Break the Silence on Menstruation

Standing outside the gate leading to her school, Anjali, a resident of Ghatkopar, Mumbai, 15, points inside to a partially broken door.

“This is the only toilet in the school which has running water. Now do you understand why I prefer to stay home on ‘those’ days”?

“Those” are the days when Anjali is menstruating when she, and most of her friends miss school. That is nearly seven days every month and the frequent absences Anjali fears will come in the way of her dreams of becoming a doctor. Many girls in her neighbourhood have dropped out totally shortly after hitting menarche.

What is a natural process marking the onset of adolescence in girls is fraught with huge challenges for girls in developing countries. Studies in different parts of Africa have documented how menstruation significantly compromises the education of girls.

The same is the case with India where according to an pan-India sanitation study by Dasra and Forbes Marshall, almost 23% of girls drop out of school when they start menstruating, and as many as 66% of girls skip school during this time. The same study also highlighted that 88% of India’s 355 million menstruating women have no access to sanitary pads – a lack that affects the health of women and adolescent girls.

An unsupportive environment in schools that includes lack of adequate toilets, absence of gender-segregated facilities, poor sanitation and inadequate water is one of the main causes. Another factor that explains the low school attendance is access to sanitary products that girls, especially in rural India, face.

A recent study focused on 53 slums and 159 villages in Madhya Pradesh, Chhattisgarh and Uttar Pradesh found that 89% of girls and women used cloth during their menses, with over half of them using the same cloth for more than one period. Two per cent used cotton wool and ash. Just 7% used sanitary pads.

The reality seems to have been taken note of at the policy level. In his Teachers Day address in 2014, PM Narendra Modi expressed concern about the large number of girls dropping out of school and the need to find ways to make sure girls don’t quit school early. The Swachh Bharat, Swachh Vidyalaya mission aims to build “at least one incinerator in the girl’s toilet block and a niche to keep sanitary napkins”.

What hold out greater promise is innovations in this field. Among the most prominent are those by A. Muruganatham, the Tamil Nadu-based creator of low cost sanitary napkin making units, who is aiding the Uttar Pradesh government’s efforts to reach total menstrual hygiene.

Guided by the UP government and Arunachalam, a pilot unit was set up in the village of Mahoba in 2013 to produce low cost sanitary napkins. The unit employs only women and is part of a decentralized enterprise model. This was coupled with a massive drive on menstrual hygiene across nearly 15000 schools in the district. The program was a massive success with the demand for Subah napkins far outstripping the supply and the UP government plans to take it across the state.

Also effective has been the UNICEF program in Kanchipuram district, Tamil Nadu, under which a vending machine disposing sanitary napkins was installed in schools.

Awareness too has to go hand in hand with affordability and availability. There is tremendous shame and stigma associated with menstruation and schools must address this, among boys and girls, to break the silence.

This blog was published in healthyurbanworld.com 

Breastfeeding promotes a smarter, healthier & equal world

The lives of over 800, 000 children and 20 000 mothers could be saved each year with universal breastfeeding says a new series by the respected medical journal The Lancet.

Breastfeeding leads to fewer infections, enhanced IQ, probable protection against obesity and diabetes, even breast cancer prevention in mothers, says the series which has been hailed as the most in-depth analysis done so far into the health and economic benefits that breastfeeding can lead to. It also highlights that breastfeeding leads to economic savings of 300 billion dollars

The data published is based on analysis led by scientists at the Federal University of Pelotas in Brazil who looked at data from previous research.

Reporting on the findings, The Independent, a UK daily, quotes the study head Professor Cesar Victora as saying, “There is a widespread misconception that breast milk can be replaced with artificial products without detrimental consequences…. The decision not to breastfeed has major long-term negative effects on the health, nutrition and development of children and on women’s health.”

However, globally, only 37% of children under the age of six months are exclusively breastfed in low and middle-income countries.

Women avoid or stop breastfeeding due to many reasons ranging from medical, cultural, and psychological, to physical discomfort. Turning to formula milk, which is heavily pushed by multinational companies and many hospitals, becomes a convenient option.

There is a need to create a supportive environment for a mother who is breastfeeding says Dr Armida Fernandez, Founder, SNEHA. This includes addressing the many myths and misconceptions that are still widely prevalent.

“Mothers, and this includes women from poor backgrounds, want to breastfeed their babies. But if their baby keeps crying, and this happens due to many reasons, they feel it’s because they are not producing enough milk and so they resort to formula or diluted cow’s milk leading to malnutrition”, says Dr Fernandez.

She believes that doctors need to aggressively and consciously encourage breastfeeding.

“I find many doctors do not support it at all. The moment the baby is a little underweight they tell the mother to start a top feed. “ Dr Fernandez suggest that health centres and clinics must have counsellors on their staff who actively encourage women to breastfeed.

Currently India is still some distance away from reaching its targets on improving infant nutrition as per an assessment report by the Breastfeeding Promotion Network of India (BPNI) and Public Health Resource Network (PHRN) published in late 2015.

