Cost Of Maternal Healthcare Is Pushing Families Into Debt Trap In Maharashtra
Few women in impoverished packets of rural Maharashtra are aware of government welfare schemes or do not have the documents to access them
Anjali Waghmare, 21, and her infant boy were two of the 60 patients who died last October at the Shankarrao Chavan Government Medical College in Nanded due to a crisis caused by multiple factors – shortage of medicines, poor infrastructure, non-functioning incubators among these.
However, Anjali’s death was not the last tragedy to hit her family who are landless Dalits. Her father Kamaji Tompe, who had borrowed Rs 50,000 from the mukadam (contractor) who employs them as cane-cutters, is now struggling with a massive debt. The family migrates every year around Diwali to western Maharashtra or northern Karnataka during the cane-cutting season. This year they had to put in extra work in Gulbarga to start repaying the debt.
In India, over 50% of health expenses are paid through out-of-pocket expenses (OOPE), according to this 2023 study. High OOPE figures indicate poor investment in public health infrastructure, inadequate health facilities, heavy dependence on private hospitals and poor insurance coverage.
Private spending on health pushes people into financial distress and impoverishment and India studies say it leaves 63 million Indians impoverished annually, nearly two every second. This means that families have little to spend on food, basic necessities, other medical expenses and so on. The outcome of these is often a brutal debt trap, as our story shows. And in a patriarchal society, women tend to bear the brunt of this impoverishment, given less nutritious food and healthcare.
As much as 83.9 % of those carrying the burden of OOPE in India spend the money on hospitalisation and 94.7% on outpatient care in India, per the 2023 study. Childbirth is the most common cause of hospitalisation.
The cane-cutters we interviewed said they paid an average of Rs 30,000 for an institutional delivery, marginally higher than the national average of Rs 24,663 that women paid for deliveries in private facilities. The women approximately earn (couple – Koyata) 1,50,000 for a six month season from October to March. The OOPE for deliveries in a private facility in India is 8 times higher than a public facility (Rs 3,245) per data from the National Family Health Survey- 5.
Women like Anjali, working class and constantly on the edge of precarity, should be the prime beneficiaries of the government’s maternity benefits schemes such as Pradhanmantri Matru Vandana Yojana and Janani Suraksha Yojana. But a month-long investigation across Maharashtra, when we interviewed women who work as migrant cane-cutters and brick kiln workers, showed that they rarely benefit from schemes that could allow them better healthcare.
“This year, our family is working the entire season to repay the loan we took for Anjali’s delivery,” said Kamaji Tompe. The family lives in Kurula village of Kandahar block, 57 km from Nanded city, but not one person in the village had stepped up to help them with emotional support or credit when the family lost the child, he added.
The three men of the Tompe family, Parashram, Nagnath and Rajesh, work as labourers and the family lives in a tiny house with three rooms. They know nothing about the maternal welfare schemes Anjali could have availed of.
To understand why out-of-pocket expenditure on maternal healthcare was so high and debt-inducing among the poor, we interviewed over a dozen migrant women workers in Nanded, Chhatrapati Sambhaji Nagar(Aurangabad), Hingoli, Kolhapur and Mumbai. Most of them said it was because they had to seek out private healthcare because they knew nothing of the government schemes to help them or did not have the documents needed to access these schemes, as we elaborate later. They also reported being treated badly at public health facilities.
Why The Benefits Don’t Reach The Poor
When it comes to access to migrant workers’ access to welfare schemes, the lack of documents and a single window system to process the schemes is a big hurdle. Daily wagers are reluctant to take the time off to get these documents together because it means the loss of workdays.
ASHA workers often do not go to the sugarcane fields and brick kilns to reach out to these workers because those are mostly on the outskirts of villages and cities and they do not get sufficient travel allowance. Also ASHA workers find it hard to maintain files on migrant workers so they can be informed of maternity schemes and be given the help to access these.
