A.1 Case Studies

Samastipur District – Bihar

February – March, 2019


SMA01 – SMA13 : ASHAs

SMF01 – SMF03: ASHA Facilitators

SMM01 – SMM03: Mamtas

SMT01 – SMT03: ASHA Trainers

A.1.1 Family Planning Day with SMA01

Place: PHC, Warisnagar Block, Samastipur District

Date: 15/02/19

The team meets SMA01 outside laboratory where blood tests are being done. The place is crowded since a number of ASHAs are waiting with women they brought for tubal ligations to the PHC. Tuesdays & Fridays are “Family Planning Days” at the PHC in Warisnagar. SMA01 has brought two Muslim women for surgery. The research team speaks with one of them – a 23 year old, married, with three children. The youngest child is six days old; the woman is getting the surgery done on the seventh day after delivery. She has come to her mother’s place for the surgery as there is no one to take care of her at her marital home. The second woman, who is the first woman’s sister-in-law (brother’s wife), has four children and says that she is getting the surgery done as there is no gap between her children. The women were accompanied to the PHC by their mother/mother-in-law and husbands.

Talking to the researchers while waiting outside the lab, SMA01 says that they use the ‘Mobile Kunji’ when working with pregnant mothers. It has information about the benefits of breastfeeding and diseases like diarrhea (that they make the mothers listen to). She also says that now with Mobile Kunji they have to talk less. She talks about her gram panchayat, Rahua and says that it has 22 wards. Each ward has one anganwadi and one ASHA and for a higher population there could be two or more than two ASHAs assigned to one angawadi. There is one ASHA for a population of 1000. She is asked about Mobile Kunji and the training received by ASHAs on how to use it. She says that the training was given in 2012-13 and that the app has helped a lot in explaining the different issues to the women.

SMA02 is also there who has been at the PHC since yesterday. She had come with a delivery patient and today she is accompanying two other women who have come for their sterilization surgeries. She says that she was up all night as there are no facilities for ASHAs to sleep when they have to spend the night at the PHC. She also mentions that the toilet is kept locked so there is no place to relieve themselves either. She expresses concern over being able to make it back home today as her daughter is writing her finals for 12th standard. The exam venue is in Samastipur and she is worried about her daughter leaving in her absence.

SMA01, SMA02 and other ASHAs are present, chatting with one another while waiting around for their turn at the lab. Family members accompanying women who were to undergo surgery are reserving spots in the post-op room for them. If they left the room, someone else’s family would take away the space. They also carried their own bedding to the PHC.

The research team resumes conversationabout their deliveries with the 2 women (and their mother-in-law/mother) who have come for their tubal ligations withSMA01. One of the women says that she has had all her deliveries done at the PHC. She adds that her ASHA visits her when her children are scheduled for vaccination. The women and their mother/mothers-in-law are asked what makes them choose sterilization surgery over other family planning methods. The elderly woman refuses to answer and walks away with her daughter & daughter-in-law. SMA01 joins the conversation and says that oral contraceptives like MALA-D and MALA-N can have harmful effects on uterus even resulting in hysterectomy. She also mentions that when women have to have their uterus removed before the age of 40, they feel ‘handicapped.’ There is also an understanding (among the women) that an affected uterus may lead to fetal abnormalities. Female sterilization surgery, on the other hand, is a stable method with an incentive of INR 2000 for the patient and INR 300 for the ASHA. When women undergo this surgery within 6 days of delivery, they are paid an incentive of INR 3000 while the ASHA receives INR 400. She says that women are smarter these days and they do not need a lot of convincing now, as she has seen in her 12 years of working in the community. She has to do fewer home visits because women’s awareness levels have been raised in the 12 years that the ASHA programme has been running. She talks about the things she needs to teach pregnant women before their delivery – identifying a ‘trained’ dai (those trained at the Patna Medical College and Hospital (PMCH) or other government hospitals such Mamtas who work in the delivery rooms of PHCs), storing contact number of the ambulance and keeping some cash in the house.

2-3 ASHAs also join the group who are asked about the number of deliveries they have to do in a year. SMA02 says she has to do 30 deliveries in a year. SMA01 says she does about 45 deliveries in a year because her catchment includes a Muslim hamlet as well. Another ASHA says she only gets around 17 deliveries a year as her catchment area has general and OBC families. On being asked about the rituals around giving massages to the mother and the newborn, ASHAs say that earlier a small fire was lit before giving massages and heat compresses to the newborn. The fire would be lit outside before taking it inside (where the massage took place). They say the ritual is still practiced in some families. SMA01 says that in her pregnancy days, women were not given anything to eat other than milk and sweets for the first six days after the delivery. She adds that newborns were given water or cow’s milk until a priest was consulted on when to begin breastfeeding. She says that now they ask families not to burn sage and herbs in the room where the newborn is kept. She tells them not to bathe the child for the first 48 hours especially if the child is underweight and to give him sponge-baths with water and antiseptic solutions if not bathing is not an option in keeping with tradition. She says that they were taught these things during their ASHA training. She says that on family planning days, she usually have to wait for a long time along with her patients as TB/Kala Azar patients are given preference.

Its SMA01’s patients’ turn to have their blood samples taken at the lab and the patients are in another building at the PHC (they were waiting in the post-op rroom). SMA01 asks an ASHA to call her patients from the other building. The ASHA who is busy with her own work, leaves her work in the middle and brings SMA01’s patients from the other room. A third ASHA is phoning her patient and asking her to come to PHC. Once the lab worker is done with the TB/Kala Azar patients, he starts examining the women who have come for sterilization surgeries. SMA01’s patients have their blood tested while SMA01 is stands next to them and oversees the proceedings. She guides the women at times, by adjusting the position of their hand or pushing back their sleeves (during the blood test), so that they are able to comply with the lab technician’s instructions. While this is going on in the lab, the patients’ family is asked to reserve space in the make-shift post-op recovery room so that the women can be taken there after surgery. Since there is a high volume of patients on these days, there is quite a rush to secure proper recovery places for patients. As a result, each patient usually comes with at least 2 or 3 family members, in addition to the ASHA.