The report says that nearly 15 million babies, who comprise of 55% of newborns in India annually, are deprived of optimal feeding practices in their first year after birth.

The assessment also points to gaps in policies and programmes outlined for enhancing breastfeeding rates. Countries like Afghanistan, Bangladesh and Sri Lanka fare better than India in comparison.

Aggressive promotion of baby foods by companies, lack of support to women in the family and at work places, inadequate healthcare support, and weak overall policy and programmes were some of the reasons identified as responsible for lack of improvement in infant and young child feeding practice indicators.

This article was published in healthyurbanworld.com 

Taking Community Health to the Market

As she rocks her restless baby, Tia Pertiwi listens as three women with aprons imprinted with images of the reproductive system explain how contraception works.

Besides her are some 20 odd women, most of them market vendors, and the atmosphere is relaxed and carefree with many asking questions and cracking jokes.

Pertiwi, 25, who recently gave birth to her first child, wants to delay the second by a few years but is not sure what birth control method to adopt.

Fortunately, the answers are available close at hand; at the Pasar Badung marketplace where Tia works at a fruit stall.

Guiding her with information about contraceptive options is the Yayasan Rama Sesana, a health clinic situated inside Pasar Badung, a traditional marketplace in the Bali capital Denpasar, where Tia works as vendor at a fruit stall.

Since 2004, YRS, a non-profit, sexual and reproductive health clinic has reached out to thousands of low-income group women in Bali. Most of them, like Tia, work in traditional market communities with an average daily income of US$5.

The YRS started in 1999 and initially worked in the field of AIDS prevention among risk groups in 1999. It later developed a plan to open health centers to provide information and services on breast and cervical cancer prevention, HIV/Aids, family planning, prenatal care and sexually transmitted infections.

“Breast cancer is the leading cause of cancer-related deaths in Indonesia and over 9000 women die of cervical cancer in our country every year”, says Dr Luh Putu Upadisari, founder, YRS. “Early detection is key to prevention but women lack information and they don’t have the time and money, especially towards preventive care”.

To ensure maximum reach, these health clinics were set up at traditional marketplaces. “They are open 24 hours a day and thousands of people – girls, women, housewives in particular – come here. This creates a supportive environment to inform them about their reproductive health and empower them,” says Upadiseri.

The YRS has two such clinics at Bali and also runs mobile clinics that carry out monthly visits to markets around Bali. The services offered are on a donation basis and include breast exams, Pap smears, STI and HIV testing, and counseling.

The centers report about 520 clients per month on average – over 67% are women. Their location draws a wide variety of clients – not just market vendors but laborers, cleaners, office workers and shoppers.

Trusting women with information about their health not only empowers them but also helps save lives. And the Balinese approach of reaching women directly at their workplace is one that has the potential to benefit thousands of women in India as well.

Like Indonesia, India reports a high death incidence due to cervical cancer. According to a 2014 study by the Cervical Cancer-Free Coalition, it tops the world in cervical cancer deaths with nearly 73,000 women dying every year. It is also the second most common cancer in women aged 15–44 years.

Cervical cancer is treatable if found early but in the absence of a nationwide screening program in India, there are widespread disparities in screening, treatment as well as survival.

“Early detection is essential as it is completely curable at that stage but we do not have a comprehensive screening program with the outreach required to provide access to services to underprivileged women”, says Dr Aparna Hegde, founder of NGO ARMMAN, which is behind several maternal health initiatives in Mumbai and other parts of the country.

ARMMAN’s mMitra project uses mobile phone technology to take preventive health care information directly to the phones of pregnant women through pregnancy and infancy.

Hegde says innovative approaches could offer the way forward as traditional models of caregiving leave a lot to be desired.

“Initiatives like YSR emphasize preventive care and this paradigm shift essential because our health care system has almost always focused on curative services”, adds Hegde. “Preventive care will prevent overloading of our public health system and help them provide better care to the patients who access it.“

This article was published in the Business Standard on January 27, 2016

Greater contraceptive choices for youth – key to economic growth

One of the key statements to come out of the 2016 International Conference on Family Planning is the Global Consensus Statement supporting the expansion of contraceptive choices for young people to include long-acting reversible contraceptives or LARCs. Over 40 leading global health and development organisations have endorsed this statement.

1.8 billion – that is the estimated number of adolescents in the world and a significant number of them are sexually active and don’t want to get pregnant until they finish their education, get a job or they want to space their children. However, the limited access to LARCs restricts their ability to exercise full contraceptive choices. Lack of information, myths and misconceptions, lack of availability and poor community support are some of the key barriers.

Speaking at a press conference, C.M Purandare, president of the International Federation of Gynecology and Obstetrics (FIGO) said that the goal of heir organisation is to encourage midwives, gynaecologists and obstetricians to work towards removing barriers in their countries to the use of LARCs to meet the reproductive needs of young people.

