Maternal Health of Tribal Communities in Chamarajanagar District, Karnataka

Maternal Health of Tribal Communities in Chamarajanagar district, Karnataka

A community’s reflection on their access to maternal health services August 2016

August 2016

This report is published in both Kannada and English. It is an output of work conducted by the Zilla Budakattu Girijana Abhivrudhhi Sangha in Chamarajanagar district, supported by The Malki Initiative and Vivekananda Girijana Kalyana Kendra, BR Hills under the Participation for Local Action project (PRA). The PRA project is financially supported by the Implementation Research Platform of the World Health Organization Alliance for Health Policy & Systems Research, Geneva.

Preferred citation: Zilla Budakattu Girijana Abhivrudhhi Sangha (2016) Maternal health of tribal communities in Chamarajanagar district, Karnataka: A community’s reflection on their access to maternal health services. A report submitted to the Implementation Research Platform, WHO Alliance for Health Policy and Systems Research.

Photograph on cover: A Soliga woman carrying her child and rations walking back to her podu from the main road in Chamarajanagar district. Photograph by Bhargav Shandilya (2016) under the PRA project. Shared under Creative Commons Attribution-NonCommercial-ShareAlike license 4.0.

TABLE OF CONTENTS

Introduction to the project ...... Error! Bookmark not defined.

About this report ...... 5

Background ...... 8

Status of Access to Maternal Health Services ...... 11

I. Chamarajanagar Taluk ...... 11

II. Gundlupet Taluk ...... 17

III. Kollegal taluk ...... 23

IV. Yelandur taluk ...... 35

District-level Summary ...... 41

BACKGROUND

The full title of the project is Participation for local action: Implementation research with indigenous communities in southern India for local action on improving maternal health services, in short referred to in this report as the PLA project.

The key objectives of the PLA project are as follows: 1. To study local socio-political issues that influence access to the safe motherhood component of National Health Mission for indigenous people in Chamarajanagar district. 2. To engage relevant stakeholders in a participatory approach to contextualize the existing program implementation in primary health centres covering indigenous populations. 3. To develop a model of stakeholder engagement that can guide contextualization of the safe motherhood program of the mission in districts with indigenous communities.

The overall study design adopted was that of participatory action research (PAR) to bring together different stakeholders to develop contextualised solutions to improve utilisation of safe motherhood services by local indigenous communities. Simultaneously a theory-driven inquiry (TDI) approach was attempted to explain implementation outcome of the stakeholder engagement strategy. While PAR focused on a participatory critical reflection and local action, the TDI focused on building a context-sensitive analytical explanation for the change seen. Although the initial duration planned for the project was for 12 months from December 2014, the project extended for a total of 22 months (December 2014 to September 2016).

The main implementing partner was Vivekananda Girijana Kalyana Kendra, Chamarajanagar (VGKK)1 led by Dr Tanya Seshadri (principal investigator). They led the project in partnership with the following institutions/individuals: • Institute of Public Health, Bangalore (IPH) led by Dr Prashanth NS (co-principal investigator) • Zilla Budakattu Girijana Abhivrudhhi Sangha, Chamarajanagar (ZBGAS) led by Dr C Madegowda (treasurer) • District Reproductive and Child Health Officer, Chamarajanagar (Dr Visweswaraiah KM) • Karnataka State Health Systems Resource Centre, Bangalore (KSHSRC) led by Dr Sadhana SM (executive director) • Dr Giridhara Babu, Public Health Researcher, Bangalore at the Indian Institute of Public Health, Hyderabad-Bangalore campus • Dr Arima Mishra, Public Health Researcher, Bangalore at the Azim Premji University, Bangalore • Dr Bruno Marchal, Public Health Researcher from Institute of Tropical Medicine, Antwerp, Belgium

The project was financially supported by the Implementation Research Platform of the WHO Alliance for Health Poicy & Systems Research, Geneva. It was selected through a completitive open grant process culminating in a protocol development workshop in Geneva. The outcomes envisioned at the project conceptualisation stage were: (1) a platform for district-level planning with inter-sectoral engagement across various government departments with community-based organisations, civil society, and academia and, (2) a theory explaining poor coverage of reproductive and child health schemes’ utilization by indigenous people in Chamarajanagar district. These were expected to be crucial inputs into district and state health and development policy, and were expected to help in making

1 VGKK is an NGO founded in BR Hills of Chamarajanagar district with an overall focus on integrated and tribal-led development and empowerment. In its three decades of work, it has received local and national recognition for its model of community-led and participatory development approach. See vgkk.org for details.

these more inclusive. We anticipated that the advocacy of our findings could also lead to further activities to address safe motherhood problems in Chamarajanagar district particularly focusing on indigenous communities.

About this Report

This report is an output of an extensive community-led effort in mapping out access to maternal health services among all tribal (indigenous) people2 in the district. The Zilla Budakattu Girijana Abhivrudhhi Sangha (Kannada for District Indigenous Peoples’ Development Association), hereafter called the Sangha, partnered with VGKK representatives (NGO) and research team through Dr C Madegowda (co-investigator) to undertake the mapping and analysis of access to maternal health services by women in their communities. The community reflection process was overall a combination of different methods including repeated meetings and workshops, field visits to tribal villages with brief group discussions and interviews followed by repeated reflection on the findings by different groups resulting in a report based on consensus and a list of possible community-led actions to address issues identified (see figure 1).

Figure 1. Methods adopted for community-led reflection on their access to maternal health services

The Sangha created a sub-committee to partner with the research team and oversee the process. They recruited ten field investigators (five men and five women) and a field supervisor from the community to visit every tribal village and collect relevant data. The research team led by the principal investigator supported

2 For the purposes of this report, we have only considered forest-dwelling tribal communities. In the PAR project, this included the Soliga, Jenu Kuruba, Betta Kuruba, and Yerawa people in Chamarajanagar. The Indian Government’s Scheduled Tribe category includes a few other communities designated as Scheduled Tribe, but not necessarily forest-dwelling. In our view, the forest-dwelling tribal communities are the most marginalized from wider development processes and debates.

the orientation, capacity building and mentoring of field investigators in terms of relevant information, data collection and analysis methods.

Each team of field investigators were allotted one taluk by the Sangha except in Kollegal where due to the larger number of villages, the taluk villages were divided between two teams. Each team visited every tribal village in their area, and interacted with different groups of people including village elders, pregnant women and/or recently delivered women, school teacher, anganwadi worker and ASHA as available. They collected information broadly categorized in three sections: a general profile of the tribal village visited, a hand-drawn map of the village with some indication of access to the nearest health centers and transport for the same, and a detailed note on how women and elders in the village felt about their access to maternal health services through pregnancy, delivery, and after in the postpartum period. The research team conducted a follow-up meeting a month later to discuss the experience of the field investigators, refresh knowledge about the various services and schemes, and discuss challenges faced by them in the field. These visits were initiated in July 2015 and completed within six months (see figure 2).

Figure 2. Timeline of community reflection

There onwards the field investigators met once a month with their field supervisor, and research assistant handing over the information with feedback on difficulties faced, and quality of data collected. A total of 135 tribal villages (of the 148 reported) were covered across the four taluks of Chamarjanagar. Few small-sized tribal settlements were clubbed with nearby villages, hence the gap between number of villages covered and reported. After three months of data collection, a two-day workshop was held to initiate reflection on the content of the field notes, and to prepare a taluk-level analysis (see figure 2). This workshop focused on themes emerging from the various field notes taking into consideration both positive statements and issues highlighted. The themes that emerged were used as a framework to analyze each village field note to prepare a summary table highlighting any significant cases identified. The training and all documentation were conducted in Kannada the local language. Village-wise summaries were created simultaneously by the Sangha and the research team, and compiled to prepare taluk- and district-level summaries in English.

The findings of the community-led reflection are shared in this report. They are organised across the taluks with glimpse of village-wise summaries. Data presented in this report was collected via discussions in the

village, and while the data could not be validated by secondary data or by conducting a census, it allows visualisation of the status of access to maternal health services by the tribal communities through their perspective, and the context of their social environment in the absence of availability of such data in the existing health system. A draft of the final report was shared with tribal leaders in Kannada during a workshop in June 2016 (see figure 2). In two sessions across two days, the tribal leaders, NGO representatives and research team together reviewed the findings presented in the final report, prioritised the issues, and then brainstormed on possible relevant community-led actions that would seek to address the issues identified. The community report was finalised incorporating the comments and suggestions from this workshop.

A subsequent meeting with tribal leaders, NGO and research team focused on further prioritisation, implementation priorities, feasibility, sustainability beyond project timelines and budget estimations. This resulted in selection of few proposed actions that will be implemented and monitored in Chamarajanagar district in the coming year.

BACKGROUND

Scheduled Tribes in India

As per Census 2011, the total tribal population in India is 10,42,81,034 constituting around 8.6 per cent of the total population with 705 recognised scheduled tribes (ST) across the country.(Census Commissioner, 2013; Statistical Profile of Scheduled Tribes in India, 2013) This catch-all ST category however is heterogenous with diverse ethnicities with socio-cultural and genetic differences among them. Unfortunately little information is available about their health status due to the absence of disaggregated data in the existing health management information system. The overall development indicators including health reflect a grim picture of these communities when compared to the rest of the population due to historical social exlcusionary processes. For instance according to the Census 2011, their literacy rate is only 59 per cent while the national average is 73 per cent.(Census Commissioner, 2013)

Apart from their persistent poor health outcomes, information from government and civil society reports suggest that the illness profile and epidemiology of various illnesses including non-communicable diseases are different among tribal communities than for others. Social determinants of health are key to influencing their health outcomes. Their geographical location on hilly, thinkly forested or remote areas, their relative isolation from larger societal development, their socio-cultural differences from local non-tribal communities and political neglect by public authorities resulted in a situation where their health outcomes are significantly poorer than the rest of the population.(Sudarshan & Seshadri, 2015 in press) For instance, according to NFHS- 3 (2005-06), institutional deliveries in the ST category was significantly lower (17.7 v 38.7 per cent) while the child mortality rate was significantly higher than the national average (35.8 v 18.4 per cent).(Statistical Profile of Scheduled Tribes in India, 2013) Apart from lagging behind in terms of health indicators, certain genetic conditions like haemoglobinopathies are reported in some tribal communities, and their relationship with forests exposes them to environment related conditions like snake bites and animal bites/related injuries.

Given the heterogeneity of the ST category, and the regional socio-political contexts, the picture of tribal communities in terms of their health status varies significantly from state-to-state. In Karnataka, there are 50 notified tribal communities as of 2003. Studies on health of these communities are mainly limited to a few tribes like Jenu Kuruba and Koraga.(Roy, Hegde, Bhattacharya, Upadhya, & Kholkute, 2015) The literacy rate among tribal population is 53.9 per cent only when compared to the state average is 75 per cent according to Census 2011. However within the communities, the female literacy is as low as 42.5 per cent.(Census Commissioner, 2013) Key indicators reflecting the overall health status and utilisation of health services of ST communities in the state in comparison to others are shown in Table 1.

