond tribal woman named Khemwanti Pradhan tells IPS she was married at 15, and became pregnant shortly after.

A resident of the Sindurimeta village in the conflict-ridden Bastar region, she was forced to delivered both her sons at home because the closest health centres were shut when she went into labour late at night. “My mother-in-law helped me cut the umbilical cord,” she said.

An ongoing Maoist insurgency against the government keeps most people indoors for fear of being caught in the crossfire.

Though Pradhan was aware of the JSY government health scheme, violence prevented her from accessing the services. “Doctors and nurses will not work after dark because they are scared of the Maoists. No transport is available after four in the evening. If our men go out to fetch a car or a doctor, army personnel suspect them of being terrorists and arrest them for interrogation,” she lamented.

Integrated Solutions

According to UNICEF, over 52 percent of girls in the Warangal district of the southern Indian state of Andhra Pradesh are married in their teens. Experts say the region is in dire need of targeted interventions that can slow this trend.

Here, an NGO called ‘Thaurni’ trains adolescent girls from vulnerable communities, such as children of migrant labourers, landless farmers and nomadic tribes, to become anti-child marriage campaigners. In the past five years, the organisation has stopped 56 child marriages in the district.

Still, hundreds of girls continue to get married every year because existing laws do not cater to their specific problems, Mamatha Raghuveer, head of Thaurni, told IPS.

“According to the Prohibition of Child Marriage Act, anyone found guilty of planning or conducting a child marriage can be fined up to 2,000 dollars and also be jailed for a maximum of two years.”

But while this law has relevance for mainstream society, where families have other options, it does not address the specific problems in marginalised communities.

For people in dire economic and political straits, living in regions where rape and sexual abuse is rampant, “early marriage is the only way to…ensure a girl’s physical safety.” Unmarried teenagers face untold risks, including being kidnapped and sold to brothels. “We need a policy that focuses on reaching out to these people,” Raghuveer stressed.

According to Swapan Debnath, a local homeopathy practitioner and school teacher in Tripura, the prevailing “anti-immigrant” climate in India also forces many families to turn to early child marriages as insurance against deportation.

Therefore, policies to improve maternal mortality must necessarily tackle issues of violence and immigration, incorporating, wherever possible, cross-border solutions to prevent child marriage and early motherhood.

Debnath hopes that the Women Deliver global health summit, scheduled to run from May 28 to 30 in the Malaysian capital Kuala Lumpur, will provide the perfect opportunity to discuss such integrated strategies.

While activists and experts from around the world debate on what action can be taken, women in vulnerable situations have no choice but to rely on the support of their families.

At the moment, Injuara is happy that her husband Zakir Mohammed is not asking for another child just yet.  Since contraceptives and abortions are considered a sin, family planning means abstaining from sex – something that her husband has agreed to do until she regains her strength. “I am happy,” she says, “that he understands.”

About 99 percent of patients with obstetric fistula cannot afford to pay their doctors. Credit: Jugran Bahuguna/IPS

By Zofeen Ebrahim
KARACHI, May 27 2013 (IPS)

Sherhshah Syed is a highly qualified doctor and president of the prestigious Pakistan National Forum on Women’s Health (PNFWH) but his income does not match his qualifications.

He often spends long hours treating women with obstetric fistula, a severe reproductive health condition arising during childbirth that primarily affects women and girls who have no access to even the most basic medical care.

But since fistula is considered to be “the poor woman’s” disease, few of his patients can afford to pay him for his labour.

Dr. Sajjid Ahmed, who heads a PNFWH fistula project, tells IPS with a smile, “More than 99.9 percent of (our) patients are so poor, all they can offer us in exchange for giving them a new life is gratitude and an embroidered handkerchief.”

Labelled an “entirely preventable condition” by the international medical community, fistula develops during prolonged labour, “when the baby’s head puts pressure on the lining of the birth canal and eventually (rips) through the wall of the rectum and bladder, resulting in urinary or faecal incontinence,” Syed told IPS.

Fistula also causes stillbirths, kidney failure and a perpetual faecal odour emanating from the woman’s body.