“We have women who get pregnant and who come for an abortion and are not given information about the basket of contraceptive choices”, said Dr Purandare. “After a few months she is back for the same thing. If we do not provide her with information and contraceptives, we are failing her for the second time”.

In many countries it is hard for adolescents to walk into hospitals and ask for contraceptive advice. “Injectables are a boon to adolescents and efforts have to be made to ensure the knowledge is available as widely as posisble”, added Purandare.

At the very core it boils down to a question of agency and autonomy for young women believes Ramya Jawahar, Vice Chair, International Youth Alliance for Family Planning who is from Bangalore, India.

“Women are shuffled between the homes we are all born into and those we are married into”, says Jawahar. “Now that LARCs are in the health centres, the challenge will be to get women into these centres and getting the men on board”.

The safety of LARCs for adolescents also came up for discussion at the conference. There are misconceptions and myths relating to the impact of long acting methods on the health of adolescents.

“Adolescents are eligible to use all methods like adults”, said Dr V Chandra-Mouli of WHO-HQ, pointing to a WHO study which said there was no medical evidence to support the perception that implants or any other LARCs impact fertility.

“The most important rationale for investing in young people is demographics”, he added, pointing to countries like Hong Kong and South Korea that have invested in education and health. “Investing in young people is good for them, their families and their countries”.

India: Need for gender equity in family planning

Activists and experts from around the globe have gathered at Bali, Indonesia, for the 2016 International Conference on Family Planning. It’s an opportunity to take stock of goals that have been met with, and for countries to evaluate how to boost workforces and tweak their approaches toward achieving the new Sustainable Development Goals.

India has a lot to feel proud about. Phase 1 results from the National Family Health Survey-4 for 2015-16 that covered 13 States and two Union Territories show that total fertility rates or the average number of children per woman have dropped considerably, ranging from 1.2 in Sikkim to 3.4 in Bihar.

All the states in the first phase, barring Bihar, Madhya Pradesh and Meghalaya have either achieved or maintained replacement level of fertility and this is a major achievement in the past decade. All have rates below 51 deaths per 1,000 live births, although there is considerable variation among the states.

However, there is plenty to be done when it comes to how we approach family planning at the policy level. On this count, India lags behind countries like Sri Lanka and Bangladesh despite being the first country, globally, to have a government-backed family planning program.

India still reports the highest unmet need for contraception worldwide at 21%. In Bihar it is 31% among women between 15-19 years and 33% between 20-24 years. Maternal and neo-natal mortality is five times higher among girls who conceive before they hit the age of 20. They are also more likely to experience spontaneous abortions, infections and anemia.

This is largely because on the ground the emphasis on female sterilization remains high. According to UN data, in India, over 37% of women between 15-49 years use sterilization as a method of contraception. Only 3.1% use a pill and 5.2% rely on condoms.

“The rights perspective on family planning is missing at the policy level and it is high time that this changed”, says Dr Pranita Acharya, Gender, Poverty and HIV/AIDS specialist at the International Centre of Research on Women. “It is the right of couples to decide when and how many children to have. This is only briefly touched upon at the policy level and forgotten on the ground”.

Other contraceptive choices require counseling and careful monitoring – an investment that most states find burdensome. Sterilization, on the other hand, is a one-time, “gunshot” intervention. The result is that many women have been sterilized even before they need it.

Bridging the gap between the two genders in family planning matters is key believes Sushma Shende, Program Director, Maternal and Newborn Health, at SNEHA, a Mumbai-based non profit that works in urban slum communities.

“Considering the socio-economic set-up of the areas in which we work, it is difficult for women to take decisions with respect to FP”, says Shende. “Her husband and mother-in-law play an important role in decisions regarding child bearing and family planning. Moreover, the pressures of bearing and rearing the child is considered to be the responsibility of women so increased awareness amongst the men will make them more supportive and help address misconceptions or fear”.

There is also a near complete lack of awareness when it comes to contraceptive choices among married adolescent girls and newly married couples. Filling this gap is critical given that India accounts for 19% of maternal deaths, worldwide. Educating newly married couples about various contraceptive methods could help prevent many more such deaths.

Challenges top health ministry officials said they are addressing by offering a wider choice of contraceptives, improving service delivery and taking these services to the doorstep of those who need it. Speaking at the India Caucus held on the eve of the 2016 International Conference on Family Planning, C.K Mishra, Mission Director, National Rural Health Mission said that the goal ahead was “to ensure no woman should be left behind and no partner should be left behind”.

Admitting that the focus on female sterilisation was troubling, Mishra said there was now greater emphasis on expanding the basket of contraceptive choices to include injectables, Centchroman, a non-steroidal agent and POPs or progesterone only pills. Centchroman, marketed as Saheli, is a potent non-steroidal non-hormonal birth control method, is a once-a-week oral contraceptive that acts on the hormones produced in the body, especially progesterone. POPs thicken the mucus in the cervix, stopping the sperm from reaching the egg.

Attractive packaging for contraceptives, a sharper FP communication campaign and mobilising local health workers is also being looked at to add momentum to India’s family planning program.