Life on the river islands of Assam in north-east India is full of ironies. Floods are an annual affair here during monsoons, ravaging homes and fields, sweeping away lives, and eroding chunks of land mass, sometimes devouring an entire village. And yet it was the dry season that caused trouble for Kaushalya Das of Majuli — the world’s biggest river island, on the Brahmaputra — as she stood on the brink of motherhood again. Well aware of the benefits of institutional delivery, she was determined to have her third child in a hospital, unlike the first two. However, when her labour pain began at the break of dawn early this summer, she could not get to a health centre, and was forced to give birth at home.
“My husband called for the ambulance, but like always it stopped four kilometres short of our village because of the bad road. Had it been the monsoon, I would have been transported by a boat to that point. But in the summer, I had to deliver at home,” Das said. Assisted by an accredited social health activist (ASHA), Monju Phukon, the delivery went smoothly, but then the bleeding refused to stop and the new mother started having blurred vision.
“There is a private vehicle which the villagers sometimes hire during emergencies. It was unavailable at first, but after a few hours we managed to get it in order to rush Kaushalya to the community health centre at Gormuh, about 10 kilometres away. Thankfully the doctor there could get the situation under control,” Phukon recalled. Although her five-month-old baby boy is healthy, Das still complains of weakness.
On the edge of Majuli, Samuguri village, where Das lives, is one of 260 villages on the river island. For the people there, and the rest of the nearly three million dwellers of the 2,500 islands on the Brahmaputra, everyday life is a challenge. The Brahmaputra, which flows 620 kilometres through Assam, is a source of livelihood for the island dwellers and those living along its banks. Most of the island dwellers are farmers and the river is the main source of irrigation; fishing is also important. During monsoons, however, the Brahmaputra wreaks havoc, displacing families, washing away homes and lives.
Add to this the poor infrastructure, like lack of proper communication to the mainland, poor health and education services. Amina Begum, a resident of Baleswar island in Nalbari, 70 kilometres from Guwahati, says that for most of them a boat ride to the mainland and back means spending Rs.20 (US$0.33), something they cannot afford easily. The school on the island is non-functional for lack of teachers, and, as Begum puts it, “health is a major concern because there are no hospitals.”
Boat clinics bring healthcare to remote islands
“Our only hope is the boat clinic and we wait eagerly for the health camps,” Begum says. The boat clinic is the only healthcare for which residents do not have to pay. An initiative of the Centre for North East Studies and Policy Research the boat clinics were started in 2005. The NGO initiative later got the support of the National Rural Health Mission (NRHM), Assam and Unicef. Equipped with medicines and a team of doctors and paramedics, boats visit the islands at regular intervals, conducting health camps with a special focus on maternal and child health.
According to state data, between 2008 and February 2014 the boat clinics organised 13,068 health camps, providing 58,921 women with ante natal care, 15,333 women with post natal care, and vaccinating 121,292 children.
Riturekha Baruah oversees the boat clinic programme in Jorhat district, where Majuli is located. She says, “Conventional methods of reducing maternal and infant mortality risks, like pushing institutional delivery, does not work in the islands.” Assam has one of India’s highest maternal mortality ratios, at 328 deaths per 100,000 live births.
“In adverse conditions, like at night, when the weather is bad, or when there is an emergency, a boat ride can be risky. In such times, home delivery seems like a safer option; hence what the island community needs are more skilled birth attendants,” Baruah said.
Ranu Dole, a neighbour of Das, knows the consequences of taking such a risk. Three years back, when the rain was beating down her village in the dead of night, her labour pain started. “Our village was partly flooded. My husband called out to our neighbours for help, and in that rain with a sheet for cover, I was put on a hand cart and pushed through the waters to a point where a boat could float. Drenched and in pain, I was then rowed for nearly 20 minutes, to the point where concrete roads began and an ambulance stood waiting to take me to the community health centre,” Dole recalled. The health centre, the only one on the 875 square kilometre island, was a further 10 kilometre drive. At the end, it was a normal delivery and Dole named her son ‘Dhumuha’ (storm).
“We were lucky, but in hindsight I think we took a big risk by making that journey. It would have been safer delivering my baby at home,” Dole says.
According to Phukon — who is in charge of maternal and child health in six villages — the nearest health sub centre is nearly four kilometres away, with the river in between. “The sub centre caters to 15 villages, but there is just one village in its vicinity. The other 14 are all across the river, and although every family usually has a boat, communication is a risky affair especially during emergencies.”
The Assam government has set up an emergency helpline that is supposed to bring an ambulance to your home and take you to hospital if necessary. But due to transportation problems, that does not really work for the island dwellers. Hiring a private ambulance can cost around Rs 600 (US$10) in an area where most people are farm labourers earning around Rs 120 (US$2) a day.
Sonu Das of another island village, Bhimpora, also had a home delivery. She said, “My due date was February 25, but I started experiencing pain four days before. So we hired a car and went to the hospital. But after doing an ultrasound, the doctor said it wasn’t time yet, and asked me to come back three days later. As soon as we reached home I started getting the pain again, but how could we afford to hire the car again? So I delivered at home.”
Phukon admits that if there is a false alarm and the woman’s family had hired the vehicle, there is very little chance they will return for an institutional delivery. Add to this the widespread perception that going to hospital “ensures a caesarean delivery,” and you can see why there are so many home births.
Mondakini Gogoi, an NRHM official in Jorhat district, agreed that “there is a high incidence of home deliveries among the river island community because of communication problems, but skilled birth attendants assist the birth.”
Majuli at least has a health centre on the island. Residents of others islands have to depend on hospital services on the mainland. “We did start an initiative of hiring hand carts and boats to ferry the ill and pregnant women for deliveries from the river islands to the mainland civil hospital in the Jorhat district under the aegis of the district commissioner, but it has not taken off on a big scale because of paucity of funds and non- approval from the state government as yet,” Gogoi said.
Azera Parveen Rahman is a freelance journalist. This article is part of her work under a National Media Fellowship awarded by the National Foundation of India