The illness profile of these communities is similar to tribal communities in similar contexts in nearby states. High proportions of malnutrition among children were noted with prevalence increasing with age of children, and demonstrated links with adverse social factors.(Roy et al., 2015) Among non-communicable diseases, few studies report high prevalence of hypertension among both men and women in studied tribal communities. Issues of alcoholism and related illnesses are also noted. Sickle cell anaemia is also reported among few tribal communities in the state similar to tribal communities in other states.(Sudarshan & Seshadri, 2015 in press) Access to health services are reflected by relatively poor coverage of full antenatal care and institutional deliveries among these communities in comparison with others in the state (see table 1). Most tribal communities also seek traditional health care and practices for illnesses and deliveries.(Sudarshan & Seshadri, 2015 in press)

Table 1. Selected indicators for Karnataka disaggregated by ST-status

Indicators Karnataka India ST Non-ST ST Non-ST Proportion of ST1 (%) 7.0 93.0 8.6 91.4 No. of tribes2 50 - 693 - Sex ratio1 (%) 990 972 990 938 Full Antenatal check-up in ever-married women aged 15-49 years3 (%)♯ 39.9 52.2 14.8 19.6 Institutional delivery in ever-married women aged 15-49 years2 (%)♯ 49.5 66.7 32.8 49.8 Newborns who received check-up within 24hrs of birth2 (%) 54.6 70.4 34.4 51.4 Children aged 0-5 months who were exclusive breastfed2 (%) 47.8 66.8 61.1 43.3 Children aged 12-23 months who were fully immunised2 (%) 72.3 77.2 45.5 55 Infant mortality rate3 46 43♯ 62 49♯ Under-five mortality rate3 78 60♯ 96 59♯ Source of treatment seeking behaviour – public2 (%) 47.2 41 77.3 47.7 Households using cooking fuel1 (%) 14.3 35 9.5 31.1 Household that practice open defecation1 (%) 66.9 43.3 74.7 47 Availability of piped water supply1 (%) 21.3 35.6 10.7 28.5

Prevalence of alcohol consumption among men aged 15-54 years3 (%) 35.8 28.5 50.5 30.4 Prevalence of tobacco consumption among men aged 15-54 years3 (%) 55.3 44.5 71.7 56.3 ♯ Women who had their last live/still birth from 01-01-2004. 1Census 2011 2Statistical Profile of Scheduled Tribes 2013 3National Family Health Survey (NFHS-3), 2005-06

Chamarajanagar district profile Chamarajanagar is the southernmost district of Karnataka, and is one of the under-developed districts. It has four sub-districts i.e. taluks (Chamarajanagar, Gundlupet, Kollegal and Yelandur (see figure 3)) and 428 villages with total population of around 10,20,791 according to Census 2011. It has 2.76 lakh hectares of forest land.

About 86 per cent of district population lives in rural areas, higher than the state average (69 per cent). According to the last state Human Development report in 2005, Chamarajanagar ranked 22nd in overall human development index among 27 districts.(Government of Karnataka, 2006) The literacy level in the district overall is 67.9 per cent, lower than the state average 75.4 per cent. Unlike most other districts, the health indicators for rural areas are quite similar to the overall district barring access to general amenities (see table 2).

Figure 3. Map of Chamarajanagar district and its four taluks

Source: These maps are derivatives of ‘Karnataka map blank’ and Chamarajnagar location map’ by User:Planemad from Wikimedia Commons(shared via Creative Commons license)

Table 2. Selected parameters for Chamarajanagar district

Variable Chamarajanagar (in per cent) Total Rural Sex ratio (Females per 1000 males)1 993 991 Literacy rate above age 7+ years2 67.8 57.4 Pregnant women who underwent blood test for haemoglobin2 86.3 76.1 Pregnant women who took 100 or more IFA tablets (or syrup equivalent)2 74.5 77.0 Pregnant women who received three or more antenatal care visits2 96.7 95.1 Pregnant women who delivered at institutions (health centres)2 96.3 91.8 Children aged 0-5 months who were exclusively breastfed2 84.8 86.7 Children aged 12-23 months who received full immunisation2 82.5 86.2 Children aged 6-59 months with anaemia2 80.5 81.0 Pregnant women aged 15-49 years with anaemia2 72.9 73.3 Access to improved toilet facility2 47.8 25.1 Use clean fuel for cooking2 57.9 35.8 1Census 2011 2District Level Household Survey – round 4 (DLHS-4) 2012-13

The SC/ST population accounts for nearly one-third of total population. ST communities constitute around 11.7 per cent, of which one-fourth are forest-dwelling tribal communities according to Census 2011. Majority of working population is dependent on agriculture. Due to the absence of disaggregated data at the district level, information on health of tribal communities in the district is not available at this point. Few studies on the Soliga tribe report presence of high proportion of anaemia and other nutritional deficiencies among women and children, and presence of sickle cell anaemia in this community.

STATUS OF ACCESS TO MATERNAL HEALTH SERVICES

I. CHAMARAJANAGAR TALUK This taluk is the headquarters of Chamarajanagar district with a population of 3,58,419 of which 80.3 per cent reside in rural area according to Census 2011. Of 175 villages, 22 tribal villages are reported with 4,144 tribal population, majority belonging to the Soliga community according to the Zilla Sangha.

Table 3. Profile of tribal villages in Chamarajanagar taluk

Name of tribal Panchayat Popula- No of Distance to nearest (in km) Anganwadi village tion families Main PHC Government present road primary school Bellatta Hunganuru 250 50 0 0 0 Yes Kadigere podu Punjur 70 20 0 0.5 0.5 Yes Marigudi Punjur 229 75 0.5 1 0 No Badregowdana podu- punjur Punjur 100 20 1 1 0.5 Yes Banavadi Punjur 242 67 0 2 1 Yes Srinivasa pura colony Punjur 300 150 0 2 0.5 Yes Yattegowdana doddi Punjur 189 60 2 2 0 Yes Godemaduvina doddi Punjur 253 76 0 3 0.5 Yes Hosa podu Punjur 197 56 0.5 3 3 Yes Monkai podu Punjur 30 20 4 6 6 No Attuguli pura Attugulipura 120 40 0 7 0.5 Yes Hittalagudde Hebbsuru 60 30 6 8 1 Yes Muneshwara Colony Punjur 251 80 0.5 10 1 Yes Navodayakuntaguddi Colony Jothigowdanapura 150 45 1 10 1 Yes Kalikamba colony Attuguli pura 30 10 12 12 0 Yes Kulluru Attuguli pura 143 42 1 15 0 Yes Sanivaramunti Hunganuru 50 20 1 15 3 Yes Muruty palya Hunganuru 120 30 0 17 0 Yes Budipadaga Punjur 370 160 6 3 0 Yes Bangale podu Punjur 300 75 0 0.5 0 Yes Bisilugere podu Punjur 70 30 0 60 1 Yes Kanneri colony Punjur 620 100 0.5 25 3 Yes Source: data collected during village visits by discussion with village leaders and elders

Figure 4. Hand-drawn map of Chamarajanagar taluk showcasing tribal villages (not to scale)

Village-wise summaries of Chamarajanagar taluk

1. Atugulipura: Information on maternal health services was most-often available through ASHA, anganwadi worker, and village leaders. They reported that women in the village received tayi bhagya benefits, used 108 ambulance service and those who delivered at hospitals received madilu kits. However, few reported incidents of government hospital staff asking for informal fees for services. Some even went to private hospitals for these services where significant amount of money was spent. The main source of livelihood in the village was through daily wage labour.

2. Badregowdana Podu: This village was close to the forest but is well-connected by all-weather roads. Pregnant women most-often availed antenatal care satisfactorily. While both ANM and anganwadi worker were mentioned to be available, they were not seen as informants for maternal health services. Women relied on other villagers to get relevant information. Gradually women have started going to hospital to seek services and are satisfied. For example, in one delivery case, an ambulance arrived on time and the woman delivered in hospital without any problem. However many women complained that they did not receive madilu kit.

3. Bangle Podu: While the village was generally easily accessible, the distance to the nearby PHC was 50 km from the village. Main informants about health services were villagers and anganwadi worker. Antenatal care was found to be satisfactory and pregnant women were examined and sought care in hospitals. They were also aware about JSSK facility, and availed Madilu kit, and tayi bhagya schemes. Issues reported were informal fee payment to government hospital staff, and expenditure for purchasing medicines from outside hospitals. However, out of fear few women delivered at home.

4. Banavadi: Respondents reported that they firmly believed in their traditions, and did not like to go to hospitals. Few opined that if they went to hospital they would have to spend money, and hence some women chose home delivery. Many pregnant women used 108 ambulance in the village, and also availed tayi bhagya scheme.

5. Belavatta: ASHA and ANM did not visit pregnant women in the village regularly according to village respondents. Despite this, good awareness among the community about health services led many to accept these services and visit hospitals for them. There was mention of a positive hospital delivery experience (type of hospital not clear). There still were few women who did not accept hospital services due to shyness. They also reported that many women did not receive services like tayi bhagya, madilu kit etc. 6. Bisilugare: Anganwadi worker and local villagers were main informants about health services. Public transport is the only means of transport with no private vehicles around. In this village, they preferred their household traditions over available services. Informal fees by hospital staff was reported whenever they visited hospitals. Most of the deliveries here were conducted at home. ASHA was not considered to be helpful during emergencies. Government schemes were availed by few only.

7. Boodipadaga: This was one of the farthest villages with people needing to travel 30 km to the nearest main road. Bad roads made travel difficult especially at night due to thick forests and wildlife. ANM and anganwadi worker were present and they provided relevant health information. However, ASHA did not visit women during pregnancy or delivery. In general, antenatal care received was perceived to be good. In spite of being fearful of going to hospitals for delivery, availability of free ambulance motivated them to utilise hospital facility for delivery. At the time of this survey, it was found out that out of eight pregnancies in the last year, only one received madilu kit and tayi bhagya benefit. 8. Gode maduvina doddi: This village had no problem with access by roads. Women received information about health services from ASHA and ANM. They were aware about JSSK and nagu-magu schemes. During the delivery time, 108 ambulance was not available so patients took autos to reach hospital. The women’s self help group was well active in spreading awareness about maternal health services.

9. Hittala Gudde: Anganwadi, ANM and ASHA were present but ASHA apparently did not receive any training. Still, due to lack of awareness many did not avail antenatal care services. PHC was located at a distance of 8km. Many pregnant women were not well informed about needed services and were shy to obtain information on their own, and hence did not approach any hospital. Those who went to hospitals complained that the facility available for delivery was not satisfactory, staff was unskilled in conducting delivery, and still demanded money from pregnant women. Patients needed to spend money on vehicles for transport and to buy medicines from outside when they went to hospitals. Few women did not receive any benefits from government schemes.

10. Hosapodu: The village was around 500 meters inside the forest. Health services were available and people accepted these services due to efforts by their ASHA and anganwadi worker. ASHA visited the podus regularly. Women in this village also received madilu kit and tayi bhagya when due.

11. Kadigere Podu: There was limited public transport to this village. Anganwadi was present here. Due to poor awareness, women did not receive health services. They relied on information from other villagers and followed the same instead of going to hospital. For those who wanted to go, ambulance service was not reliable. Women did not report receiving madilu kit.

12. Kalikamba Colony: This village was easily accessible by road. Antenatal services were reported to be satisfactory, and most pregnant women underwent all required check-ups. ASHA, anganwadi worker and

ANM were visiting regularly and provided relevant information on health and nutrition. Women were aware that maternal and child health services were free of cost in government health facilities. Here also women complained about hospital staff demanding for informal fees for services. They also had to spend towards buying medicines from outside. They were yet to receive government schemes like tayi bhagya, madilu kit, etc.