The MOIC comes and asks the lab worker to be at the PHC by 8 AM on family planning days (Tuesdays and Fridays) as women cannot be sent for surgery without having their blood and blood pressure tested. He asks them to give preference to women who have come for sterilization over TB/Kala Azar patients on these days. On seeing the researchers, he walks up to them to explain why he lost his cool at the meeting a couple of days ago on ASHA Diwas. They work under extreme pressure conditions, not enough human resources or hospital infrastructure to cater to large in-patient needs on days like this. Plus, doctors and nurses themselves haven’t been receiving their salaries for the past many months. Tempers tend to flare under such conditions, he says. He adds that the ANMs were on strike all across the state as they had not received their salaries either. He also mentions that there is only one lab worker who examines TB/Kala Azar patients all by himself without any assistance. He says that his workload gets worse on family planning days when the crowd is bigger. All things given, when the pressure gets too much, sometimes he vents his frustration on the ASHAs. He says that there cannot be any comparison of healthcare infrastructure with other states in the country, as according to him, Bihar is far behind. He goes on to explain that there are only six beds in the actual post-op room, which have been supplemented with three more beds. They have also allotted a hall (used for meetings otherwise) to be used as make-shift post-op for the surgery patients. The patients bring their own bedding that is put on the marble floor for the patients to rest overnight.

The patients get done with their tests one by one and are asked queue up in front of the operation theatre (OT). The ASHAs are also standing with their patients in the queue. An ANM comes to give tetanus shots to the surgery patients. SMA01 tells the researchers that women from Muslim community feed their babies before the operation and do not allow their child be breast feeding by a wet nurse (usually someone from the extended family). This is in contrast with women from Hindu families whose children are fed by other lactating women from the patient’s family. The research team enters the OT with the SMA01’s patients who have received their tetanus shots. Once the doctors arrives, two women at a time are made to lie on their backs on the OT table. The ASHA is also inside the OT but the doctor scolds her for wearing her shawl inside despite being repeatedly told by him that they should not due to risk of infection. OT helpers are preparing for the surgeries by cutting strips of leucoplast and sticking them on the window panes. Women are put under general anesthesia (GA) and surgery is begins. [Researchers leave the OT before the surgery begins]. SMA01 stays inside the OT the entire time with her patients while the surgery is underway. After the procedure is completed and once they are somewhat regaining consciousness they are put on the stretcher and taken to the post-op room in the adjoining building. The same OT helpers are carrying the women on (hand held) stretchers from one building to the next.

SMA01’s husband had come early in the morning to the PHC to get the receipt/registered, which would determine SMA01’s patients’ position in the queue - the earlier one registers, the higher the position in the queue. Otherwise SMA01 would have to make two trips to the PHC, once to get the receipt and then to accompany the patients. Her husband returns to the PHC around the time when the surgeries are happening. SMA01 breaks her shoe in the process of trying to help out in post-surgery movement of patients. Her husband offers to take her shoe from her, outside the OT, and goes to get it mended at cobbler’s shop outside the hospital.

Outside the OT, researchers observed family members and ASHAs consoling other women who were awaiting their turn to go in for the procedure. They were telling them that they should not cry, the operation does not hurt and that it will be done before they realize. SMA01 accompanies the two women and family (mother-in-law/mother, husbands and newborns) to the make-shift post-op room. She waits till women regain full consciousness. The way she checks this is by asking patients to name and identify her once they wake up fully. Only once they are able to satisfactorily identify her, she leaves the PHC. On this day, SMA01 stayed at the PHC from 11am until 4pm or 5pm, depending on when the women’s surgeries get done and when they regain consciousness.

SMA01 adds that earlier patients were given ether for these surgeries and that when she had hers done she had to vomit on her way back from the hospital. A woman approaches SMA01 who has come to the PHC looking for her. She has a small child who needs to be vaccinated (and she seeks ASHA’s help). SMA01 says that sometimes women are seen to conceive despite having the surgery done. She says it happens because some women are "gifted by god" with three tubes (instead of two) but the doctors only know about the two, which they stitch together in these surgeries. The spare tube is what leads to subsequent pregnancies. She also explains the surgical procedure, where after making the incision, the doctor empties the section and keeps the organs outside. He looks for the tube with two fingers and puts a clamp on them. He then places the organs back and stitches the tubes together. He removes the clamp and the tubes slide back inside on its own [as described to us by SMA01].

A.1.2 Family Planning Day with SMA02

Place: PHC, Warisnagar Block, Samastipur District

Date: 02/04/19

It is family planning day at the PHC. Women have come with their families – mothers, mothers-in-law, sisters, and newborns. They are accompanied by their ASHAs. The entrance to one of the hospital buildings is crowded, where patients are being brought after the surgery, to recuperate. The researchers are told that even though this area is out in the open and a bit exposed, it is still preferred since there is a natural breeze and better ventilated than the other room (meeting hall) that is allotted as the post-op. Unconscious or semi-conscious patients are surrounded by family members. A meeting between PHC senior staff, ANMs and ASHA facilitators is also taking place in the conference room. Once the meeting gets over the conference room is also turned into a post-op to bring in patients after surgery. There are no beds in these areas. Patients are lying down on rugs and beddings which they carried from home. The newborns are being taken care of by their grandmothers or aunts while their mothers sleep – after effects of the general anesthesia. SMA02 is present with a patient who has come for her surgery. The patient is unconscious and lying down while ASHA is sitting next to her. Patient’s mother-in- law is also present. The patient’s sister is holding the newborn. The research team speaks with SMA02. She talks about her family and says that she has three daughters and two sons– two daughters are married. The second daughter got married on 8th March this year. She comes from Lakhanpatti village in Lakhanpatti Panchayat which has a total of 11 ASHAs. Her village alone has four ASHAs. SMA02 then talks about her pregnancies and says that of her five children, two were born in the hospital and three were born at home. She says the home births happened at her mother’s house. She used to go their neighbors, a couple, who were both local medical practitioners. The doctor was present during her delivery as well as a dai. She says her oldest daughter has two children, one of whom was born at the Warisnagar PHC (had needed an episiotomy) and for the other she had to have a C-section in a hospital in Mumbai, which is her where her marital home is located. SMA02 says she had accompanied her daughter to the PHC at the time of her delivery. She says these days most people come to PHC though home births also happen sometimes. She says her husband works in Delhi as a JCB operator. She says she has studied till 10th standard.

