The abandoned mothers

Thirteen-year-old Rupa Akter begs on a foot over-bridge in the capital's Shewrapara area, with her eight-month-old son, Nirob. Akter lives in a makeshift house (if one can call the threadbare tarp tent a house) under the bridge—her unemployed husband left her and married another woman during her pregnancy. 

When her contractions started, she was alone, on the streets. Where would she go, after all, and with whom? She gave birth to her child in her roadside tent without the help of a trained or traditional birth attendant. A "khala" who lived beside her helped during her delivery.

"When I conceived I was 11; I was too weak to work. On the fifth month of my pregnancy, my employer told me to quit the job. I tried to find work in several other places, but no one was willing to give me a job, considering that I could not do any heavy lifting," says Akter. "Finally, after two months, I started begging and living on the streets as I could no longer pay for a room at Agargaon BNP Slum."

"Did you get any medical care at all during that time?" I ask. 

"No," she replies simply. "I don't know anyone here... I am afraid of doctors and needles. I didn't even take any vaccines in my childhood," she adds.

According to Akter, she knew nothing about the delivery process. She was scared and helpless, crying loudly from the pain. "Even khala knew nothing about how to deliver a baby and couldn't decide what to do. It's a miracle that my baby made it into the world," shares Akter. "Now I cannot breastfeed him properly so I try to feed him rice powder." 

Bangladesh's maternal mortality rate has been on a steady decline over the past decade. Poor women in rural areas now have access to maternal healthcare through community clinic services put in place by the National Health Policy 2011, and there is an abundance of national and international non-governmental organisations to provide them with necessary support on maternal healthcare. As a result, the maternal mortality rate has fallen at a rate of 5.5 percent between 2005 and 2015.

Yet, despite these developments, there seems to be a blind spot when it comes to maternal healthcare—the urban poor. In the villages, community health workers go from house to house to deliver care, their sample populations spread out in neatly planned neighbourhoods. In the cities the urban poor consist, of the homeless, the street-dwellers, the squatters, the inhabitants of semi-permanent slums that are razed to the ground on a whim.  

Two weeks ago, the story of Pervin Akter went viral on social media because it laid bare just how vulnerable our urban poor are. The pregnant woman was homeless, and she gave birth in the Azimpur Maternity Hospital parking lot after being denied treatment in three hospitals. The video of her writhing in pain on the tiled tarmac was shared widely. Her baby did not survive the traumatic labour. "They could do this with me because I'm poor!" a sobbing Pervin told reporters later on.  

An overwhelming majority of the urban poor do not receive the recommended antenatal or postpartum health care, nor have access to a trained birth attendant at the time of giving birth to a child. This is despite the fact that according to the 2016 guideline provided by the World Health Organisation (WHO), "A minimum of eight contacts are recommended to reduce perinatal mortality and improve women's experience of care." 

In addition, mothers in developing countries are strongly recommended to take daily oral iron and folic acid supplementation, eat nutritious food, get tetanus vaccination and an early ultrasound (before 24 weeks), to reduce the risk of pregnancy complications. 

Dr Ratu Rumana Binte Rahman, Professor, Obstetrics and Gynaecology Department, Salimullah Medical College Hospital informs that most mothers from slums suffer from anaemia during pregnancy, as they do not eat the nutritious food that their bodies need. "If a mother doesn't take nutritious food during her pregnancy, the strength of the sac around the baby weakens, which results in their water breaking early. This way, the risk of premature deliveries and the number of neonatal deaths increases," says Dr Rumana. 

Expecting mothers also lack general knowledge about pregnancies and what warning signs to look out for. "For example, since they don't do regular checkups, most of them don't know that excessive swollen feet during pregnancy might cause eclampsia, or that excessive bleeding after delivery can end in death," she adds. Besides, many of them cannot practice proper hygiene, which is very important during pregnancies. 

Sadhan Kumar Das, Service Promoter of Surjer Hashi Clinic, funded by USAID and DFID's NGO Health Service Delivery Project (NHSDP), informs that superstition is still rampant among the urban poor, which aggravates health risks. "Though many of them want to get regular checkups and take vaccines, most of the times families don't allow them to do so. I remember a newborn baby who started twitching violently and ultimately died in the Kazipara area of Mirpur. If she had been hospitalised immediately, she might have been saved. But her in-laws would simply not allow us to take her to the hospital. Rather, they started blaming the mother, saying that a jinn had possessed her and killed the baby," he says. "Some of them think that if a pregnant mother takes nutritious food, the weight of the baby will increase, and it will create complexity while giving birth," Das adds. 

Fifteen-year-old Champa Akter—eight months pregnant—residing in Karwan Bazar slum, says she has not received any antenatal care. Champa's mother, who already has a 15-month-old child, is also pregnant. Champa, like her mother, prefers a home delivery. "I have five sisters and one brother, and everyone was born at home, with the help of our Dai khala (traditional birth attendant)," says Champa. 