13. Kanneri Colony (and Buthani Podu): Maternal health services were mainly accessed via the VGKK mobile health unit (a NGO hospital unit) and Chandakavadi tribal mobile health unit. Due to thick forests, hilly terrain and limited public transport, it is difficult for pregnant women to reach any hospital. A family would spend money towards transportation, diagnostics and medicines. Both ASHA and ANM motivated women for institutional delivery. Deliveries usually occurred at taluk hospital.108 ambulance was stationed at a far distance and so patients were not able to avail 108 services. No information about postnatal care was available.

14. Kulluru: Access to health services was an issue due to wildlife. The nearest hospital was 17km away. Information about maternal health services was mainly available through Anganwadi worker and village leaders. ASHA did not visit the village but pregnant women were regularly going for antenatal care services. When asked about quality of health services in government hospitals, women had two different opinions with some reporting that hospital staff demanded informal fees while others provided positive experiences with free services. Due fear of operation and lack of money, some women preferred home delivery, otherwise most deliveries took place at taluk hospital. Madilu kit was received by them.

15. Marigudi podu: Access was via an all weather road. Anganwadi worker provided women with needed health information. Belief in God and traditional practices was strong in the village. Only few people went to hospital for any issue. ASHA did not visit the village but monthly check-up was conducted by doctor and nurse. Generally access to health services was poor. Some people did approach hospitals for delivery but spent a lot of money. Few women also noted that treatment was given without proper knowledge in the hospitals. Postnatal care was not satisfactory.

16. Monakai Podu: Access to main road via game road, and was difficult for vehicles to travel on this. Lack of availability of medical services was highlighted by the community. Pregnant women did not receive antenatal checkups due to lack of awareness. This situation is better now with women starting to go to hospitals for checkups and delivery. Non-availability of 108 ambulance was reported, and postnatal care services were not satisfactory.

17. Muneshwara Colony: Maternal health services were reported as available but details were not provided about them. Anganwadi worker helped out with acceptability of health services by the community. Superstition, fear of operation and expenditure of money were key reasons for not going to hospital. People did not use 108 vehicle but reasons were not explained.

18. Muruty Palya: Issues with access by road was better. ASHA did not come regularly visiting only once or twice a month. Community received information mainly through anganwadi worker. Few women went to hospital while most others did not go. During the time of delivery, services are reported to be satisfactory. Even though the government services were available free of cost, staff at health facility demanded money as informal fees. Few women did not utilise health services because of this.

19. Shanivara Munti: ASHA did not come regularly. During the time of delivery, services were sought from government hospitals. Here also women complained that staff at health facility demanded money as informal

fees. Many women were aware about JSSK and other schemes. They were yet to receive services such as madilu kit and tayi bhagya.

20. Yette Gowdana Doddi: Angwanwadi worker was available and was the main informant for information but ASHA was not available. Women availed 108 ambulance services when they were in labour. They are aware about JSSK, JSY and other schemes. Details about postnatal care were not available. Alcohol abuse by men of this village was one of the pressing issues reported by the women.

Few cases identified in Chamarajanagar taluk* C001: One postnatal mother had severe anemia so she was taken to hospital for blood transfusion. She was later discharged with medications following which she was healthy. C002: Jayamala was nine months into her third pregnancy when she was diagnosed as severely anemic. Many days later she was unable to perceive foetal movements. She was taken to government hospital to Mysore and even after allegedly spending 3000 rupees her baby could not be saved. Few days postnatal, she developed swelling all over the body with body ache and weakness. She was started on medicines from government hospital and gradually she recovered. C003: A multigravida Kempamma was in her third trimester. She ate mud and refused to consume iron and folic acid tablets. Due to severe anemia, she developed swelling of legs and headache. She lost her two earlier children during delivery. She is still reluctant to go to hospital and does not take medicines. C004: 108 ambulance was waiting in front of Muttulakshmi’s house when her labour pains started. However she refused to get into the ambulance as she wanted to deliver the baby at home. The ambulance driver apparently attempted to persuade her but she scolded him and sent the ambulance back. Few hours later her labour pains increased but she could not deliver. A distraught Muttulakshmi finally listened to her neighbours’ advice to go to hospital. The same 108 ambulance was called back and it took her to the nearest PHC. She delivered normally but her baby died within few minutes apparently due to prolonged labour and birth asphyxia. C005: One family refused to go to hospital due to their traditional beliefs. They did not accept any help offered by the ASHA and anganwadi worker. After sometime there was some problem with the umbilical cord problem of the newborn. Later family took both mother and child to hospital and now both are well. (more information not available) C006: Siddamma knew delivering twins was not common, and during her delivery she had a lot of bleeding. One of the twin died during delivery and due to massive haemorrhage she was taken to a private hospital in Talavadi (~35km from her village). After taking treatment from there both Siddamma and her baby are doing fine. The family organized the transport and trip to Talavadi by themselves. C008:A postnatal woman developed severe anaemia and was taken to hospital and received blood transfusion. She continued treatment and eventually recovered. But her baby continues to be bottle fed. *Names changed for all cases

Summary of Chamarajanagar taluk

§ Some of the villages were located close to main road while others were very close to thick forest and accessibility to these was problematic. Road problem and issues with access improved over the years for most villages, yet for some remote villages this was the main challenge. § Women self-help groups were active and effective in spreading awareness about maternal health issues and services. Anganwadi worker was also reported as key informant of maternal health related information. Women were well aware about maternal health schemes such as JSSK, nagu-magu and prasooti aaraike. However it was mentioned that madilu kit was not received by many postnatal women. ASHAs and ANMs were reported to visit infrequently, some even quarterly. § Overall maternal health care was accessed through VGKK mobile unit (NGO health unit), government hospitals and tribal mobile health unit. Private sector was seldom approached barring some emergencies. Few villages relied mainly on the mobile health units that visited villages once a month for maternal health services. § Women who went to hospital were not satisfied with delivery facilities. Poor availability of staff at hospitals was reported. It was noted that government hospital staff were perceived to be unskilled in conducting delivery and almost always demanded money as informal fees from pregnant women. In addition to this many spent money to buy medicines from outside. Overall, there appears to be a deficiency in trust on health services with a perception of poor quality of services at government health centres. Informal payments, lack of trust in services, and minimal and irregular services by ANM and ASHAs were the major issues highlighted by the community. § At the time of emergency, people seldom relied on ASHA or receive timely support from 108 ambulance services. Due to road problems from main road to village and wildlife movement especially at night, 108 ambulances hesitate to come and often do not make it in time to these villages. This is of grave concern since this is an area with limited availability of public and private transport. § Due to low income and anticipation of high expenditure, and fear of operation some women preferred home delivery. § Apart from health services related information, some key points emerged from the field visits and discussions with the tribal leaders. These are: o Overall poor awareness of health related issues like sanitation and better nutrition were also identified apart from about health programmes. The government had initiatied a scheme in recent years to provide additional rations for tribal households comprising of finger-millet, eggs, etc for six months of the year to supplement diet during rainy seasons when work availability was lesser. However tribal leaders believed that the rations were not meeting nutritional requirements given the large prevalence of malnutrition (including nutritional deficiences) among the community especially women and children. Thereby the possible benefits in nutritional improvement for pregnant women were missed. In addition, nearly 800 families in the district were yet to receive this scheme. o Alcohol abuse by male members of community was one of the pressing issues reported by women in most villages and by tribal leaders too. Leaders explained that for a household dependent on daily wages, spending a significant proportion on alcohol limited expenditure on basic amenities including nutritional food and accessing health services when needed. A person with an addiction is also viewed to not be healthy by leaders, and they admitted that addiction most often led to domestic violence in households and disrupted the family’s mental health even for pregnant women. Women also at times consumed alcohol and tobacco and continued use during pregnancy.

II. GUNDLUPET TALUK

According to Census 2011, Gundlupet taluk has a population of 2,22,932 and 87.3 per cent is constituted by rural population. Out of 159 villages, 32 tribal villages are reported with 4,362 tribal population mainly belong to the Soliga, Jenu Kuruba and Kadu Kuruba communities according to the Zilla Sangha.

Figure 5. Hand-drawn map of Gundlupet taluk showcasing its tribal villages (not to scale)

Table 4. Profile of tribal villages in Gundlupet taluk

Name of tribal village Panchayat Populatio No of Distance to nearest (in Anganwadi n families km) present Main PHC Governmen road t primary school Hangala Hangala 10 3 0 0 0 Yes Melukamanahalli Hangala 380 36 0 0 0 Yes Chikkaelechatti Bachalli 120 30 0 5 0 Yes Kaaremala grama Mangala 220 60 0.5 1 1 Yes Guddekere grama Mangala 24 6 0.5 2 2 No Buradarahundi grama Mangala 20 8 0.5 6 1 Yes Jakkalli grama- Danamanda Mangala 20 4 1 2 1 Yes Aananji hundi grama Mangala 110 20 1 2 1 No Adinakanive Mangala 140 30 1 2 4 Yes Guddekere Mangala 80 25 1 3 2 No Maguvinahalli Hangala 60 20 1 5 0 Yes Maguvinahadi Hangala 120 30 1 6 1 Yes Kaniyana pura grama Mangala 120 95 3 5 0 Yes Upakara colony Bomanahalli 195 35 4 22 0 Yes Chelvinapura Mangala 50 12 5 1 1 Yes Channamalli pura Berambadi 40 12 5 1 1 Yes Chinikatte grama Mangala 120 30 10 1 4 Yes Navilu gundi Berambadi 80 30 30 2 1.5 No Hangalapura Shivapura 30 8 4 1 0 Yes Mukahalli Bargi 275 86 0 1 0 Yes Berambadi girijanabedi Berambadi 49 14 0 2 0 Yes Lakkipura Colony Berambadi 475 125 3 2 0 Yes Madduru Colony Berambadi 475 125 0.5 2 0 Yes Devarahalli Kannegala 9 3 4 3 0 Yes Hagadahalla Kannegala 250 60 4 3 0 Yes Mukthi Colony Bargi 363 82 2.5 3 0 Yes Desipura Bargi 100 29 4 4 0 No Kanumayanhundi Shivapura 8 2 4 5 0.5 Yes Kallegowdanahalli Shivapura 20 6 4 6 0 Yes Kunnagalli Kannegala 179 40 7 6 0 Yes Kundakere Bomanahalli 90 20 0 18 0 Yes Kaniyana pura Mangala 130 29 0.5 2 1 Yes Source: data collected during village visits by discussion with village leaders and elders

Village-wise summaries of Gundlupet taluk 1. Aadina Kanive: The main occupation for villagers was agriculture. A gameroad connected the village to main road. People usually used jeep and autorickshaw for transportation. Maternal health services were delivered by the ASHA and ANM, and their advice was well-accepted by the community. Pregnant women took IFA tablets and TT injections. However, apparently many women still feared to utilise hospital services. At the time of survey, three cases who underwent home deliveries in the recent weeks were identified. They apparently used traditional medicines and practices for conducting delivery. No complication was reported and both ANM and anganwadi worker visited mother and children.

2. Ananji hundi: This village was also connected to main road by a gameroad (semi-weather). However, no means of transportation were regularly available. According to women, good quality antenatal care was provided by both ANM and ASHA. Pregnant women received IFA tablets on time. Even though ANM and ASHA were well respected by all, women still preferred home delivery here. During general illness also people relied on traditional medicines and preferred not to go to the government hospital.

3. Derambadi girijana beedi: Manual labour was the main occupation in this village. Antenatal care services were available through subcentre which was located in the village itself. Information about health services were given by ANM and ASHA, and were accepted by the community. For delivery, women went to taluk hospital. 108 emergency service was available to the people, and they often availed the facility. No delay in receiving madilu kits was reported after hospital delivery. Health seeking behaviour of the community was quite good for all maternal health services. Post natal mothers were well aware about the immunization schedule and immunised their children on time.