Sangeeta*, 30, is a cane-cutter from a Beed village and she had to take a loan of Rs 15,000 from her mukadam to pay for her third child’s delivery because a private doctor had warned her of a complicated delivery. Sangeeta’s first two children, both girls, were delivered at home but the third pregnancy was stressful. The family was emphatic they wanted a son and they decided to not take ‘any risk’ with the delivery and sought out a private hospital.
Sitting outside her makeshift tent near one of the cane fields in Karveer taluka of Kolhapur, Sangeeta was despondent as she recalled her ordeal and the debt trap she is caught in. “This was eight years ago, and it cost Rs 15,000 for a normal delivery, and a little over double that for a C-section. Now medical expenses have shot up even more,” she said. “Darvarshi aamhala uchal ghyaylach lagati lakh-don lakh rupaye. Kadhi ghar bandhayala, kadhi diivarila kadhi lagna-karyala. Rin kadhi fitatach nai (we have to borrow in advance every year, anything between Rs 1 lakh to Rs 2 lakh, sometimes it is for housing, sometimes a delivery, or a wedding. But once we borrow it is never repaid, it becomes a part of a vicious cycle of debt).”
‘We Are Humiliated At Public Hospitals’
We asked the women we interviewed why they choose to go to private hospitals for delivery despite the wide network of government health facilities. As this report based on the National Sample Survey Organisation’s health survey showed, public health systems cater to only a third of Indians, the rest look to the private medical sector. Even though the poor seek out government hospitals more than the rich, a majority depend on private healthcare providers. This is despite the fact that private hospitals are reported to charge patients eight times as much as government facilities and have a tendency to deliver through expensive Caesarean section operations (47.4 %) unlike public hospitals (14.3%), per NFHS-5 .
Anita*, a cane cutter from Latur, said the experience at government hospitals was not just dissatisfying, it was also humiliating for women like her. “At government hospitals, doctors don’t attend to us for hours. They think we are filthy and they should not touch us. Because we migrate everywhere, people feel we carry infections from different places. We don’t get any dignity or respect at government hospitals and now they also insist that we buy some medicines, pay for certain treatments. In another 4-5 years, I will have to borrow Rs 30,000-40,000 from the mukadam for my daughter’s delivery. That’s our fate,” said Anita.
The Pradhan Mantri Matruvandana Yojana provides financial assistance of Rs 5000 in three instalments to women – the first of Rs 1000 at the time of registration of the pregnancy at a public hospital, the second of Rs 2000 at the end of the second trimester. The last instalment of Rs 2000 is paid to a woman post-birth and the first round of immunisation for the child.
There is also the Janani Surakasha Yojana, a scheme that gives financial assistance to women who are below the poverty line or belong to Scheduled Castes or Tribes. The amount is Rs 1400 in rural areas and Rs 1000 in urban areas. In the cases of C-section deliveries, the women are given Rs 1500. This financial aid is supposed to be given in the form of direct benefit transfer within the week of the birth of the child for institutional deliveries. For those delivering at home, the assistance is of Rs 500.
However, this scheme requires as many as eight documents for registration and for availing its benefits – Aadhaar card, BPL-Ration card, domicile certificate, address proof, a Janani Suraksha Card, registration certificate for the pregnancy from a public hospital, a bank passbook, mobile number and a passport size photograph.
Up to 73 % of women in Maharashtra have bank accounts as per the national family health survey- 5 but there is no data available on women actually accessing bank accounts.
“Tumhi hospitalcha vicharta, Aamchi lekara usachya pachatat janmtat. Lekarala ithaca zolit takun aamhi uoos todayala jatav. Itha koni yet nahi aasha bisha aani bank account pan nahi maza, kase milnar paise? (you ask about hospital deliveries, we give birth to our children in cane fields. Soon after birth, we keep our children in a zoli (a makeshift cradle created by folding a saree) and go to work. No ASHA worker has ever reached out to us here in the fields and I don’t have a bank account. How would I get this assistance),” asked Usha*, a cane-cutter from Beed district working in Kolhapur.
