How Araku Valley's nurse-midwives have brought down maternal mortality rate to zero


In Araku Valley, Visakhapatnam, a land where superstition and regressive practices are still prevalent, a group of auxiliary nurse midwives (ANMs) treks long distances every day to provide healthcare services to pregnant women and new mothers. As a result, the maternal mortality rate in the tribal region over the past two years has been zero. The valley has also seen a 68 percent rise in institutional deliveries (babies born in a hospital or primary health centre), compared to just 18 percent in 2010.

I met one such ANM working with the Piramal Swasthya Foundation’s ASARA project educating tribal families about maternal health and child birth. Twenty-six-year-old Prema greets me with a smile and a namaste when I meet her on a sultry August morning in Landiguda of the Araku Valley Mandal, about 120 km from Visakhapatnam. Dressed in a white lab coat over a red salwar kameez, she is enthusiastic about her work and eager to share their progress.

Prema during an interaction

To understand more about the challenges of working in a tribal settlement, I accompanied Prema and her team to document their journey, ground realities, and understand the hurdles faced by them.

Hailing from the tribal community herself, Prema has dedicated the last five years of her life to educating tribal families about childbirth. The only daughter among four children, her parents are retired government teachers who now spend their time farming.

The women folk of the tribe

I ask Prema if she always wanted to be a nurse.

“I was born in a tribal community which was deprived of even basic facilities,” she replies in Telugu. Prema graduated from a local college in Araku as an ANM in 2012. The two-year programme gave her the qualifications she needed to remain in the region and work for her community.

Prema interacts with women during her trek to the tribe
I had access to education only because my parents could afford it. But despite the little luxuries I had, healthcare was one area that needed the most attention, and which we had no access to, and so I decided to work in this sector. My three brothers chose to help my parents in the fields, while I found the job I wanted to always do, and that too, closer home, she explains.

Prema’s day starts at 8.00 am at the office, which also serves as a telemedicine unit. Each ANM is then assigned a certain tribe for the day. That day, Prema was directed to the Parnagi Poorja tribe located at Landiguda village. A primitive tribal group, it comprises 32 families and a population of 250.

A pregnant woman being carried on the stretcher to the nearest MMV

Most tribals in the area live on hilltops with no access to roads, so in case of an emergency, medical mobile vehicles (MMVs) help take them to the nearest hospital. At times, when the patient cannot move, there are stretchers to carry them along the route till a motorable road is reached.

On most days, her job entails visiting each house and conducting a survey of the women and children. When asked about expectant mothers in the tribe, she rattles off their names with familiarity. A total of six pregnant women raised their hands that day and Prema chose 28-year-old Vimalakanthamma to show us a quick demo of the medical tests she performs.

The medical kit and its essentials

The medical kit provided to all Asara workers by Piramal Swasthya contains a blood pressure monitor, health charts, diet charts, pregnancy kits, iron tablets, blood type test kit, height and weight checking machines, diabetes and hypertension kits.

Prema checks their blood pressure and weight gain, and neatly documents the details of every woman under observation in individual files.

Prema checks a pregnant woman for her BP and weight

On most days, Prema is accompanied by a pilot (male nurse) with whom she travels to remote places and forest areas. “Forget phone networks, on most days our only company is the noise coming from the forest.”

It is an arrangement that many frown upon. “I travel on a motorbike with a pilot who is usually a young man. While many may look down upon this arrangement, my family is confident about letting me travel even if it means that I’m on duty in a remote place, with a man,” Prema says with a sense of pride about her work.

The file where Prema makes a note of all checkups

Leading me through lush paddy fields and orchards dotted with jackfruit trees, Prema tells me all about what she does. On the first visit after the pregnant women in the community have been identified, the family, especially the husband and the women folk, are trained to understand and accommodate their needs. The second visit to the same patient is scheduled for when she is 28 weeks pregnant and the third is at 32 weeks. The fourth is when she is taken to the hospital for a checkup prior to delivery.

The ASARA workers and pilots during a discussion

Though this time table is set up by the team at Asara, not every tribal is comfortable visiting a hospital. The language barrier also acts as an impediment as tribals speak their own dialect and not all of them are conversant with Telugu. Convincing a family to allow the mother to deliver in a hospital is one of the biggest tasks, she says.

“They still believe in the age-old ritual of inviting a local dai-ma (midwife) to assist in the delivery. Added to this is the tradition of not allowing the mother and the child to step out of the house for the first 21 days or they wait for the right ‘muhurtham’ (auspicious time) to step out. Since most important vaccinations and tests need to be done during this time, very often they end up missing them because of ignorance. This is why awareness is a big part of our job and we train the families from the very beginning to get accustomed to institutional deliveries for the good health of both the mother and the child,” she adds.

An ASARA worker assisting a mother with a video call at a tele-medicine centre

Prema shares that there has been no case of child infanticide, which leads one to believe there is likely no gender bias among the tribal population. In fact, as per the 2011 Census data, the sex ratio for Araku Valley is 1,061 females per 1,000 males - better than the state and national averages. Other discussions centre around the age gap between two children and menstrual hygiene. And unlike in the rest of the country, talk of family planning is not encouraged as the government is promoting an increase in the tribal population.

The team also ensures that both mother and child undergo medical follow-ups for 42 weeks after delivery. Due to the lack of sanitation and water, these regions are prone to a high number of cases of malaria, typhoid, dengue and other viral fevers.

A makeshift cradle adorns this house

The days are long and arduous, but Prema is happy that the tribal population is slowly getting comfortable with the idea of seeking medical attention for other ailments too. Along with other ANMs, she is training a new group of nurses that has joined the programme.

Buts it’s not all work and no play for an ANM like Prema. I am enthused by her child-like enthusiasm as she talks about her love for Telugu films and actor Prabhas (of Baahubali fame).

But these moments, I realise, are few and far between. There is a lot of work to do. The roads here may be less travelled, but Prema’s hard work and determination are certainly taking her places to make a difference.



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