4. Buradarahundi grama: Manual labour was the main occupation in this village, and the men during off season migrated to Kerala in search of job. Access was via game road with good connectivity via jeep, auto and bus. ANM, ASHA, and anganwadi worker actively provided maternal and child health services. Community also accepted their services and were satisfied with them, and delivery usually took place in the nearby Hangala PHC. Home deliveries still occurred from time to time, and recently two home deliveries occurred but with no complications. Reasons for home delivery were not known. Post natal care was good with mothers getting government schemes such as madilu kit etc.

5. Cheluvinapura- This village was located on the main road so transportation was not an issue. The community was mainly involved in agriculture. ANM visited weekly once along with anganwadi worker while ASHA usually distributed the IFA tablets. Women utilized antenatal care services regularly. Delivery usually took place in Hangala PHC. Postnatal mothers were visited by ANM according to the schedule, and received all benefits of hospital delivery.

6. Chennamallipura girijana street: This village was well connected with an all weather road. ANM provided antenatal care along with ASHA and anganwadi worker to pregnant women. Pregnant women consumed IFA tablets regularly and received TT injections. ANM also visited school and distributed IFA tablets to adolescent girls.

7. Kaniyanapura- Transportation availability was good and the nearest PHC was in Hangala. People here were mainly involved in agriculture and daily wage labour. Maternal health services were provided through ANM and ASHA mainly, and hospital delivery was common.

8. Kaniyanapura colony: Village was well connected by an all weather road. Men and women here mainly worked as manual labourers. ANM visited village twice a week and anganwadi worker visited once a month.

Together they provided health education, distributed IFA tablets and motivated women for hospital delivery. Nearest PHC was at a distance of 5km, and women usually delivered at the PHC. Post natal care was observed to be satisfactory.

9. Karemola: Majority of the village work in agricultural fields. Road infrastructure was absent, no bus facility was available. ANM visited the village once in a fortnight, and most women delivered at nearby Hangala PHC. Post natal mothers received madilu kits.

10. Kunagalli- ASHA and ANM were actively involved in providing antenatal care and distributed IFA tablets and TT injections while the anganwadi worker provided nutritional supplements to pregnant women. Tribal women were well informed about pregnancy care and birth preparedness which was well accepted by the community. Details regarding intranatal and postnatal care were not available at the time of report writing.

11. Lakkipura Colony- Villagers could access transportation at the main road only after walking 1.5km through a gameroad. Even the subcentre was 3km away from the village. However, walking through the forest was restricted. Team of ANM, ASHA, and anganwadi workers provided antenatal care services in the village. For deliveries pregnant women went to nearest PHC situated in Hangala. Community utilised 108 services for emergencies and deliveries, but at the time of discharge postnatal mothers and newborn babies were not provided transportation, and this was an issue. Quality of services at the PHC was considered to be of good quality. Madilu kits were received by the postnatal women.

12. Maddur Colony- This was one of the villages that did not report any transportation problem. Community also did not highlight economic issues as significant to accessing services. ASHA provided health education, and even accompanied pregnant women for getting ultrasound scans and blood tests during pregnancy. Interestingly, it was noted that the PHC doctor visited this village every fortnight for health check up and during the same time anaemic children were given iron tablets. Hospital deliveries were preferred as ASHA escorted pregnant women to taluk hospital during labour using 108. Madilu kits were distributed to postnatal women.

13. Maguvina Hadi- Availability of transportation was reported as an issue in this village. Most villagers worked as daily wage labourers. Community reported that services were not provided by ASHA, ANM, or anganwadi worker. No information regarding pregnancy care and birth preparedness was provided to pregnant women. It was revealed that ANM visited the village irregularly and left early. IFA tablets and TT injection were also not received by pregnant women. Home deliveries often occurred in the village. Main reasons for this preference were fear of injections and that women feared that the doctor or nurse would harm them. At the time of data collection, a complicated pregnancy which ended in child’s death before delivery was reported. Due to absence of anganwadi worker, poor awareness was noted among the women.

14. Mookahalli- Access to main road was not an issue in this village. PHC was located only at a distance of 1.5 km and subcentre at 2 km. Antenatal services was also reported to be of good quality. Doctors from the nearest PHC visited the village once in three months and ANM visited every week. Rations for pregnant and postnatal women were provided in the anganwadi centre. ASHA and ANM facilitated hospital deliveries by coordinating transport of pregnant women using 108 services. Women mainly delivered at the PHC. JSY and madilu kits were received by postnatal women. Every two months a meeting was conducted by ASHA, ANM and anganwadi worker where adolescent girls, mothers and pregnancy women participate, educating them in sanitation, pregnancy, and immunisation.

15. Mukthi Colony- Health education was provided though ASHA and ANM, and also at the PHC. Antenatal care was perceived to be of good quality. Antenatal HIV screening tests were also mentioned by the

community. Doctor visited once in a month while the ANM visited every week. ASHA coordinated transportation of pregnant women in labour to the PHC or taluk hospital in Gundlupet. Madilu kits and JSY benefit were received by postnatal mothers.

16. Navilu Gundi- Regular antenatal services were available to the community even though ASHA and ANM visited the village only fortnightly. Heath related information was provided by both ANM and ASHA. Those who delivered in hospital received their cash incentive and madilu kits. No case of home delivery was identified in the recent months.

17. Upakara Girijana Colony- This village was 4 km from the main road and the subcentre, and was accessible through a game road. PHC was however 22km away. Doctor visited the village once in three months and ANM once in a month only. ASHA worker was from the neighbouring village and hence visited this village weekly. Antenatal care services were satisfactory. For delivery women most often went to Terakanambi PHC. Issues with 108 service were reported. Madilu kits were received by those who delivered in the hospital.

Few cases identified in Gundlupet taluk*

G001:It was past midnight last year when Madamma who was second time pregnant noticed a watery discharge which increased on straining. Immediately she developed pain abdomen. As time passed the pain abdomen increased but the baby could not be delivered. Even the local dai could not help Madamma and her husband, Ketegowda tried to call 108 ambulance but his efforts were in vain as there was no mobile coverage inside the forest area. He was unable to even get a private vehicle to take his wife to the nearest government hospital. It was morning when she breathed her last. Ketegowda lost both his wife and his unborn baby.

G002: One postnatal mother who recently delivered in taluk hospital was well aware of immunisation, and her baby received all immunization on time.

G004: Madevi was 24 years old and her first two deliveries were at home as no health facility was available nearby. They followed home remedies for any problems during the deliveries. For her third child birth also, she chose home delivery, but this time due to some complications, both she and her unborn child died during delivery itself.

*Names changed of cases

Summary of Gundlupet taluk

§ Most tribal villages in Gundlupet taluk were connected to main road by game roads and mainly relied on private vehicles for transportation. During the field visits, accessibility was not reported as a major barrier to accessing services except for certain remote villages. However taluk leaders reported lack of proper road connectivity as a key problem for reaching health services. § The team of ANM, ASHA, and anganwadi worker together provide antenatal care services in most of the villages. Subcentre was not easily accessible for many villages and in most, ANM visited only once in a fortnight which is less than the recommended. Some villages did not have ASHAs, and due to poor road and transport availability ASHAs from neighbouring villages do not visit regularly. § Tribal women appeared to be well informed about pregnancy care and birth preparedness which was well accepted by the community. However, a small proportion of tribal women feared utilising hospital services due to different reasons mentioned. No delay was reported in receiving madilu kits. Interestingly, postnatal mothers were well aware about the immunization schedule and timely doses were received by the newborn. This indicated good health promotion and outreach services by frontline health workers. Every two months meeting was conducted by ASHA, ANM and AWW in some villages where adolescent girls, mother and pregnant women participated, educating them about nutrition, sanitation, and pregnancy care. § Non-availability of staff at nearby health centres inevitably compel villagers to travel to higher facilities at times nearly 60km away. In some villages though, it was reported that the PHC doctor visited occasionally for health check up and during the same time anaemic children received iron tablets. § Emergency services were available for most villages, and ASHA was reported to coordinate transportation of pregnant women in labour to nearby PHC or taluk hospital. It was observed that community was still not satisfied with emergency services as they wanted postnatal mothers and newborn babies to be transported back to village which was not the case. § However, during data collection, few cases of home delivery were identified in many of the villages. It was noted that women used traditional medicines for conducting delivery, with some stigma about using modern medicines. Further details need to be gathered to understand the reasons for home deliveries even when transportation was available § The issue of informal payments to health workers in villages or at health services was not recorded. § Apart from health services related information, some key points emerged from the field visits and discussions with the tribal leaders. These are: o Villagers mainly worked as daily wage labourers and at times migrated to nearby states in search of jobs. o Poor availability of sanitary toilets was reported across most villages. Poor sanitation was reported as significant problem in the taluk by the tribal leaders. o Poor nutrition of tribal people especially women and children was noted. o Alcoholism was a significant issue that emerged in this taluk similar to others.

III. KOLLEGAL TALUK

Kollegal, known for its silk industry has a population of 3,57,776 with rural population constituting 81 per cent according to Census 2011. Of 185 villages, 69 tribal villages are reported with 15,927 tribal population belonging to the Soliga community, highest in the district according to the Zilla Sangha.

Figure 6. Hand-drawn map of Kollegal taluk showcasing its tribal villages (not to scale)

Table 5. Profile of tribal villages in Kollegal taluk

Name of tribal village Panchayat Population No of Distance to nearest (in km) Anganwadi families present Main PHC Government road primary school

Gullada bayalu Utturu 550 200 0 0 0 Yes

Kanchugalli Siganalur 157 37 0 0 6 Yes

Kullegowdanadoddi PG Palya 50 10 0.5 0 0 Yes

Nakkundi Miniya 187 65 0.5 0 5 Yes

Bangalada oddu Punachi 31 9 4 0.5 0.5 Yes

Gotte dimba Punachi 42 20 0 0.5 0 No

Gundi Seedu Punachi 402 89 0 0.5 0 Yes

Hosakola MM. Hills 11 5 0.5 1 1 Yes

BudiHola Punachi 150 15 10 1 0.5 Yes

Ramegowdana halli Punachi 350 60 0 1 1 No

Astur Punachi 1300 300 0 2 0 Yes

Aane hola MM. Hills 523 135 0 3 3 Yes

Hosadoddi PG Palya 50 10 0 3 0 Yes

Sabina kobe Nukanhalli 300 61 1 3 0 Yes

Hoyilnatta PG Palya 250 40 4 3 0 Yes

Rajapaji Nagara Telanuru 550 100 0 4 0 Yes

BG Doddi Utturu 50 80 2 4 0 Yes

VS doddi Utturu 123 50 2 4 0 Yes

Jadegowdana Doddi PG Palya 100 30 5 4 0 No

Chikkamarur Punachi 115 34 1 4 4 No

Donemaduvina Doddi Punachi 210 50 1 4 4 Yes

Basavanagudi PG Palya 150 50 0 5 0 Yes

Budi padaga Lokkanahalli 225 57 0 5 0 Yes

Kuduvaale PG Palya 85 20 2 5 2 Yes

Hande Kurudana Doddi Byluru 150 40 3 5 0 Yes

Jeerege gadde PG Palya 200 66 3 5 0 Yes

KK Dam Nukanhalli 250 50 0 6 1 Yes

Kanamale doddi Byluru 180 45 0.5 6 0 Yes

Puttaerammana Doddi Siganalur 154 45 4 6 0 Yes

Soppina Gudde Utturu 50 20 4 6 5 Yes

KK podu Utturu 259 22 6 6 0 Yes

Gandhi nagara Byluru 50 10 0 7 1 No

Hosahalli Kurati 26 8 7 7 1 Yes

Medagane MM. Hills 32 12 6 8 0 No

Name of tribal village Panchayat Popula- No of Distance to nearest (in km) Anganwadi tion families present Main PHC Government road primary school