While talking to SMA02, the researchers meet another ASHA at the centre whom the team had met on ASHA Diwas on 14 February at the PHC. She is here with her daughter-in-law, who had come for her tubal ligation surgery. The ASHA is on her way out to get some water – she says there is no drinking water facility at the PHC for the last four years. There is a hand pump inside the PHC premises but it has run dry. She proceeds to bring water from outside the PHC.

The team then resumes conversation with SMA02, asking her about a woman sitting next to her, who is holding a newborn in her arms. She says the child belongs to her patient (who is unconscious at the time) and the woman holding the child is the patient’s sister. The child is three months old. [When the researchers first spotted this woman holding the child and sitting under a tree near this area, she was feeding the baby milk (in all likelihood, cow’s milk) from a bottle. The woman, on being questioned by the researchers, shied away and did not answer.] SMA02 says that the child was born during the time ASHAs were on strike in December 2018. The patient’s sister is there to take care of the child. She then says that, on an average, she gets one or two family planning cases to the PHC every month.

The other ASHA comes back with water and joins the conversation. She is asked if she has brought other women from her area as well. She says she has brought her daughter-in-law, who also falls in the population of 1000 to whom she is meant to cater. She says she treats her daughter-in-law as she treats all her patients, since the people in her catchment are also like family. She says there was another woman in her area who wanted to come but did not have enough money. She adds though the surgery does not cost any money, they are required to buy medicines from outside. The team goes with her to see her daughter-in-law, who is unconscious and resting on a bed in the ward inside the hospital. She is surrounded by her family. ASHA introduces another woman sitting in the room as her second daughter-in-law (married to her older son), who is also pregnant. This is her second pregnancy. ASHA then talks about herself and says that she has three sons and two daughters – two of her sons and both her daughters are married. She further talks about the scarcity of water. She says that people can die of thirst at this hospital as there is no facility for drinking water. The hand pump is dysfunctional and they have to buy water from nearby hotels. She says water scarcity is an issue even in her area and the motor at her home supplies water to 25-30 families in her neighborhood. She says it’s not possible to refuse someone who needs water as we cannot let them die of thirst when they have access to drinking water. She talks about her family again and says that she has one grandson and one granddaughter, both of who were born at the PHC. She mentions again how her own family is also a part of her catchment area.

While patients brought by SMA02 and other ASHAs were recovering on the floor in the shaded area at the entrance of the hospital building and in the other make-shift post-op room (meeting hall), this ASHA had been able to secure a bed for her daughter-in-law inside the hospital building in the actual post-op room, indicating a higher negotiating power with hospital authorities and a desire to do so (on part of the ASHA) for a family member as opposed to regular beneficiaries she accompanies to the PHC.

A.1.3 Interview with SMT01

Place: ASHA Training Centre, Sub-divisional Hospital (SDH), Patori Block, Samastipur District

Date: 24/2/19

SMT01 talks about ASHAs and their work in the community. She says they stay in the community with their husband and children. They work for 3-4 hours and then go home. She says that the ASHAs consider themselves to be health workers and that is good because they get paid for their work too. She says the money that the ASHAs receive is just enough and meant for encouragement but they are getting paid at the least. She adds that it serves her well as a trainer when ASHAs get to go out of their houses and work in the community for four hours and the ASHAs know that well. She says that earlier ASHAs were not known in the village but now every house knows what ASHAs are know them by their names. When asked if they know ASHA, they would recognize her as someone’s daughter-in-law in the village. She says that villagers do not know about the encouragement incentives received by ASHAs. They get money on ASHA Days that takes place at the hospital. She says that earlier people used to hesitate to go to hospitals but now all women go there and that this has been possible because of ASHAs. She adds that the biggest reason behind their motivation is that they get to go out in the village, get the brand of being a government worker, and receive incentives albeit little and that they get to do good work. She narrates an incident from a few days back where there was a dispute between the MOIC of Patori PHC and a Mamta over the payment of her allowances/salary for the last 30 months. The fight got physical when Mamta pulled him by his collar and the MOIC slapped her. There were other Mamtas in the room who supported their colleague and beat up the MOIC. The Mamtas went to the women’s police station to file a complaint. The trainer says that ASHAs are feistier than Mamtas. We used to think of ASHAs as someone low (in hierarchy) but they have a lot of reach and they are aware of that. They have a good relationship with the village head. They might be lower (in social hierarchy) in the village but they are influential. She adds that it’s difficult to get your work done unless an ASHA is there with you in the hospital. If you are someone unknown at the hospital you will have to wait in queues, but with ASHAs you don’t. She further gives an example illustrating his point. She says that she fell sick in Saharsa district while she was there for some work. She was given accommodation in the girls’ hostel at JNM School situated next to the district hospital. She was there for ASHA training scheduled to take place at the same venue. As it was a girls’ hospital, no men were allowed in. She says she had been training ASHAs for a long time but until that day she never realized their reach. She always relied on private hospitals for treatment and was apprehensive about going to a government-run hospital. She was not satisfied with the services provided at government hospitals. In spite of her reservations, she went to the neighboring district hospital with one of the ASHAs from the training. They left after she instructed the other trainees to sign on the registration/attendance sheet. After reaching hospital, the ASHA helped her get the registration slip and examined by the doctor without any hassle. She was prescribed a blood test and medicine. The medicine was not available at the hospital and she was not carrying any money. The ASHA ran out and got her medicine with her own money which she paid her back later. She says that the ASHA was able to get the work done in ten minutes. On being asked whether the ASHAs get any recognition at the PHC, she agrees. She says that the reason is when an ASHA takes a woman for delivery the ANMs try to get it done during their time so they can demand money that could amount to INR 200-500. She adds that a while the ASHA stays with the woman for nine months, she might also have a few demands (that aren’t met). No one wants to be ASHA. They work because they come from poor families and need the money. ASHAs tell her they are poor but people don’t see that and perceive them as government employees who get paid (there is a lot of social value associated with government jobs in rural areas). She further talks about trainings that have been given to ASHAs. The first five modules were given in 2006 followed by modules 5, 6 and 7 which are being given now. She says modules 8, 9 and 10 will be given later followed by subsequent modules. She says ASHAs are the link between community and hospital. Without them it is difficult to get work done. Nowadays every hospital has an ASHA room for them to stay when they come with their patients. Even Patori Sub-divisional Hospital has one. When asked if only sub-divisional hospitals have that facility, she says she has received information from ASHA resource centre that all hospitals should have one as the focus is now increasingly on ASHAs. She says without ASHAs’ participation, programs like Rubella campaign would not be successful as a lot of beneficiaries in the village would be left out. ASHAs are also compensated for this work but no one would want to work if they were not. When asked if ASHAs also charge money for their work she says she has information that ASHAs also charge INR 200 but that’s fair as they help women throughout their pregnancies and accompany them all night during delivery. However, ANMs charge anything from INR 500-800 despite being salaried employees. ASHAs have told her that even Mamtas demand money from the new mothers. She says she had asked ASHAs if they charge INR 200 to which they had said they only charge if they have to get the birth certificate but most of that amount is spent paying off the PHC staff. She refers to a conversation she once had with an ASHA during a training session in Saharsa. ASHA told her that they are supposed to get an incentive of INR 600 that gets deposited in her account but they only receive INR 200. She said when they inquire about it they ask them to check their accounts and that they have already sent it. The trainer says this conversation took place in front of the BCM and someone named Parmila. The BCM had asked the ASHA to give him a formal complaint in writing. The ASHA however said that ever since the BCM has joined their payments are regular. The trainer was then asked about a survey that was done in Munger district among ASHAs. She says the situation is same everywhere. She says the ASHAs stopped cooperating once the strike began December, 2018 because ASHAs also adopt unscrupulous practices and everyone knows that. Some ASHAs poach patients from other catchment areas. She refers to an ASHA who used to bring five pregnancy cases every month though she does not know whether it is a result of higher population in her area or that she is poaching patients from other areas. Another example is from Saharsa district where one ASHA owns a scooter and has a link with the women in the area. Some go to private hospitals because they receive a higher commission there as compared to district hospital. She says this information was given to her by a civil surgeon in Saharsa. She mentions that ASHAs are never asked to give injections nor do deliveries in their trainings, yet, as she was told by ASHAs themselves, some do it. She refers to another ASHA who runs her own clinic and do deliveries by herself. She says the husbands of most of these ASHAs are RMPs and if someone had a MBBS they would never make their wife work in this sector. She says that RMPs have a good network across the village (which helps their wives’ work as ASHAs). She finally talks about training sessions and says that ASHAs come to her if there is any problem with food. Someone named Anita from the district hospital has asked her to go to her if ever she faces any problem.

