Nasreen and Minara (names changed) are both five months pregnant. The two women live in Bengaluru’s Kundalahalli slum colony with other migrant workers from West Bengal. Nasreen moved to the city around seven years ago. Minara is a recent arrival, having shifted with her husband shortly after their marriage eight months back. Now, Nasreen works as a cook for multiple houses in a residential complex. Nisara is a homemaker.
The pandemic and its aftermath have seen little change for the better for pregnant mothers like Nasreen, expecting her third child and Minara, pregnant with her first.
Nasreen told this writer that due to her family’s economic difficulties, she did not want to keep the third child. But having discovered the pregnancy after the 12-week mark, a private healthcare provider convinced Nasreen against an abortion.
Many women, including Nasreen, have reported being denied the procedure by doctors. Nasreen says the doctor led her and her husband to believe that Nasreen’s health might be in danger if she chooses to abort. Second trimester abortions are safe and legal in India. But up until 20 weeks of pregnancy, the Medical Termination of Pregnancy Act (amended in 2021) mandates the consent of a medical practitioner before a woman can abort.
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Despite experiencing body weakness, she goes to work to keep their family afloat. Her husband is a Zomato delivery worker. Nasreen is uncertain how they will raise a third child in a home which is too small even for the present family of four.
Minara, on the other hand, is home bound. Her health has been deteriorating with frequent bouts of nausea and fever. Her mother has travelled from their village in West Bengal to care for her while Minara’s husband works in a company nearby. She opens a box of medicines prescribed by her doctor, one of which costs over Rs 500 for just a single pack.
The women were entirely unaware of Jan Aushadhi Kendras and that they could likely get medication in these kendras for almost 50% to 90% less.
Unaware and unable to access govt health care
There are four BBMP Primary Healthcare Centres (PHCs) around the slum. Bangalore’s Chief Health Officer (Clinical) Dr Nirmala Buggi says that apart from the 12,000 deliveries that annually occur in BBMP’s hospitals, PHCs play a huge role in bringing healthcare to impoverished pregnant women in the city.
As of 2019, there are 435 functioning PHCs in Karnataka (Urban). The Indian Public Health Standards Guidelines (IPHS) states that PHCs must provide natural or caesarean deliveries to pregnant women at no expense. All drugs and consumable medication should be free. Transport to and from their homes is also supposed to be covered by PHCs. IPHS also mandates diagnostic tests and diet maintained during the post-delivery stay within the centre to be free.
But awareness of the PHCs is low. There are four PHCs in a 20 to 30 minute radius of Kundalahalli. Nasreen and Minara don’t know of any of them.
This is not just the story of Kundalahalli. A study titled ‘Maternal Healthcare Services and the Health Workers among the Migrant Slum Dwellers of Bangalore City’ by independent researchers Suchismita Mishra and T Rajendra Prasad revealed that 64% of pregnant migrant women they surveyed had not been visited by any health worker either during their pregnancy or after delivery.
The study adds that serious “lack of sufficient manpower and basic infrastructure” could explain migrant mothers’ low utilization of public resources.
Health workers are crucial for ensuring adequate care and medical awareness reaches pregnant women. This link seems to be largely missing for migrant women in low-income housing across Bengaluru.
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Low-income pregnant women are often at-risk of several vulnerabilties, including anaemia. PHCs and health workers become important mechanisms to identify and treat such women.
Anganwadis also initiated a scheme of giving hot meals to pregnant and lactating mothers.
Investigations have, however, found that no cooked meals have been dispensed in Karnataka’s anganwadis since April 2020. Instead, ration has been distributed through these channels. Even this does not reach many migrant mothers in Bengaluru.
Apart from a serious lack of awareness, many migrant mothers often do not possess the required documents and bureaucratic paperwork required to gain access to state support.
“Migrant workers fall out of the ambit of most social safety nets,” says noted public health researcher Dr Sylvia Karpagam. She points out that recent migrants are at a further disadvantage. Language barriers being just one aspect of the problem.