Soole Kobe Miniya 182 56 0 8 0 Yes

Are kaduvina doddi Byluru 400 100 3 9 0 Yes

Mavatturu PG Palya 150 42 5 9 0.5 Yes

Ardha naripura Byluru 350 80 0 10 0 Yes

Gurumallapana doddi Byluru 40 11 0 10 0 Yes

Kadakal kundi Hanuru 50 15 0 10 0 Yes

Yerakatte Vadarabalu 250 50 0 10 0 No

Hiriambla Utturu 578 152 4 10 0 Yes

Haavina Moole PG Palya 450 100 7 10 0 Yes

Mendare MM Hills 82 25 10 10 0.5 Yes

Kamduki MM Hills 105 30 10 10 0.5 Yes

Hosapodu Byluru 1200 200 4 12 0 Yes

Mole katte Timarajipura 120 35 2 13 2 No

Ganiga Mangala Sagya 500 126 0 15 0 Yes

Satti mangala Dinahalli 145 35 1 15 0 Yes

Changadi Kurati 13 8 8 15 8 Yes

Nalli Kadiru PG Palya 218 56 12 15 0 No

Panchaldane Punachi 5 2 15 15 15 No

Jalli palya Ugyam 128 35 5 15 0 Yes

Karala katte Timarajipura 200 50 2 15 0 Yes

Palar MM Hills 204 63 0 18 0 No

Kempu Siddana Doddi Miniya 65 15 0.5 20 0 Yes

Koppa Hutturu 527 85 1 20 0 Yes

Gombegallu PG Palya 81 27 8 25 4 No

Kare dimba PG Palya 145 37 0 30 0 Yes

Alambadi MM Hills 375 42 5 60 0 Yes

KonanaKare Matahalli 750 175 0 15 0 Yes

Dantalli /Mariyane Kurati 187 35 10 10 1 Yes

Echalakabbe doddi Punachi 150 40 0 1 3 No

Gorashane MM. Hills 421 64 4 4 0 Yes

Jadeswamy doddi Lokanhalli 75 22 0.5 5 0 Yes

Kagligundi podu Chikamalapura 180 43 4 10 0 Yes

Kallatti Bayalu Ugyam 48 8 0 10 1 No

Kambigudde Doddi Byluru 120 52 5 15 3 Yes

Naal road Matahalli 121 40 0 5 3 Yes

Source: data collected during village visits by discussion with village leaders and elders

Village-wise summaries for Kollegal taluk

1. Alambadi : Community reported transportation problem as there was only one bus connecting this village with others. ANC care was not satisfactory. There was no health education or pregnancy related information given to community either by health worker or anganwadi workers. Pregnancy registration was not done nor TT injection or IFA tablets distributed. There was no health facility available inside the village. Information related to institutional delivery was not given to pregnant women. Therefore they accepted traditional practices and preferred home delivery. Postnatal mothers did not receive madilu kit and cash incentives. Information regarding ANM, ASHA and their visits was not available.

2. Anne Hola: Villagers accessed main road easily. Antenatal care was regularly provided by ANM. ANM visited pregnant women once in a month. Pregnancies were registered and received TT injections and IFA tablets. They also mentioned that checkups were conducted by doctors. Both home and hospital delivery was common. In order to go to hospital community used autos instead of 108 services. Even though community members were aware about 108 services they did not use it. Many women who delivered on hospital did not stay for 48 hours.

3. Ardhanaripura: PHC was located at a distance of 8 km. Health system related information was available with the community but according to them it is not satisfactory. During pregnancy related emergencies many hired auto to go to hospital as 108 service was not available. Due to economic problems few took loans (up to Rs 15,000) from self help group that was active in the village. Hospital deliveries were reported.

4. Arekaduvina doddi: ASHA and anganwadi worker were involved in providing maternal and child health care. Anganwadi worker provided nutritious food to pregnant and lactating mothers. Since anganwadi worker was a local person she provided services regularly. Also, tribal mobile health unit visited the village every month. Pregnant women preferred PHC for delivery. Some women also mentioned that due to shyness they did not seek institutional delivery. Many reported that they did not receive prasooti aarike from hospital but did not get JSY benefit. At time of survey, there were 19 postnatal mothers and all of them delivered at PG Palya PHC.

5. Astur: Community reported that there was no problem with transportation and access to other places. Antenatal services were available and considered satisfactory. However, they mentioned that further services were limited i.e. blood tests were not done in those who were anaemic, delivery services not available. Hence deliveries were at home. Details about postnatal care not available.

6. Bangalada Oddu: Transportation was a problem. Elder women in village, ASHA and anganwadi worker provided maternal health related information. Antenatal services are availed by pregnant women. But deliveries occurred at home and were conducted by traditional birth attendant from the same village. Even though there were complications following home deliveries, family members were hesitant to approach any hospital mainly due to their traditional beliefs. Details about postnatal care were not available.

7. Basavanagudi: Antenatal services were available at PG Palya PHC and for other investigations such as ultrasound scanning they went to taluk hospital. For transportation they use bus, auto, and taxi. Anganwadi worker was actively involved in spreading awareness about maternal health. Community believed in traditional practices as well as modern medicine. They utilized hospital services for institutional delivery. They received madilu kit and JSY incentive.

8. BG doddi: Maternal health services were available in PG Palya PHC and tribal mobile health unit which were 4km and 2km from the village respectively. Sub-centre was present in another village but ANM rarely visited the village and provided services. However, ASHA and anganwadi worker provided services. It was reported that patients paid 20 rupees for obtaining services at tribal mobile health unit. Staff behaviour at mobile unit was perceived to be not good towards tribals. Due to lack of necessary information, few pregnant women went to private hospital for delivery. Post natal care was not satisfactory and many did not receive incentives.

9. Boodi hola: This village was close to forest and transportation problems were mentioned. People walked on game road to reach the main road. Antenatal care was received by pregnant women. ASHA was present in the village. Community was aware about 108 service and during emergencies that has been utilised.

Unfortunately there were times when 108 ambulance was not available and pregnant woman was transferred in a cloth sac. Sometimes women went to a government hospital in Hunur for delivery.

10. Boodipaadaga: Health services were availed from Lokkanahalli PHC which is 5km from the village and taluk hospital. ASHA visited pregnant and postnatal women but ANM did not visit the village regularly. If women went to hospital for delivery they hired auto for transportation. Post natal mothers received madilu kit and JSY incentive.

11. Changadi : Sub-centre was present in the village and ANM visited the village once in a while. Pregnancy registration was done by ANM but other services were not provided. She did not visit the houses, and maternal health and services related information was lacking.

12. Chikkamarur: There were problems with road access. People here mainly work as daily wage labourers. Health workers never visited the village and information about health services was lacking. Home deliveries were common and traditional birth attendant assisted these deliveries. No complication was reported at the time of survey.

13. Dantalli: The village was located half km away from main road. Doctor or ANM did not visit the village. Health education component was lacking. Therefore pregnant women were not registered and received TT injections or IFA tablets. Complicated pregnancies were reported at time of survey. Even though there was a high risk neonate (low birth weight), ANM or ASHA did not visit the home, and the family took the baby to the hospital for different reasons. Post natal care was unsatisfactory.

14. Donamaduvina Doddi: This village was located inside the forest and accessibility was a problem. It was reported that there was no ANM for this village. Health education was imparted through ASHA and anganwadi worker. Antenatal services were satisfactory. But deliveries occurred at home. Reason for same was not known. Since there was no ANM, quality of post natal care was unsatisfactory.

15. Gandhi Nagara: Health care was accessed at taluk hospital, PHC hospital at PG Palya, tribal mobile health unit as well as private hospitals. Sub-centre was 5km from the village but ANM did not visit the village. Community felt that nurse and doctors at mobile unit treated tribal patients insensitively. Even though basic obstetric services are available at the PHC, many preferred to go to CHC at Santemaralli. This was due to lack of satisfaction with treatment at the PHC. Post delivery incentives were not received on time by the mothers.

16. Ganiga Mangala: The road was in bad condition and access to main road is problematic with bus only once a day. Antenatal services were available at Bandalli PHC which was 15 km from the village. Community believed in traditional practices but they also accepted information given by village leaders. No information was available from ASHA or anganwadi worker. However, in some instances ASHA had motivated pregnant women to go to PHC for delivery. Since the time taken by ambulance to come was long, they had to take auto to go to PHC which cost them 500 rupees. Many a times family members sold their cattle to go to hospital for delivery purposes. Quality of postnatal care was reported to be bad.

17. Gombegallu Podu: Village was located inside the forest and there was vehicle problem along with the problem of wildlife. Women self help groups were active in spreading awareness. Community availed health services from VGKK hospital as well as tribal mobile health unit. Information about ANM and ASHA was not available. Those who availed 108 ambulance had institutional delivery and those who could not go delivered at home. Also, due to economic considerations and fear of going to hospital many had home delivery. Community did not give preference to postnatal care of mother and newborn.

18. GottiDimba : Community believed in traditional practices and customs. They did not accept health services and did not go to hospital. Hence most of them delivered at home. Elderly women from the same village delivered the baby and provided postnatal care.

19. Gullada Bayalu: Accessibility was good and people mainly worked as daily wagers. Antenatal care was availed from tribal mobile health unit. ANM, ASHA, and anganwadi worker worked towards health promotion. ASHA motivated pregnant women for institutional delivery. They did not depend on 108 ambulance but hired auto to go to hospital for delivery. Quality of services was reported to be less than satisfactory.

20. Gundi Seedu: Pregnant women went to nearby hospital for antenatal care. Information about antenatal care and nutrition was given by anganwadi worker. Many pregnant women delivered at home with the help of elderly women in the village.

21. Gurumallappana Doddi: All weather road was present so accessibility was not an issue. Tribal mobile health unit provides health services mainly. The women also went to PHC and taluk hospital. Their sub-centre was closed from many years and no ANM visited them. During emergency 108 ambulance was not available. Quality of service in the hospitals was reported to be poor.

22. Hande kuruban Doddi: Health information was provided by ASHA and anganwadi worker. Tribal mobile health unit delivered maternal health services to the community. Antenatal care was partly available. Their sub-centre was closed for many years. Even though the ANM was present, she often visited the village when people had gone for work. Hence the services were not satisfactory as per pregnant women. Institutional delivery was the preferred choice. However, many mothers did not receive cash incentive for institutional delivery.

23. Hiriambala: Here people walked 4 km to reach main road and then take private vehicle to go to nearby PHC. Anganwadi worker provided information regarding nutritious food. But ASHA did not visit the village regularly. Women went to PHC for antenatal care which they found satisfactory. All investigations were done in PHC and pregnant women received TT injections and IFA tablets regularly. Women also went to PHU, and taluk hospital for accessing health care. Tribal mobile unit nurse visited once in 15 days. However, they reported that when they went to these hospitals for check up, at times the staff asked for informal fees despite maternal health services being free. In some instances family took loans on high interest rates or sold their cattle to pay towards pregnancy and delivery care. Fearing bad condition of the hospitals, some women delivered at home. Those who delivered at hospitals were motivated by ASHA or nurse at mobile health unit. Emergency vehicle/108 ambulance was not available at the time of delivery. Quality of postnatal care was poor as there were no check-ups.