A.1.4 Home Based Newborn Care (HBNC) with SMA04

Place: Indwara Mathua Village, Morwa Block, Samastipur District

Date: 27/02/19

The research team reaches SMA04’s house to meet with her and sets up next day’s schedule to visit the field with her. SMA04 discusses a woman’s delivery, who she took to the PHC (also her neighbor). She had a complicated birth because a part of the placenta was retained in her uterus and she kept bleeding despite the various drugs she had been administered. Finally, the ANM inserted her hands into her uterus and brought out a tiny bit of the placenta which was retained. Only then did the woman stop bleeding.

The woman, at whose house the ASHA (and researchers) was scheduled to do an HBNC visit (Day 3) the next day, had delivered her 5th child. Her first child was a cesarean and ever since then she was apprehensive that all her deliveries would be the same. But SMA04 had insisted with the doctors at the PHC for all her 4 other deliveries that they first try for normal. She had told the doctors, who at first instance wanted to refer the woman to another facility because she had had a c-section in the past, that the doctors and she could share the ‘work’ that it would take to ensure a normal delivery - _‘kuch kaam hum karenge, kuch aap karna. Milke kar lenge_.’ This was how she made sure that doctors did not automatically recommend a C-section for her. The woman refused to eat at the hospital. Even when SMA04 brought her litti and samosa (local fried food made of dough) from outside, she did not eat it. There was chicken, dal (pulses) and sabzi (vegetables) that the hospital gave, which SMA04 says even the doctors were eating. The new mother refused it too and finally SMA04 gave up.

The team then goes with SMA04 to the house where the woman lived. In the room, the new mother and her baby are on the bed. The mother-in-law is sitting on the floor. There is a hanging basket on top of the bed with the sweet porridge (halva) made especially for the mother. She is however not eating anything. She would only eat properly on the 6th day after the chhatti ceremony. The room is dimly lit and her older child is hovering around her and the baby. ASHA asks the mother how she and her child were. She also asks the mother questions about her diet. Mother says she is on a diet of "milk and ginger halwa" but she is not eating the halwa that her mother-in-law prepared for her. ASHA tells her to have rice and pulses as well if she is to produce nutritious milk and be strong and healthy but the woman says she cannot have any grains before the sixth day of the child’s birth when the chhatti is celebrated. ASHA enquires with the mother-in-law, who says there is no obligation from her side to follow any such rules and that this compliance is her daughter-in-law’s own wish.

Mother-in-law comes outside and the group is also joined by some young women from the neighborhood, who tell us about the various dos and don’ts that a new mother has to observe in the first 6 days after birth. The mother-in-law explains the chhatti pooja - on the sixth day of a child’s birth, gosai (room/area inside the house where idols/images of gods are kept)is worshipped and sigari is done using kohl and vermillion powder. A lamp is lit and the child is put in front of the gosai, wrapped in a blanket. After a while the flame of the lamp is put out. The child is not supposed to see the flame; it is believed that if the child looks at the burning flame then their eyes might develop a squint. The mother-in-law says they had to do their son’s chhatti before he got married as his was not done due to the death of another child in the family, when he was born. No one present here is able to tell us, in clear terms, what would happen if these rites and rituals were not followed. The women discuss among themselves about IFA tablets, SMA04’s instructions to pregnant women and their families, nutrition, etc. One woman says she threw away all the IFA tablets that were given to her when she was pregnant because they made her nauseous. SMA04 talks about the delay in receiving JBSY allowances in her area (Patori) as opposed to Morwa, where the allowances come on time. One of the women (the one who threw her IFA pills) questions the advantages and benefits of having the baby at the PHC. She says it costs about INR 2000 and that she would prefer to have it at home as she had had all her deliveries at home. As the team departs, the mother-in-law prepares the coal/fire to take inside the room to put near the mother and baby. She lights it and allows the smoke to subside before taking it inside the room.