The condition is rarely found in the developed world but is common in many Asian and African countries, affecting an estimated three million women, according to the World Health Organisation (WHO).

The fact that there are no country-specific statistics available for Pakistan is indicative of the indifference and stigma that surrounds the ailment.

Syed made a “conservative” guess that anywhere between 5,000 and 6,000 women in Pakistan are suffering from the condition, which can only be treated through reconstructive surgery.

“While we are able to (treat) 1,000 women each year, there are many more who suffer silently,” he said, attributing this silence to a sense of shame, a culture that does not allow women to make decisions about their own bodies and a lack of awareness among health practitioners.

Some experts blame this on flaws in medical colleges’ curricula. Dr. Qazi M. Wasiq, general secretary of the Sindh chapter of the Pakistan Medical Association (PMA), says colleges are “out of touch” with the needs of the country and the community.

“We train our young doctors to serve in countries like the United States, the United Kingdom and the Middle East, where fistula is non-existent. Most students have only a bookish knowledge of the condition, with hardly (any awareness) of the debilitating details.”

This oversight has heavy ramifications in Pakistan, a hotbed of maternal and infant mortality. According to official statistics in the Pakistan Demographic and Health Survey of 2007, the last time such data were gathered, the maternal mortality rate (MMR) of 276 per 100,000 live births is one of the highest in the region.

In comparison, according to the WHO, the MMR is 35 in Sri Lanka, 170 in Nepal, 200 in India and 240 in Bangladesh. Many other countries in South Asia are showing signs of progress, but Pakistan’s MMR has remained virtually unchanged since 1991.

In addition, the infant mortality rate is 78 deaths per 1,000 live births; for those under five the rate is even higher, touching 94 deaths per 1,000 live births. This means one in every 11 children born in Pakistan dies before reaching his or her fifth birthday.

The vast majority of these fatalities occur in the countryside, where women have little or no access to basic care. Most qualified female gynaecologists are reluctant to take up posts in remote rural areas, particularly in provinces like Balochistan and the northwestern Khyber Pakhtunkhwa (KP), according to PMA’s Wasiq.

According a recent report by the British medical journal ‘The Lancet’, evidence-based interventions can prevent roughly 58 percent of an estimated 368,000 deaths of mothers, newborn babies and children. In addition, 49 percent of an estimated 180,000 stillbirths could be prevented by 2015.

For years, Syed and his colleagues have urged the government to invest in providing basic emergency obstetric care by deploying trained birth attendants into rural areas to advise families against early child marriage, one of the leading causes of fistula.

According to Syed, dispatching an additional 400,000 nurses, paramedics and midwives to some 80,000 villages across Pakistan would have a huge impact on maternal mortality rates.  So far, however, there only 148 schools training 28,000 midwives.

With no official monitoring of the situation, women who develop conditions like fistula have to rely on concerned relatives to take action on their condition.

Ahmed says it is always mothers, fathers and brothers who accompany fistula patients to treatment centres – rarely, if ever, do husbands or in-laws volunteer to deal with the condition.

In 2006, the PNFWH in collaboration with the United Nations Population Fund (UNFPA) started the Fistula Prevention and Treatment Project with the aim of providing free treatment services to fistula patients all over the country, and training service providers.

On May 23, the UNFPA marked the first-ever International Day to End Obstetric Fistula, with the aim of building on local efforts to raise awareness of a condition that is not “understood even in societies where it is prevalent.”

In the eight years since the UNFPA project began, 13 fistula repair centres have been set up across Pakistan, all in government hospitals; but trained doctors, who currently number about three dozen, have not increased proportionately.

Ahmed says building an adequate medical force to deal with the problem requires commitment, compassion and sensitivity without the expectation of anything in return.

“Then again,” said Syed, “not everyone is mad enough to spend hours on something that earns you prayers but no economic benefits.”

Medical practitioners tell IPS that an obstetrician’s salary in a government hospital is anywhere from 600 to 1,000 dollars per month. In comparison, those with private practices earn the same by performing just one caesarian section.