24. Hosahalli: People did not own any agricultural land and depended on daily wage work for livelihood. Awareness about health and related services was lacking even for antenatal care. No health worker provided services here or motivated women for institutional delivery, hence home delivery was the norm. People perceived the quality of services to be very poor and were dissatisfied with maternal health services available.

25. HosaPodu: Game road was present and they walked 4 km to the main road to find transport to any health centre. Anganwadi worker provided information about nutritious food. 108 service was not available. ANM did not visit the village and ASHA visited quite irregularly. They received services from PHU- Odeyarpalya, PHC-PG Palya and other private clinics. They paid fee of rupees 10 at the PHU. ASHA and PHU staff encouraged women to seek antenatal health services and institutional delivery.

26. Hoyilnatta : Community members believed in traditional methods, however they also sought treatment from doctors. It was mentioned that ANM did not visit the village and ASHA visited them only during delivery time in hospital. Pregnant women sought health services from PHU-Odeyarpalya, PHC- PG Palya as well as tribal mobile unit which visited once a month. For delivery women usually went to PHC at PG Palya but did not receive any incentives.

27. Jadeswamy Doddi: Village was located close to the forest limits. ASHA provided maternal health related information. People sought health services from Lokkanahalli PHC. Apart from this tribal mobile health unit van visited this village fortnightly. Women delivered at the same PHC but complained that they did not receive JSY money (cash incentive). Information about postnatal care was not available.

28. Jeerige Gadde: Accessibility was an issue here since the village was located close to forest limits. People walk to for 2 -3km to reach main road. Women did not mention about ANM or her work. ASHA was present but did not visit regularly. Anganwadi worker gave information to pregnant and lactating women regarding nutrition. Nurse from the tribal mobile health unit nurse came once in 15 days for general check-up. Women preferred PHC for delivery and they received madilukit.

29. Jelly Palya: They did not receive information regarding available government health services. There was no ASHA worker in that area, and ANM or doctor visited the village only once in a month. Information about antenatal care was not available. People mentioned that since ANM visited the village only once a month, they did not get complete information about antenatal care and related services. Women went to the PHC for delivery but 108 was not available usually, needing them to organise their own transport. They also complained that they did not receive any incentives for institutional delivery.

30. Kadakala Kandi Podu: Village was close to thick forest without electricity so relatively high incidents of wildlife encounters were reported. They did not receive health services from any health worker, and themselves, hence, did not seek antenatal care or others. Women largely relied on elders’ advice on seeking health services. They feared going to hospital and only went in case of a complication during pregnancy or labour. In most cases, the delivered at home.

31. Kagli Gundi Podu: This village was 2kms from the main road and 10kms from PHC. Due to lack of work opportunities nearby, many migrated to other places for work. While belief in traditional practices was good, they also accepted maternal health services provided at hospital. Women consumed IFA tablets and received TT injections. They received services from ASHA worker and tribal mobile health unit during pregnancy. ASHA helped during delivery by arranging for auto and took them to hospital as the 108 service was not available when needed. Few alleged that they paid ASHA 200 rupees, ANM 200 rupees and cleaner at PHC 100rupeess after delivery. They also went to nearby PHC for general treatment. They reported that at times the doctor at nearby PHC charged 10 rupees for consultation. In spite of the informal fees paid, they were satisfied that services they received were of good quality.

32. Kallatti Bayalu: They did not receive any information regarding maternal health services. None of the health workers (ANM or ASHA) nor doctor visited the village. They did not receive any services apart from madilu kit. Generally awareness on maternal health and related services was found to be lacking.

33. Kambi Gudde: The village was connected to the main road 4 km away via a game road. No transportation was available till the main road. Services were available through tribal mobile health unit and PG playa PHC. Maternal health information was available from mobile unit, ANM and ASHA worker. Free ambulance service was not perceived as not being available. ASHA arranged for transportation and took them to hospital for

delivery for which nearly 800 rupees is spent. However they were satisfied with institutional delivery and related services.

34. Kanamale Doddi: This village was connected via a game road to about half a km away. No transportation was available till main road. PG Palya PHC is 6km while tribal mobile unit was 5km away. Tribal mobile health unit visited the village once a month and provided antenatal care services. Delivery conducted in PG Palya PHC. Quality of service was reported to be average.

35. Kanchulgalli : The main road was 4 km away, and PHC was 6 km away while taluka hospital was 15 km away. The anganwadi worker provides information and nutritious food for pregnant women. She also informed women about immunization. The ANM and ASHA did not visit regularly. The doctor also did not visit regularly. Women availed antenatal services from Kamagaere PHC and taluk hospital. They got regular ANC checkups, blood examination and TT injection and IFA tablets. During emergencies 108 services was utilized. Post delivery but they returned in bus or in auto. JSY and madilu kit was obtained but prasooti arike was not obtained. They relied on traditional ways for post natal care.

36. Karala Katte: Women availed maternal health services mainly in taluk hospital in Kollegal. They did not know who their ASHA was. The subcentre was under repair and ANM visited once in 3 months, and PHC was 14kms away. Hospital deliveries were common and pregnant women went to PHC for delivery. For pregnancy and postnatal care services, some families sold domestic animals to meet the expenditure. They did not get prasooti arike or any other scheme though.

37. Keredimba: They got maternal health services from VGKK (an NGO) and local government hospitals. Anganwadi worker and ANM provided health information about maternal health services. Apart from this, they also got information from self-help groups and elders. They hesitated going to hospital mainly due to their traditional practices. They walked through thick forests to reach hospitals. Deliveries were conducted at home and also at hospitals. They availed VGKK ambulance and 108 services. However, it was mentioned that it was difficult to obtain services during emergency.

38. Kempsiddana doddi: Women in this village did not register for or receive antenatal care services. Even though there were no problems with accessibility, health staff did not visit the village. They did not receive madilu kit, JSY or other schemes. Due to the absence of health workers’ visits, deliveries occurred at home with the help of traditional birth attendant. No information was obtained from ANM or Doctor even after delivery and neither the ANM nor ASHA visited and advised about further course of action.

39. Yerakatte: Services utilised at taluk hospital mainly. Antenatal care services was satisfactory. However ANM visited the village once a month only but there was no ASHA for the village. For delivery women went to taluk hospital by hiring auto. Sometimes they also went to a PHC that was 14 km away. They spent a lot of money towards transportation (upto rupees 1500). Even in the hospital patients gave money to the nurse for conducting delivery (400-500 rupees) and after delivery mothers received madilu kit by paying 500 rupees.

40. Nallikatre podu: People availed health services from private hospital in Kamagere as well as PG Palya PHC. ANM did not provide any maternal health services to the village. Tribal mobile health unit visited twice a month. For delivery, women went to either PHC or private hospital. Many did not receive madilu kit. Overall people were not satisfied with the maternal health services available to them.

41. Karalakatte: They availed maternal health services mainly from Kollegal taluk hospital. Despite their low economic status, they spent money to buy nutritious food, undergo tests and scan, and purchase needed injections and tonic. To avail this, they would even borrow from others and also sell their livestock. They did

not know who the ASHA was for their village. The sub-centre did not function properly and the nurse visited only once in 3 months. For delivery, they used bike or auto (private vehicles only) and went to PG Palya PHC. Quality of services was perceived to be bad and hospital staff demanded money (informal fees) for conducting delivery. Those who underwent institutional delivery received cash incentives provided by government.

42. Konanakere: No anganwadi was working in the village, and ASHA and ANM hardly visited the village. They did not receive any services from the government PHC nearby. However pregnant women went with help of their parents and availed antenatal care at the PHC. Most deliveries took place at home.

43. KullegowdanaDoddi: The PHC is next to the village so they did not have any problem with access. They availed maternal health services from PG Palya PHC. Information is received from ASHA and anganwadi worker. They walked to PHC and delivered in the hospital. Before going to a PHC, at times they took loans to go to the PHC. May women opined that they paid the nurse in PHC for conducting delivery. However following delivery at hospital, they did not receive any cash incentive.

44. Medagane: This village was located deep inside the forest and people usually walked 8km to reach the main road. Health workers did not visit the village. Due to poor awareness, many pregnant women did not seek or receive antenatal care services. Further information about delivery and postnatal care services is yet to be collected.

45. Naal Road: Village was located on main road and was easily accessible. ANM did register all the pregnant women and post delivery, women received madilu kits. However the villagers felt that the general awareness on health services was poor and that apart from documentation or paperwork, that no services were provided for pregnant women.

46. Nakundi: The awareness about maternal health services available was lacking among the community in the village. Anganwadi worker was present but did not participate in providing information or services regarding maternal health. Neither ANM nor ASHA visited the village. Women were not aware about 108 services or importance of hospital delivery. Most of them hence delivered at home. Postnatal care was also unsatisfactory.

47. PuttirammanDoddi: Villagers availed services from Kamagere PHC, taluk hospital and hospitals in Mysore. They were well aware about pregnancy care and ASHA, ANM and AWW workers were actively involved in providing services. Antenatal service was reported to be good and well received. They utilised 108 ambulances as transport for delivery to the hospital. However family members still needed money by selling livestock or taking loans from money-lenders. Despite the expenditure, women perceived the services to be of good quality. ASHA worker accompanied them to hospital for delivery, and received schemes like madilu kit and JSY from the government.

48. Rachappaji Nagar: They availed maternal health services from Thelanur PHC. Community complained that ASHA did not visit the village properly which resulted in poor services. ANM and ASHA visited only once in 15 days. The anganwadi worker belonged to the same village but did not provide information regarding maternal health services. People organised their own transportation to reach the PHC for delivery, and even reported paying informal fees to the hospital staff post delivery. Women did not receive any cash incentives following delivery.

49. RamegowdanaHalli: In this village people did not complain about accessibility. Majority opined that they did not receive any maternal health services. No information was available about ASHA, ANM or anganwadi worker. Most families preferred home delivery. Information on postnatal care is yet to be elicited.

50. Sebina Kobe: This village reported several issues with access and 108 ambulance service does not ply there apparently. Pregnant women here did not receive regular antenatal care, and, ASHA and ANM did not visit the village. For treatment, people visited private hospitals in Kollegal town. At the time of delivery at times, people carried pregnant women on their shoulders till the main road as vehicles do not reach their village. In some cases, when they reached PHC (Lokkanahalli), they felt neglected by staff and doctors prescribed medicines to be purchased from outside pharmaceutical store. Family members even made informal payments to the tune of 200 and 300 rupees to the ASHA and staff nurse respectively for their services with delivery. Hence only few women preferred hospital delivery while the rest delivered at home. Those who delivered at hospitals received madilu kit.

51. SoppinaGudde: For maternal health services, they look to PG Palya PHC. ASHA did not visit regularly and pregnant women did not have information regarding government services. Also they could not get emergency vehicles during delivery. Doctor and nurse at PHC provided information about postnatal care. However due to fear, many women delivered at home. After delivery, anganwadi worker visits and provides some services. They received like madilu kit and cash incentives when applicable.

52. V S Doddi: Women usually availed services from tribal mobile health unit that visited monthly and from PG Palya PHC. ANM visited only once a month. Women delivered at the PHC but 108 service was not available for transportation. Those who delivered at hospitals did not receive madilu kit or JSY cash incentive.