A.1.5 Home Based Newborn Care (HBNC) with SMA04

Place: Indwara Mathua Village, Morwa Block + Sub-divisional Hospital, Patori Block, Samastipur District

Date: 28/02/19

The research team reaches SMA04’s house early to see what kind of preparation she needs to do in order to set out from the house on a work day. Everyone in SMA04’s family is very involved in her work. One daughter says she goes to administer polio drops (orally) when her mother is unable to go/tied up with something else. The younger daughter knows where her registers are and which register is for what. The younger son sets out on his cycle to get some papers signed by SMF01 for his mother to take with her to SDH, Patori. In the meantime, SMA04 runs over to the neighbor’s house to inform her that we will be leaving shortly so that she can also get ready. The newborn (3 day old) has developed an eye infection of some sort and has to be taken to the doctor. SMA04 comes back and begins her own preparations to leave. First, she washes the utensils and cleans up after her family (they had just eaten their morning meal). She realizes no one has washed the dishes. Then she hurriedly goes into the room to change her sari while her younger daughter gets her registers/diary out and supplies her some information that she had wanted from it. She combs her hair and ties it neatly, wears a bindi on her forehead and applies sindoor (vermillion) along the parting in her hair. There is a discussion about how she does not wear the ASHA uniform everyday but on all ASHA Diwas, RI, and other formal events. On being asked if the daughters like the work their mother does and if they would like to work as ASHAs as well, the older one expresses her interest in becoming one, she adds that sometimes when her mother is busy she is takes up the task of giving polio drops to children in her mother’s absence; the second daughter who is in eleventh standard (high school) says she wants to work at a higher position. SMA04 adds that her daughters take care of the entire household and without their help her job as ASHA would be very difficult to which the daughters add that their mother doesn’t have to do any household chores as they take care of everything. SMA04 mentions that apart from her regular duties she gives shots to patients as well, and instead of charging INR 20, like the local doctors do, she charges INR 10 only. She refers to the neighbor woman again, whose child has developed an infection in his eye by probably poking with his own finger nail. She says when she told the mother that she is going to take the child and the mother to the hospital however the mother was initially reluctant. She says that the mother told her she had no money and thus cannot afford the trip to which the ASHA suggests they go to a government hospital first and move to a private hospital if there is no child specialist at the former. She says that in case they have to visit the private hospital they can pay her later. SMA04 says she has 5 children to which her daughter replies that they are seven brothers and sisters and playfully calls out her mother for lying.

She narrates an incident that led to her recruitment as an ASHA - she mentions a case of a sick child in her family who was born at SDH, Patori and was extremely weak and sickly after birth. The ASHA who was looking after their case was not doing a good job (she now works in a different area) and hardly made visits other than the day of delivery. She says she had gone to visit the family when the grandmother expressed her concern about her infant grandson. SMA04 then took the child to a private clinic (non-biomedical, possibly local ‘ayurvedic’ clinic). The child was given medicines by the doctor there and after taking one dose, they came back to the house. The child was only 20 days old at the time and the grandmother, to expedite the process, administered a much higher dose to the child than prescribed. The child’s health was deteriorating drastically soon after, the family went to SMA04 for help. By the time she got there, the child was hardly breathing. They took the child to BB Jha Hospital (private) in Samastipur, where the doctor looked at the child and referred him to a different hospital. SMA04 took the child in her arms and went to see the doctor again insisting they start his treatment. She told him that she will take the responsibility for whatever happens and nobody will blame the doctor. She kept insisting that the doctor agrees and starts the child’s treatment. SMA04 narrates how guilty she felt that the child was probably to going to survive because she had been advising the family. She said she kept praying that nothing should happen to the baby.

The infant was given two shots (100 ml each), the child started making gasping sounds after that, the doctor asked to have the child’s clothes changed. ASHA sat with the child all night and recorded the time of his bowel movements to keep a track of his progress; by morning the condition of the child was much better. At the time of discharge, the doctor congratulated SMA04 in front of the family and gave her the credit of saving the child’s life. She was even offered a job at the hospital to which she replied that she is not qualified enough for the job and her house is also very far from this hospital, she will end up spending her entire salary on commute; she however told them that she will speak to her family and consider the offer again. (She eventually took the job and worked at the private hospital as a nurse for a while till she was selected for the position of ASHA). The doctor then informed her about ASHA positions and recruitment and that she should apply for the same. After coming home, SMA04 went to the PHC and inquired with the ANM whether she would qualify as she had only studied till Class 8. ANM said that there are ASHAs who are even less qualified than her and are doing good work.

SMA04 is finally ready and sets out for the woman’s house to tell her that we were ready to leave. She wraps the baby properly first in a soft cotton cloth (muslin) and then in a thick blanket. The newborn is not allowed to wear any stitched clothing until the chhatti formalities are complete. She then shows how/where the mother should place her hand while feeding the baby, just before leaving, since the baby was crying.

Once in the car with the researchers, discussion starts about food, and the mother says that she cannot have everything she is supposed to eat in her diet yet. SMA04 in an understanding way tells her own story, where she was not allowed to eat properly after having her baby. She jokingly shares that she would steal food (crab curry and roti) from the kitchen when her mother-in-law wasn’t looking. Sometimes when the mother-in-law caught her she would get told on how eating grains during this time (before chhatti) will result in the death of her baby. She says but she would not care and would eat anyway as she was hungry all the time and she feels was right in doing so, as her daughter grew up fine. SMA04 continues talks about her family and daughters while in the car, en route to the hospital, and how she has worked very hard to get them proper jobs. Her oldest daughter is an AWW in a nearby village, where she stays in her marital home. She is worried about her second daughter finding a proper job, who is currently at her home. The vehicle waits at a railway crossing since a train was passing and SMA04 speaks about how so many deliveries happen while waiting here, before one can even reach the PHC because sometimes it takes very long for the train to pass.