According to government guidelines, ASHA workers are supposed to conduct house to house visits in order to disseminate health related information, and to connect women to PHCs. Residents of Kundalahalli say no ASHA worker has come to their slum in years. Only one local nurse from a private clinic pays infrequent visits to vaccinate and do basic health check-ups for children and women.
Heavy cost of private care
Nasreen went to this nurse when she found out about her pregnancy, and was referred to Vydehi Hospital in Whitefield, located only 10 mins away. The hospital is now her and Minara’s preferred choice.
Though not as expensive as private care centres in the area, costs are still high. A blood test required during pregnancy cost Nasreen Rs 1,300. On its website, the Hospital claims to provide free services to the ‘poor and needy’. But its parameters of ‘poor’ is difficult to assess.
Residents of the Kundalahalli slum say that the hospital has been increasing costs of services for the past five years. Although seemingly a private hospital that comes under the purview of Vydehi Institute of Medical Sciences and Research Centre (VIMS), Vydehi lists itself as a ‘responsible partner’ for a healthcare scheme run by the government. Residents speak of it as a semi-private facility.
Dr Nirmala Buggi says that migrant women rarely come to BBMP’s hospitals for antenatal check-ups. They are admitted into facilities only at the time of delivery. According to her, BBMP hospitals offer delivery services for pregnant women at no cost. Antenatal care including medication to treat sicknesses like anaemia is also supposed to be free.
But women in Kundalahalli slum say government hospitals are far away and too crowded. Women like Nasreen and Minara choose Vydehi primarily because of its proximity.
Researcher Suchismita Mishra says that migrant women workers in Bangalore’s slums largely frequented the healthcare service “which was within two km of their place of residence for 44% of respondents” according to their study.
The fact is private healthcare providers outnumber public institutions in Bengaluru making it more likely for a private hospital to be closer to migrant sites. Despite the fact that out-of-pocket expenditure skyrockets at private hospitals, Karnataka’s government has allocated a mere 4% of its recent budget for health and family welfare. How, then, are women from poor income households supposed to brave Bengaluru’s potholed roads to travel more than 40 minutes in traffic for affordable care?
Women like Nasreen have their days packed with waged work, household chores, and childcare. On the other hand, women like Minara can barely walk without exacerbating their pregnancy-induced sickness. Going to a private hospital is therefore less a choice but a more an expensive necessity for them.
Neither woman has ever received the Pradhan Mantri Matru Vandana Yojana (PMMVY) cash benefit of Rs 5000. The scheme does not apply to pregnant women seeking healthcare in private hospitals. The only way for such women to get the cash transfer is to have a health department official approve their claim and a Health Field Functionary (such as Anganwadi workers or ASHA workers) accept the transfer. This requirement generates more hurdles for migrant families in dealing with local bureaucracy, forcing them to go to private hospitals.
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Dr Shaibya Saldanha, practicing gynaecologist at Acura Hospital in Koramangala, recommends universal healthcare coverage for pregnant women no matter where they are in the country. Dr Shaibya sees several migrant women with little information about healthy practices during their pregnancy, and even less state support to ensure access to those practices.
“Just because you are not in your home-town does not mean you should be excluded from public healthcare,” she said.
Nasreen’s husband’s work as a Zomato delivery man does not guarantee him a stable income. His monthly income can vary from Rs 13,000 to as low as Rs 5000. Before the pandemic, Nasreen ran a home garments boutique and did her own tailoring. At times she earned Rs 22,000 in a month from boutique sales.
But the lockdown brought her home-based business to a painful halt. Now her income has been reduced to around Rs 10,000 a month. With two school-going children, increasing rent, a bike loan to be repaid, and a phone EMI pending, she worries about the costs incurred because of the pregnancy.
“I will have to stop working once it is time to deliver and will not be able to resume work for at least 6 months after the birth,” says Nasreen. This would cut their household income by almost half.
Despite all these stresses, when her youngest tugs on her dupatta to ask for a chocolate, Nasreen hands him a 10-rupee note with a smile.