53. Yaragabalu (Udatti): They receive antenatal services from PG Palya mobile health unit but need to visit PHC for TT injection, and for scans, the taluk hospital. ASHA provides all necessary information on maternal health services. The tribal mobile health unit also visited once a month but off late, was not visiting regularly. For delivery they went to PG playa PHC on their own. Many women complained that only after giving informal payments in the hospital did the staff took care of pregnant women. Therefore few women went to private hospitals in Kollegal town instead.

54. Koppa: Health workers hardly visited this village. Pregnant women were not registered and did not receive information about maternal health services or birth preparedness. Almost all women delivered at home though one case of complicated delivery at hospital was mentioned. Generally, women were not happy with the quality of services, and reported that even after delivering in the hospital, no one examined either mother or child and they did not receive any incentive or madilu kit.

55. Palar: The nearest govt hospital was 18km away. Pregnant women registered their pregnancies and received antenatal care services. They were not aware about birth preparedness though. Hospital deliveries were common, and the hospital nurse mainly conducted the examinations and delivery. However no check up was done after delivery whether at the hospital or at home.

56. ErayyanaKatte: ANM and ASHA did not visit pregnant women in the village. The nearest government health facility was 18km away. Pregnant women on their own volition registered themselves and took IFA tablets and TT injections. Awareness in general was lacking about maternal health issues. Women only delivered at the hospital if the delivery was difficult. Post natal care was also unsatisfactory.

Few cases identified in Kollegal taluk* K001: 108 service was used when a pregnant woman went into labour. The delivery was conducted in government hospital after three days. Following delivery though, she developed respiratory problems, and was shifted to higher hospital. Both mother and child are healthy. K003: Chennamma was 8 months pregnant when she stopped perceiving foetal movements. Within a day she delivered a still baby at home. Till eight days after delivery she did well but on the ninth day, her condition abruptly deteriorated. Family members immediately took her to health centre at Wodeyarpalya. After examining her, the doctor infused some parenteral fluids. But later patient could not move her limbs at all. Immediately doctor referred her to the taluk hospital in an ambulance. The treating doctor at taluk hospital informed that she had a stroke due to blood clot in the brain and advised for CT-scan brain. She was then referred to a tertiary government hospital in Mysore in the same ambulance. They reached that hospital in one hour where hospital staff took 300 rupees and the doctor started treatment immediately. The family spent 3000 rupees for CT scan, and 700 rupees for blood tests. After one week of admission, the condition of the patient deteriorated and doctors advised them to take her to another hospital in Bangalore. A distraught family requested the doctor to continue treatment there itself as that they did not any money left with them and that they did not know anything about Bangalore. On the same night at 8 PM the patient died. Since an ambulance would not help, they hired a jeep to bring back her body to their village and performed last rites. K004: A women experienced labour pains for nearly two days and finally delivered a still baby in her seventh month of pregnancy. Next the right hand of the mother became numb. The family took her to the tribal mobile health unit, and with the advice of the doctor they decided to go to Mysore Cheluvamba hospital. During transport, her blood pressure increased apparently and she died in transit. K005: One pregnant woman was found to be anemic in taluk hospital, and was advised blood transfusion. She underwent blood transfusion at Holy Cross hospital in Kamagere and was charged 700 rupees per pint of blood. She needed 4 pints, and a total of 15,000 rupees was spent as hospital expenditure which was out of their own pocket. K006: One lady developed labour pains for 3 days. When she was advised for hospital delivery, they preferred home delivery and delivered at home. K007: A first time mother developed abdominal pain for a month for which she sought her family’s help. Initially they reassured her that pain abdomen was dueto doing heavy work. Later she went to tribal mobile health unit where the nursetold her there was no problem. Later when she went to her maternal home, her mother took her to a private hospital. There the doctor after examination revealed that the baby was dead inside the womb. She delivered a still born baby vaginally. The family incurred around 20,000 rupees towards her care. *names changed of cases

Summary of Kollegal taluk

§ Game-roads mainly connect tribal villages to main road in this taluk. Many villages here were located deep inside thick forests though some were easily accessible. People mainly relied on private vehicles like jeep and auto for transportation. Many did not depend on 108 ambulance for transport as they felt it seldom reached on time, and hired autos to go to hospital for delivery. Distance between PHC and higher hospitals caused delays during referrals and involved high costs. Some anecdotes of men carrying women on their backs in emergencies or using makeshift stretchers were reported. § Tribal women were not aware about pregnancy care, birth preparedness and maternal health related services. Many women feared utilising hospital services across the villages for different reasons. Antenatal care was found lacking in many villages since ANM or ASHA did not visit villages regularly. Overall in the taluk, the role of frontline health workers (ANM and ASHA) in providing maternal health services and related awareness was poor to absent. Leaders of this taluk perceived that in many sub-centres when both tribal and non-tribal communities were assigned to frontline health workers, they focused their efforts on the latter. § Health care was usually accessed through PHCs, tribal mobile health unit, and taluk hospital. Roughly half the villages had access to well-functioning health centres, but for the remaining half (nearly forty villages) the health services had acute staff shortages with some reports of closed sub-centres and largely empty PHCs. Poor availability of staff was a significant issue reported. For instance, in one PHC the doctor visited only for half hour due to lack of staff posted there. Mobile health unit did not cover around forty villages though (nearly half the villages). Many also went to private hospitals in the town. In some villages, PHC doctor visited every fortnight for health check-ups and during this anaemic children were given iron tablets. § Both home and hospital deliveries were seen. Fearing poor conditions of the hospitals, inappropriate staff behaviour, past adverse experience, need to purchase medicines from private pharmacies, and informal payments at government hospitals, many women delivered at home. Home deliveries were conducted by local dai using traditional medicines and practices. § Those who delivered at hospitals reported spending money for transportation, medicines, and towards informal payments. Given their low economic condition, such families at times took loans from self-help groups or sold livestock to meet this expenditure. Few tribal leaders also explained that if delivery occurred in private hospitals, then the high costs could even compel families to sell some of their assets just to pay the bill. § Issues of informal fees were reported from PHCs and the mobile health unit. Few reported that government doctors often prescribed medicines to be purchased from private pharmacies. The behaviour of staff in the mobile unit was perceived to be insensitive towards tribal people. There was delay in receiving madilu kits in some places and also many postnatal women had not received JSY cash incentive on time. While 108 ambulance service was known to many and available regularly for some, schemes like nagu magu were not heard of nor used. § People reported relying on traditional health practices as first choice or first aid in most situations particularly for minor illnesses or complaints even during pregnancy or postnatal period. § Similar to other taluks, alcoholism was reported from many villages as a key problem that affected not only health but also ability to access health services.

IV. YELANDUR TALUK This taluk of Chamarajanagar district has a population of 82,069 and 89.3 per cent is constituted by rural population according to Census 2011. Of 28 villages, 10 tribal villages are reported with 2635 tribal population belonging to the Soliga community according to the Zilla Sangha.

Figure 7. Hand-drawn map of Yelandur taluk showcasing tribal villages

Figure 8. Hand-drawn map of Yelandur taluk showcasing tribal villages

Table 6. Profile of tribal villages in Yelandur taluk Name of tribal village Panchayat Population No of Distance to nearest (in km) Anganwadi families Main PHC Government present road primary school Hosapodu Bangalle podu 345 75 0 24 1 Yes Muthugadde podu Bangalle podu 320 110 0 24 1 Yes Bangalle podu Bangalle podu 329 85 0 24 1 Yes Yarakanagadde podu Bangalle podu 442 125 0 24 1 Yes Sigebetta Bangalle podu 175 36 0 24 0 Yes Kalayni podu Bangalle podu 101 22 0 24 0.5 Yes Manjigundi podu Bangalle podu 83 19 0 24 0.5 Yes K Devarahalli Yaragamballi 335 185 3 16 0 Yes Purani podu Bangalle podu 480 100 3 16 0 Yes Herayankatte Gowdahalli 25 6 6 6 No No Source: data collected during village visits by discussion with village leaders and elders

Village-wise summaries for Yelandur taluk

1. Hosapodu- This village had an anganwadi and a NGO hospital next door that provided primary health services. Services related to maternal and child health were available through ASHA and anganwadi worker. Thayi cards were distributed periodically. Even though village was inside a forest reserve, it was along a main road with some public and private transportation available. Women hence often delivered in hospitals only. However, it was observed that community often preferred traditional health practices and private hospitals at the time of obstetric emergencies. One reason given was the timely arrangement of own vehicle. Involvement of ASHA and ANM was minimal in providing postnatal care to the mother.

2. Muthugaddepodu- This village was present inside thick forests, alongside a main road with easy access to VGKK hospital (NGO) and anganwadi in the village. Tribal people here mainly grew coffee and pepper for livelihood. Majority opined that services given by ANM was not satisfactory. Community was not aware about the services available in government hospitals. Pregnancy related services were accessed through VGKK hospital. General awareness on maternal health and related services was lacking. It was seen that few pregnant women were not utilising any medication due to fear of side effects like vomiting. Women hardly delivered in the hospital because they sensed neglect by nurse and also delivery by male doctor (at NGO) was not acceptable to the community. The PHC was 24 km away and due to expenditure incurred for transport and general lack of awarenesss, the women preferred not to go to other hospitals.

3. Bangallepodu- ANM apparently provided minimal services in the village even though the sub-centre is in the village; however the ASHA was absent and people hence seldom approached them for any help. Basic pregnancy related information and services were accessed mainly through anganwadi. But when it came to special interventions like ultrasound scans or higher blood tests, etc, many women were not able to afford it. Majority preferred hospital delivery still there were home deliveries at times reported from this village. The main reason for home delivery was fear of delivering in a hospital or availability of local traditional birth attendant who could deliver at home. Some also reported that reaching hospital at the time of emergency was challenging so they preferred home delivery instead. With no efficient emergency transport system and restriction of vehicle movement during night time, reaching a hospital is quite difficult. Even those women who received antenatal care, there was a delay in getting thayi cards. Madilu kits for post-partum mothers were also delayed in many instances. It was reported that severely anaemia women could not receive blood transfusion or get an ultrasound done due to poor affordability. Some of the positive points were existence of women self-help groups and active anganwadi worker who helped spread awareness among tribal women.

4. K Devarahalli- Maternal health services were available through VGKK mobile health unit. Anganwadi worker and members of self-help groups actively created awareness among locals on maternal health and related services. Women reported that the ANM, though irregular, visited their village but did not educate the community about maternal or child health. For delivery families preferred both government and private hospitals. Those who delivered at hospitals complained that they did not receive madilu kits. It was observed that mothers were knowledgeable about postnatal care particularly about child care. However, women did not give importance to their nutritional requirement. Apart from these issues community complained about drinking water problem.

5. Kalyani podu-It was a relatively small village with a population of 101. Anganwadi was not present in the village so pregnant women and children went to nearby village for availing anganwadi services. PHC hospital was not easily accessible (24 km away) but women went to VGKK hospital (NGO) which was 2 km away. Family members followed advice of head of the household in seeking health care. Acceptance of medical advice by pregnant women was good. Even though they faced economic issues, money was spent for scanning,

blood tests, as well as nutritious foods. Deliveries usually happened at VGKK hospital. Those women for whom delivery by male doctor was unacceptable, delivered at home. Emergency transport was a key problem mentioned by the community due to difficult road access. Women mentioned that postnatal services were not available since ANM or ASHA did not visit them regularly.

6. Manjigundi podu- This was a small village having 83 population. Antenatal services were provided by anganwadi worker and ANM. Thayi cards were not distributed to pregnant women during pregnancy in the last year. Women utilized maternal health services in VGKK hospital. Many follow their customs and follow advice of their elders. During pregnancy money was usually spent on travelling to PHC, hiring vehicles during emergencies, scanning, and blood tests etc even though technically maternal health services are free.