Mothers, who are not willing to go to hospitals, mostly rely on traditional midwives for their deliveries. According to data, acquired from the government's SDG Tracker website, the proportion of births attended by skilled health personnel is only 49 per 100,000. A popular midwife of Karwan Bazar slum is 60-year-old Amena Begum, who has been doing midwifery for more than 40 years. "I have no professional training on midwifery, but I have helped at least 3,000 women during their pregnancies and childbirth. Through my long experience, I know almost all techniques to ensure a safe delivery," says Begum proudly. 

"But, if the condition of the mother goes beyond my ability, I usually refer her to hospitals," she adds. Begum doesn't take any money from the mothers; rather people sometimes reward her with food or clothes. "Some NGO staff told me to get professional training on midwifery, but I could never manage the time," she says.

A certain section of the urban poor, especially slum dwellers and garment workers who come from impoverished rural areas to the city in search of employment, prefer giving birth in their respective villages. Rabeya Sultana, a 22-year-old garment worker, who went back to her village during pregnancy, argues, "People think city life is better as there are more hospitals here. But these hospitals are not for people like us. Plus, my room here is in such a deplorable state—damp and humid—I didn't want to bring in my child here. At least, my child was born in a hygienic environment in my village." 

Though some NGOs and private service providers are working in slum areas to create a safe environment for urban poor mothers, their scope and coverage are limited. 

According to Md Shahadat Hossain, Clinic Manager of Surjer Hashi, Shewrapara, the clinic spends seven percent of their total profit to purchase medicines for the extreme-poor mothers. "These mothers are identified by our service providers, who maintain direct contact with pregnant women of the community and gather information about their income capacity on a regular basis," explains Hossain. We provide "Least Advantaged (LA)" cards to people who do not have the ability to make cash payments or who do not have food reserves for the next two days. They can use these cards to receive free antenatal care and medicine from us. We also try to provide medicines to poor people at a discount." 

Surjer Hashi has a total of six clinics and two delivery centres in Dhaka, through which they provide delivery service to the poor, at a minimal cost, based on the patients' financial capability. 

BRAC has also been conducting a project called Manoshi to improve healthcare facilities for adolescents, women of reproductive age, pregnant and lactating women, neonates, and children under five years, in different slums of the city. Though it was providing these services for free from 2007 to 2016, it is now charging its beneficiaries a nominal fee to make the project sustainable. 

A number of slum dwellers allege that some healthcare providers sell iron or folic acids, even though these medicines should come free with the service package they subscribe to. They also claim that the providers sometimes charge more than the nominal fee while providing antenatal checkups or vaccines. Ripa Akter, a 22-year-old pregnant woman from Karwan Bazar slum, says, "They even tell us—you all have a lot of money from selling drugs. You only say you're poor when you need medicines. Cough up the money!"

Dr Nauruj Jahan, Senior Programme Manager, Maternal and Neonatal Child Health Programme at BRAC, admits that they too have heard of such allegations, and are taking immediate action against such practices, through their central monitoring system. "This is very challenging, as the migration rate of our workers is high and we are constantly training new people. But we try our best to ensure that the beneficiaries are getting the service properly." 

BRAC also has delivery and maternity centres near the slum, where trained birth attendants help women with a safe delivery for an amount below BDT 600. The extreme poor are exempt from this fee. In case of any serious complication, the midwives usually refer the patients to the hospitals, with transport provided by the centre. 

But do the hospitals do enough for poor mothers? 

Government hospitals are often their last destinations in cases of delivery complexities. However, many of them complain that the service providers discriminate against them because they are poor. "My wife waited for a whole day, enduring intense pain, on the floor of Dhaka Medical, but no one paid us any heed. At one point, I took her to a private clinic, where she gave birth to our first child through a caesarean delivery," claims Kabir Hossain, a day labourer in Karwan Bazar. He had to gather BDT 10,000 in hospital fees for her delivery, as opposed to the government-subsidised free delivery he was seeking. 

Although government hospitals should be providing free maternal healthcare to the extreme poor, women end up having to pay bribes and tips anyway. "Although we are told we will receive free treatment, we need to pay to get quick and proper service there," says 17-year-old slum dweller Sabina Akhter, who gave birth to her child at Salimullah Medical College Hospital, three months ago. 

"In government hospitals, there are many brokers who always take the opportunity to cheat the poor and unaware," says Dr Rumana. "Apart from this, we have a limited capacity. Our doctors deal with 60-70 outdoor patients on an average in a single day, even after their regular working hours. On the other hand, the number of indoor patients is almost triple the capacity," she adds. 

According to Dr Salma Rouf, Professor and Head of the Department, Gynaecology and Obstetrics, Dhaka Medical College Hospital (DMCH) claims that they face trouble accommodating the volume patients, yet they do not refuse anyone. "Every day, on an average, 70-80 patients get admitted here, and at least 40-45 deliveries are conducted," says Dr Rouf. "The number of admitted patients in our department is not less than 17,000," she adds. 

That all mothers—regardless of their social class and economic condition—do not have access to a safe motherhood is unacceptable, especially so, given that we tout the achievements the country has made in ensuring maternal health and sustainable urban growth. In reality, these urban poor mothers suffer the pains of labour—in silence.