[On reaching SDH, Patori, one of the researchers goes upstairs to the ASHA Training Centre to speak to a group of 4-5 ASHAs from Patori Block to tell them about the research and that the team would like to shadow them on their work days. They are asked the kind of challenges they face on field to which they reply that it’s not the field they find difficult but the PHC and the staff’s behavior towards them. They mention the degree of negligence that the nurses and ANMs have towards pregnant women in labor. They would examine her once and ask them to wait until dilation and goes back into their room and would not respond even when the patient is in a lot of pain. Eventually she would come and say, "it is going to hurt if you are going to have a baby", or, "did you not know this when you were having fun nine months back?" Until the woman dilates, it’s the Mamta and ASHA who looks after the mother after which the ANM finally arrives with her gloves on and leaves right after delivering the child. After that, it’s the Mamta and ASHA again who takes care of the rest. Finally the ANM arrives again and irrespective of how poor the woman is, demands INR 500 to be paid to her. SMA06 talks about the one time when she was called by a woman in labor. She was preparing food for her children at the time. She asked them to wait but they left without her anyway. Upon reaching the PHC, they were told that their work cannot happen without an ASHA present. So, the husband called the ASHA again who was on her way to the PHC on her own. She later confronted the husband saying they could have waited for her instead of leaving without her as that would have saved her INR 10 she spent on commute.]

SMA04 and lead researcher accompany the woman with her baby to the registration counter on the ground floor. The hospital was no longer registering patients for OPD which closes at noon and the team had reached at 12:30. SMA04 gets the woman registered under ‘emergency’ services, and goes looking for the doctor (with the woman and her child in her arms) high and low and finally meets him in the same room from where she got registered. An interaction ensues between the woman and doctor in the room. Other patients, their families and ASHAs as also hospital staff were present in the room and crowding the entrance. The doctor was refusing to meet other patients and asking them to come back after 3:30pm, which was when the OPD would begin again. He had made an exception (as mandated by the Government) for SMA04’s case since it involved newborn (3 day old) baby.

The doctor begins by insulting and shouting at the mother about the number of children she had and asks her not to stop producing children till she has a "football team". Everyone within hearing vicinity, including SMA04 laughs. He then proceeds to search her body, putting his hands under her shawl and rummaging through her clothing around her waist, without any kind of warning, in a bid to look for the iron kohl holder, which she is meant to keep close to the baby and herself all the time, as protection from spirits. While examining the baby on his table he also scolds her about not clothing the baby and suggests that since she has so many children, she must also have their old clothes, and that she should use those for this newborn. He examines the eyes of the baby and writes a prescription for an eye drop for the child and insists on sending the woman for tubal ligation that very minute. Calls the ANM and asks her to register her for a tubal ligation. The researcher manages to sneak out her out of the room, when SMA04 was sent by the doctor to an adjacent room to bring his register. Doctor also intermittently shouts at SMA04, which she laughs off and takes in her stride.

The new mother, after the ordeal and on leaving the doctor’s chamber, tells the researcher that she would have much rather gone to the private clinic near her village, even though she would have to pay for the check up, at least he would not shout at her and humiliate her this way. He would only prescribe the medicine and be done with it. SMA04 goes to buy the medicine prescribed by the doctor from the pharmacy outside the hospital (either on credit or with her own money). The lead researcher goes to drop the mother and the baby back to the village. In the car, the new mother is holding her baby in her arms and in her other hand she holds the iron kohl holder, a mobile charger, and the antibiotic eye drop.

SMA04 and other researcher stay back at the SDH to fill out and submit documents so that the SMA04 and her beneficiaries can receive their incentives for institutional deliveries. SMA04 helps another ASHA fill out her tubal ligation surgery form and tells her that she should know how to fill these forms after having done them for so long. SMA04 then proceeds to the ASHA Room that they have made at the SDH. It is one of the few hospitals in the district with such facilities. SMA04 sits there and fills out her paperwork.

As it is the last day of the month, facilitators of the Block are sitting in a large room with delivery registers that are maintained at the hospital and matching it with the papers that ASHAs had filled out for the month. These would then be submitted to the accountant at the hospital for the payment of incentives. SMA04 goes to the accountant’s room to submit her micro-plan document. She is asked to fill out another form because of some mistake. She does not have any more forms so she goes out to get copies, comes back and fills out her form in the ASHA room. She later tells the team that she is very late for home as the accountant made her fill out the form three times; the last time he asks her to fill in information since November when she had information since August.

A.1.6 Home Based Newborn Care (HBNC) with SMA05

Place: Balahi Village, Warisnagar Block, Samastipur District

Date: 01/03/19

The research team meets SMA05 in front of her house. They go to the AWC to speak with AWW. AWW talks about how the two of them (AWW and ASHA) work together and coordinate with each other in matters pertaining to maternal and child health. The AWW says that she works along with ASHA to explain the importance of having a healthy diet to pregnant and new mothers. She says that they talk to each other (and take each other’s advice) if a child at the centre falls sick. She refers to a case where a pregnant woman was complaining of stomach pains. She says that they advised the woman not to take medicines from outside and that she must go to the PHC if she has any problem. The woman then asked her to go along with her. When asked why it is important for pregnant mothers to register at the AWC, she says they need to be registered in order to obtain the benefits she is entitled to. The SMA05 then says that last month most deliveries have happened at home. In some cases the pregnant woman had delivered by the time arrangements were being made to take her to the hospital. In other cases, the delivery happened before the ambulance could arrive. She says that people do not need a lot of convincing these days as they understand it is better to have deliveries at the PHC and not at home. The AWW says she has two children – one was born at the PHC and one at home. SMA05 says that she was helped by her ASHA during her second pregnancy and had received INR 1400 in cash. She says she did not receive any money on her first delivery, which also happened at a PHC. There was no ASHA accompanying her, no power at the PHC and no ambulance available at the time. She says that she was given sweets (halwa) and milk to eat for the next six days. She adds that she was also given a natural concoction made with the barks of mango and mahua trees, and roots of chirchiri, motha and singhar trees mixed in hot water. This concoction is said to have properties that increase hemoglobin in the mother’s blood. The research team asks the kind of advice they give to women on having healthy diets. The ASHA says that they tell women to eat green leafy vegetables. Some women however tell them they do not have any appetite left after eating sweets and drinking concoctions. She says that they also make the mothers listen to Mobile Kunji on their visit. She adds that some women are foolish to refuse check-ups as they do not see any benefit in them. They finally agree to go for check-ups once the ASHA convinces them and their mothers-in-law.