Problem With Remote, Poor Areas
India has made significant progress in reducing its maternal mortality over the years. However, rural and tribal populations continue to face a high risk and burden of maternal deaths.
The crisis that hit Nanded and Chatrapati Sambhaji Nagar public hospitals in October 2023 showed that all the victims of child and maternal mortality were from marginalised castes and poor economic backgrounds.
Women labourers across Maharashtra told us that they rarely benefitted from state health interventions to ensure safe motherhood. The state human rights commission has directed that poor pregnant women be paid under the Pradhanmantri Matruvandana Yojana. But the scheme is active in only a couple of blocks in Gadchiroli district of Maharashtra, healthcare activists told Behanbox on the condition of anonymity.
Varasha Kodape, a Chandrapur-based journalist with the feminist web portal, Baimanus, and a community health activist with the Jagrut Bahuuddeshiya Sanstha, said the Matruvandana scheme is effective mostly in cities. “It was 100 % successful in a block like Mool in Chandrapur, but women in remote areas like Jivati, Korapana in Chandrapur, Aheri, Bhamragad, Allapalli in Gadchiroli still struggle to access basic necessities when it comes to maternal health, showed a survey done by the sanstha. There are no health facilities like PHC’s at the kolamgudas (where people of the Kolam community live) in our area and this is a violation of our human rights,” said Kodape. (The landless Kolam community, which lives off forest produce, is categorised as a particularly vulnerable tribal group in Maharashtra, and is mostly located in Vidarbha.)
A recent report of the Center for Labour Research and Action revealed that in Gujarat, only 2 of 198 women migrant waste-pickers surveyed had access to government schemes for maternity care.
Under the Matruvandana scheme, over 31 million crore beneficiaries have been enrolled and benefits of more than Rs 12,150 crore have been disbursed to over 27 million women since the start of scheme 2017 and till November 2022, according to the women and child development department. At least 3.2 million beneficiaries enrolled for the scheme in Maharashtra in this period but there are no numbers for the women who actually received the benefits.
Burden On Natal Family
Conventions dictate that the burden of expenses on maternity care, pre- and post- delivery, be borne by a woman’s natal family. And these expenses are often preceded by the huge cost of organising a wedding, the women we interviewed said.
Lata Babar, a migrant worker from Beed, said she had to take a loan of Rs 1 lakh to pay for the four deliveries of her two daughters at private hospitals. “Every delivery cost us between Rs 30,000 and Rs 35,000. Our sons-in-law bore some of the expenses, but the rest we did. It’s a huge burden for most of us to bear,” she said.
Babar had to borrow earlier for her daughters’ wedding. “It’s our tradition that women’s maternal families have to bear all the delivery expenses of the child – at least the first child. That includes hospital expenses along with nutritious food for both the mother and child, clothes, and other necessities for the baby. We also need to bear the expense of the naming ceremony of the baby within a few months after their birth,” she said.
Naming ceremonies are elaborate celebrations and families have to pay for cradles, decorations, new clothes, gifts for guests, and gold or silver ornaments for the baby, food, and music. “All this is impossible without the loans from the contractor. This is the cost of becoming grandparents,” said Babar. Often maternal homes of women have to bear the expenses of traditional baby showers as well.
“A large section of our society observes the norms of patrilocality [living with or near the husband’s family] and this comes with male domination and certain social sanctions. So, social reforms based on gender equality are needed along with economic measures such as Maternity Benefits Act, family care leave for both men and women employees, and affordable and safe child care facilities for working parents,” said Vibhuti Patel, a feminist economist and activist.
As we reported earlier, maternal health infrastructure is an issue in the Marathwada region and in Vidarbha district, Gadchiroli, Chandrapur where hilly and remote villages have poor connectivity and transport. This is also true of some parts of Nashik, Nandurbar and Palghar.
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