7. Purani podu-This was the biggest village in the area in terms of population. Pregnant women availed maternal health services through mobile health services via VGKK hospital and PHC Gumballi. The PHC hospital was 16km from this village. As they had to walk through thick forests and semi-weather roads, hospitals were not easily accessible. Many a times forest department also restricted movement through forest. 108 ambulance service was usually unavailable so people used VGKK’s vehicle for emergency transport service. Pregnant women attended antenatal clinics but are not regular with utilising services. Due to the issue of emergency transport and economic implications, most of deliveries took place at home.

8. Seegebettea podu- PHC was 24km away from the village. Maternal health services were provided through VGKK hospital. ANM usually visited village and provided health services to pregnant and post-natal women. Women self-help groups also actively created awareness. Presence of male doctor in NGO hospital and fear were important reasons mentioned for low number of hospital deliveries. Interestingly, it was reported by women that head of household often advised against availing hospital services. Also, family incurred expenditure for transportation for delivery or check-ups as emergency transport service was seldom available on a timely basis.

9. Yerakanagadde podu- Antenatal services were available at PHC Gumballi and VGKK hospital. ANM visited village regularly but there was no ASHA worker. There were some deficiencies in antenatal care provided by ANM like urine pregnancy test was not done. Community felt that they were not treated well when they visited hospitals. Here also economic issue was present they could not afford bus fares for transportation. Even though VGKK hospital vehicle was available for emergencies, due to fear of male doctors, women preferred home delivery. Those who delivered at hospital did not receive madilu kit. Some women reported that ANM did postnatal check upto 5-6 months.

Few cases identified in Yelandur taluk*

Y001:A 21year old Siddamma gave birth to twin babies at her home with the help of local traditional birth attendant but soon she developed massive haemorrhage which was not getting controlled. So, family decided to take her to a healerat Talawadi, which was ~35 km from their village, who advised them to take her to hospital. Family arranged for their own vehicle and decided to take her to private hospital in Santemaralli. However, one of the twins died. Y002:One month before the survey it was found out that Lakshmi was severely anaemic. She was in her third trimester but her hemoglobin was 6 g/dl. The nurse who visited the podu advised her to consume iron tablets. Even though she experienced weakness, Lakshmi continued to do her routine activities till she went into labour. However, she became unconscious during labour and family members informed this to the nearest hospital. But there was some delay in sending the ambulance. She was then taken to a private hospital. But, by the time doctors saw the patient the baby had died in utero and Lakshmi delivered a stillborn baby normally. After consuming medications now Lakshmi was doing well. Y003: A pregnant woman during her first pregnancy took TT injections. After sometime she aborted, and elders attributed it to receiving TT injections. So as per elder’s advice she refused to take any TT injection during her second pregnancy. Y004: A woman did not avail any services during pregnancy including tests. At the time of delivery her haemoglobin was 6 g/dl. She delivered at home,but because of post partum haemorrghage she lost conciousness. Family members took both mother and baby to hospital. Due to delay in treatment, both were again shifted to another hospital. But, by the time they had reached the second hospital, baby had died. However, she survived and is well. Y005:One year back Madevi was coking rice porridge when she heard a loud thud. Her one year old, Rama fell from the cot while playing. She noticed the child moved his both upper and lower limbs abnormally while drooling of saliva. After sometime Rama went into deep sleep and an unaware Madevi neglected repeated episodes even when an elder suggested that it could be seizures. But the family continues to not seek treatment for this. *names were changed

Yelandur taluk summary

§ Community was not aware about most services available in government hospitals. Involvement of ASHA and ANM was minimal in providing maternal and child health related information to the community. However anganwadi workers played a key role in filling this gap. Tribal women self-help groups along with anganwadi workers were active in awareness creation about maternal health. Mothers were knowledgeable about postnatal child care. Acceptance of medical advice by few pregnant women and their family was a good sign. Family spent money on blood tests as well a USG scan during the antenatal period. § Basic ANC services were accessed mainly through nearby NGO hospital and anganwadis. Thayi cards were delayed and did not reach all in the last year. Madilu kits for post partum mothers were not distributed on time. Home based post natal care was far from satisfactory. § The main expenditure was on travel and other related costs. In the absence of a regular and timely available 108 ambulance, availability of a mobile jeep/ambulance by a nearby NGO was a positive point. § Some reasons for not delivering in the hospital were issues of emergency transport; some sensed neglect by health providers at hospital; and delivery conducted by male doctor (as in the NGO hospital) was not acceptable. Complicated pregnancies were referred to CHC as well as neighbouring district hospital. Issue of informal payments was not recorded here. § Customs and elders’ advice regarding health were followed by many women. Some women did not consume medications due to fear of side effects; for instance, TT injection was attributed to cause abortion. Community appeared to have more faith in traditional healers present in Thalawadi (~35 km from the village) and private hospitals at the time of obstetric emergencies. Some instances have made people to lose trust in medicine system, people tend to go for traditional healing method as a first choice. § Common prevalence of early marriage was also reported as a key issue that needed to be addressed as well.

DISTRICT-LEVEL SUMMARY

Accessibility was the most discussed issue across most villages. Distance to main road, absence of all- weather road, and limited public transportation via the main road were most common issues that arose during the discussions. While 108 ambulance service was available to most villages, most reported that the time taken was too long and could not rely on them. In most instances of emergencies, the women and their families hire private autos or jeeps from outsiders to transport them to the nearest health centre. In villages within forest limits, chains restrict access from the main road, thick forests and night restriction of vehicular movement further worsen accessibility in emergency situations. Women often are compelled to walk a significant distance to the main road, and spend a lot of money to travel to health centre with relatives, thereby making frequent check-ups difficult. 108 services also do not drop families back after their hospital visit, a grievance that some expressed. Costs for travel back and forth are an important factor mentioned in nearly all villages.

The role of frontline health workers is key for maternal health and services-related awareness creation and promotion of service utilisation. Apart from ANM and ASHA, the anganwadi worker also plays a key role as an informant on maternal health relation information across the four taluks. In Gundlupet taluk, the community was relatively well informed and the community was satisfied with the performance of these frontline workers. In other taluks, either the ASHA or ANM or as in some villages of Kollegal, both health workers were found to be irregular or not reliable for either providing information or relying on for services. However, the picture is not a general one, and some villages deeply appreciated the work of their health workers. Apart from health workers, women self-help groups, village elders and village leaders were other social networks who helped provide information on maternal health and related services in the villages. Awareness was lowest about postnatal care and related health services. Many were aware about government schemes available like madilu kit, prasooti araike, and cash for JSY scheme. Across the villages, mixed picture was seen with some receiving them on time while others not.

Barring a few villages, in most areas, the community well-accepted and utilised antenatal care services, and often even sought it out in nearby health centres at least once during the pregnancy. Some misconception on injections and medication during pregnancy and their effect, and expenditure on drugs and tests were the only issues reported for seeking antenatal services.

However when it came to delivery, several service and community related issues were reported. Distance to health centre in cases of urgency, availability of emergency transport services, anticipation of high expenditure, non-availability of female doctors, behaviour of staff towards women during delivery, demand for informal fees for services, and fear of operation were many of the reasons reported that acted as barriers for seeking institutional deliveries. In very few cases, women chose to deliver home due to traditional practices.

The overall picture for accessing maternal health services varies greatly from village to village. In each taluk, some villages due to their location or distance to health centre did provide a positive picture in terms of good awareness and utilisation among women on maternal health care, services and related schemes, with good relationship and support from their frontline health workers. However there are also in each taluk some villages that are remotely located where access to general services including health is poor, with infrequent to nil outreach by health workers and where traditional health practices were sought and women delivered at home out of choice or circumstances. The disparities are seen at the village level, but also at the taluk level.

Possible steps ahead for the community:

In light of the various issues that emerged from the field visits and different discussions, the community leaders brainstormed a list of possible steps that the community could steer in the coming months to promote access to safe maternal health services for women in their community. They are categorised based on the key objective they attempt to address.

I. To overcome issues concerned with accessibility to health services: • Train traditional midwife who has experience • Bike Ambulance • Training and workshops • EDD, somebody has to stay with pregnant – or encourage woman to move to place where access is better closer to time of delivery • A local woman in podu should be trained on managing medical emergencies in poorly accessible podus • Provision of bike ambulance to the poorly accessible podus, these bikes should have emergency medications and first aid kits • Wireless walkie-talkie devices should be given wherever mobile signal does not reach • Need all weather roads • 108 which can move in difficult roads, made more accessible • more number of ASHAs in tribal villages • identify specific areas – at risk villages and monitor closely – bring traditional birth attendant to such areas to promote safe delivery • hire private vehicles when necessary – govt to reimburse

II. To create/promote more awareness about maternal health and services provided by the government • To reach tribal people information should be street play, campaign and Self Help Groups (SHG) are also the best way to reach the tribal community • Using woman self-help groups, anganwadi workers and school teachers in IEC activities • Sensitizing about health issues through street plays • Health authorities at least to give one visit to all podus to understand the problem • Sharing information related to health schemes through pamphlets, electronic medias • Creation of action group in each group to solve the health-related problems • Designating a health representative in each podu - one woman nominated in each village who could coordinate over the phone for women and child related health issues, oriented and trained • Conducting weekly radio programmes – community radio • Ensure ASHA, ANMs and anganwadi workers were visiting regularly • Encourage growing of nutritional foods, discourage addictions – smoking or chewing tobacco, alcohol • Mobile pre-recorded voice messages

III. To encourage utilisation of available maternal health services among women in the community • Recruit from local community (Tribal representative) at various levels from HSC to DH. • Train MSW guys on all health programs so that he will work with tribal people to make them aware and utilize government health services. • Tribal Health task force committee: This will find solutions to the local health problems. Zilla and taluk level Tribal sub plan to be made accountable through this body that includes NGO district officers, tribal leaders, welfare officers, etc.

• Tribal counsellor at taluka and district hospital • ASHAs should take help of Anganawadi workers in outreach activities • All woman should get a immunization information and all PHCs must provide immunization services • During the time emergency patients can hire local vehicle and the transportation expenses should be reimbursed by PHCs • Designate a tribal person in each taluka and district hospital, such provision will work as help desk in health centers • Health authorities should give priorities for tribal PHCs in recruiting human resources • Field level health workers should give education on using locally available medicines and nutritious foods

IV. To provide a safe experience at health centres for pregnant women, women in labour and after • Tribal women experienced inferiority, negligence by health staffs in health facilities. Tribal women are hesitant and have fear to go to health facilities. So health staffs at the hospital should treat tribal women with care, respect and heartiness. • Perceived as not clean or pure by staff – sensitisation needed and monitoring by higher authorities • Women also shy and hesitate to communicate – more awareness, more space for interaction with health authorities • Recruiting ANM from tribal community would be one of the solutions to provide good experience to tribal women at health facilities. • Local people and NGOs should involve in sensitizing health authorities on behavior communication change activity • To have a grievance redressed committee • Informal fees issue should be taken up sternly. Mechanisms for reporting and action to be brought into place. Informing higher authorities on instance of bribing and action should be taken against bribing • Action should be taken against health workers who dominate tribal patients with loud voices and screaming at tribal patient for their poor health seeking behavior or hygiene. Mechanisms for reporting such issues to be brought into place. • Sensitisation by NGOs and community – for fair treatment, trust and compassion.