The next visit is to a woman’s house who had given birth at home a few days earlier. She delivered by the time she could get to the hospital. SMA05 wants to collect a photocopy of her Aadhaar card so that she could get the birth certificate done. The woman says that her bank account is working but she does not have her Aadhaar card with her at the moment and that she can provide that tomorrow. SMA05 says that she has to put an application at the Women and Child Development Office after which the certificate is supposed to be available online. She says it can only happen when a birth is first registered at the AWC. She stands at the door and also gives some advice regarding what the mother should eat. The woman is asked what she has been eating since the delivery; she says that she is on a diet of halwa. She says that she feels weak but that’s what she is supposed to eat. Keeping within the traditional framework, SMA05 tells her to drink a lot of milk and have a lot of sweet porridge (halwa). She also tells her not to stay hungry and how she needs nutrition to continue producing milk but she also doesn’t mention anything about eating regular food/diet.

On the way to the next house, ASHA talks about a woman who lives nearby, who had three children. She says of the three the woman has lost two children. All three children were born with the help of C-section and she is left only with a daughter. ASHA says that the woman cannot conceive anymore. She mentions one of the deliveries and says that they lost the child because there was a delay in surgery and by that time they did the surgery the child was a stillborn. SMA05 says that the ‘fluid’ [sic] in the womb turns poisonous when the child is left inside for too long.

Next, the researchers and SMA05 go to a family where the father of the newborn is well-educated and the family is also the most well-to-do in the village. It is the third HBNC visit for SMA05 at this house. Woman, a graduate herself, gave birth at home in the presence of her mother-in-law, sister-in-law and dai. This is her second baby, first was born in a private hospital in Muzaffarpur, where they knew someone. She is having difficulty feeding her baby (also happened for her first child) and so the family is feeding the baby cow’s milk and baby formula. The dai, who was present during birth, is coming to the home every day, twice a day, to massage the baby and mother, for the 6 days after birth. SMA05 says the family is eligible to get their allowance under Kanya Uthan Yojana, as this is their second daughter. She asks the woman’s husband, who is in the front room if they have filled out all the documents and he says he is doing that. The newborn’s grandmother and aunt (father’s sister) are also seated there. They were asked if they light a small fire, as per tradition. The grandmother answers only in mornings and evenings, when the dai comes to massage the child. The dai uses the fire to give heat compress to the child and then puts it out after it is done. She says that it is part of their tradition but nobody keeps a fire lit for 24 hours anymore. SMA05 sits in the room, on the bed next to the mother and makes her listen to the mobile recording (Mobile Kunji) for what to do when the new mother is not producing enough breast milk. The Mobile Kunji is playing a recording of the benefits of giving mother’s milk to the child for the first six months of birth. The mother-in-law, at that very moment, sits at the entrance of the room on the floor, bottle feeding the baby cow’s milk. The dai sits on the floor, inside the room, near SMA05, waiting to massage the mother and child, once we leave. The sister-in-law is also living in her maternal home (she had come from Samastipur which is where her marital home is) for the moment since on the 6th day ritual she also has to perform a ritual role - she is supposed to be the one to apply the kohl on the eyes of the child. She receives gifts for her service from the family. In this family too, there were strict food restrictions. On asked about the diet the mother is on, the aunt of the child says that she is given turmeric halwa (called jirwani) made with turmeric, ginger, mangrela and cashew. Although the mother is allowed to eat grains (rice), it could only be had as a sweet, porridge like preparation.

The father is asked about the delivery and he refers to the first delivery and says that they had it there because they knew someone at the hospital otherwise it is very risky to go to a PHC or a private hospital. Patients are not given good care and the doctors do not even wait for a normal delivery and go for C-section. When asked if the presence of ASHA makes any difference he says that it is hard to coordinate as they cannot find a common time suitable for both. He also says that there is no payment (of INR 1400) if a delivery takes place at home. The ASHA had told the research team that the baby was delivered at home because they could not leave for the PHC on time though after speaking to the father, it appeared that having the baby at home was a conscious decision. The father also talks about how the first time round the mother had faced the same problem with milk production, however, the baby was fed cow’s milk and is doing fine. SMA05 then tells the mother-in-law how difficult it is for her to convince people in Ram tola (hamlet) to maintain hygiene. The mother-in-law says that they had had their clothes washed by a washer man before the child was born.

The dai is asked if she goes to other houses; she says for now she is coming to this house only. The sister-in-law (child’s aunt) says that according to tradition the dai is supposed to come for the first six days and after that it depends on need. [SMA05 is asked about godh bharai programs by researchers. She says that pregnant women are gathered and told about the benefits of a healthy diet. They are made to sit down, covered with a chunri (veil) and given fruits in the lap.] The dai is then asked if she faces any difficulty in her job. She says that they all have different arenas of work. The doctor (RMP – home delivery) does his job and once he is done, he gets paid. He leaves. Once he leaves, she moves her work begins. So they all co-exist in the birthing space.

On their way out, the team notices that the mother-in-law has spread a rug on the floor, on which the dai is massaging the new mother.

The team along with SMA05 goes to the next house where the pregnant woman was complaining of stomach pains yesterday. A few other women join and are asked a few questions about post-natal care. They say that a new mother does not eat salt. There is also a loss of appetite in the _sori__ghar_ or the cordoned off room/space in which a new mother stays for the first 6 days until chhatti puja is done. They say that times have changed and now most people go to PHC for delivery. Speaking of a few rituals that are followed after childbirth, they say that the new mother cannot touch chapa kal or hand pump for the first 42 days (sava mahina), cannot enter kitchen for the first 12 days and does not do any heavy lifting for the first 42 days (sava mahina). They mention that the new mother is given a liquid concoction for building strength and that if there is no one else in the house to help out they have to do also do household work despite these restrictions.

Moving on to the next house of a pregnant woman, and not finding her at home SMA05 tells the husband to inform her that she had visited.

At the next house, which is in the SC hamlet (Ram tola), SMA05 speaks to the pregnant woman who lives there about IFA tablets. She asks if she has received them or not. The woman says she has not received the tablets yet and that she is in the fifth month of pregnancy. She says that she was given a few tablets but they were past their date of expiry. SMA05 informs the women that this is not her job. ASHAs are only meant to inform them about IFA tablets and ensure that they are taking them as recommended. It is the ANM’s job to make sure that women are given proper IFA tablets. She expresses concern over this woman is in her fifth month of pregnancy and hasn’t started taking her IFA tablets yet. She says that only the fourth check-up/ANC is done at the PHC. The first three are done at the AWC.

Speaking to the few women who had gathered, SMA05 informs them that pregnant women from the tola should come for the godh bharai event at the AWC which was coming up. An elderly lady from the village comes up to SMA05 and asks her to help with getting a birth certificate done for her grandchild who was born at home nearly 2 years ago. She had been trying for the past year but hasn’t managed. The ASHA in the village where her daughter resides is unhelpful and had refused but because SMA05 has helped her out before, she thinks that she will be able to help her again. SMA05 is unsure what she can do in the matter but tells her she will try. Earlier, she had received a cheque for her daughter/daughter-in-law’s delivery at the hospital and had kept it safely for many months. But by the time she wanted to cash it, the cheque had expired. So SMA05 had to go through a lot of trouble to ensure that the family received the money which was then directly transferred into their account. Since this incident, this lady had a lot of faith in SMA05’s abilities to negotiate bureaucratic/official networks.

From there the group returns to SMA05’s home where she shows her registers and what she has to fill and at what intervals. The records are about pregnant women and infants in her area; the record on infants she knows how many children were born. Their names are mentioned, which families have new borns, which dates they were born and their vaccination schedules. Every year they have to do three surveys - in October, January and June/July, however they have only done it twice this year. There is another record for pregnant women. The last survey was done in January (the one before that in November); the guardians’ name of the head of the family is written down and all details are recorded, how many people are there in the family, how many married couples, how many pregnant women in the family, number of children in the age 0-1 years, from 1 month to 1 year old children, children from 1-2 years of age, children below 5 years of age. The survey is done in one ward for a population of 1000. Once they had done in April also but this year they do not have to. They have to make their rounds to each family every single time to record if there are any new women who moved in to the village recently. If there are no couples in a family, they don’t have to go otherwise but for the survey they have to go to every house because any new additions, if at all, need to be recorded. She says, "on the basis of the survey, we find out the dates of birth and stages of pregnancies in a particular family. We keep it in mind any way, but if there are 4 or 5 pregnancies we might forget (and need records) but if there are only 1 or 2 cases in month we can remember (without looking at the records). If a child needs to be vaccinated, we remember and show up at their houses and tell them bring their child for vaccination. If there is a pregnant woman we know about we will ask her for her LMP dates and then we will tell them to come for registration and her TT shots after 12 weeks." On being asked if them remembering all dates is motivated by the incentives they receive based on their work, she says the aim is not to make money. She says if their work is left incomplete, it leaves a bad impression on people (hospital authorities/NGO representatives) who come for visits; on ASHA days, the supervisors scold them for leaving their work incomplete, which makes them to go the extra mile and finish a task, they do their work whether they receive their money or not. They haven’t received their RI allowances for 2016, 2017 and 2018. She says, "they have stopped my payments for the last one year because they said I haven’t finished training modules 5 , 6 and 7 and asked me to stop me visits to finish the training - the training was finally done on 21/2/19 at Patori and now I can do visits again". "There is another thick register (RCH register) which is meant for the ANM but we are made to fill it - it has information like ADHAR card details. The ANMs make us do this work even though they are supposed to and tell us that if we don’t they will change the ASHA; they tell us if we can’t do this, we should just leave our work. SMA05 says that they are bound to do Routine Immunizations (RI) because their supervisor (Block level RI supervisor) insists the sessions happen every month. However they haven’t received their RI commission for four years now as the Accountant at the PHC charges a 20% cut to release the payments.

At home, she says she has to do the cooking herself. They have relatives but the food is prepared separately. She says she has to get up, prepare the food, send her children to school before leaving for field; it’s usually 10am by the time she gets to leave her house. She says unlike the research team members, she is used to walking and standing up through the day without having any physical complaints. SMA05 shares that sometimes she comes back at 4 in the evening and has to do work their (agricultural) fields as they cannot survive on ASHA incentives only; she says taking care of children and their studies requires money and how is she supposed to do that if she does not receive the money she is owed on time, hence she needs another source of income – they sell the produce from their field. She says after coming back from field she has to prepare meals for her family again, check on her children and their studies as that is also important. If survey/due is not complete, we have to work on that as well. A day before the ANM visits at the AWC for immunization; we have to go and call on women to bring their children for vaccines while the ANM is here but to be safe we go and inform them a day before as well. She describes a usual day – "I wake up, do morning chores - clean the house, prepare food quickly, get the kids ready for school and then get ready for work. We have to reach meetings on time, leave at least an hour before. My facilitator is SMF03. We have to walk to the school a kilometer away to catch autos for Warisnagar PHC, there are no tempos in village so we have to walk unless someone lives by the main road, they can get on a vehicle and come pick us up. We have to run around a lot but we can get vehicles easy on our way back to village; it’s always on my mind the chores I am supposed to do for the day, if documentation work like filling out the registers doesn’t happen during the day we have to stay up at night to work on that".

SMA05 says she was just an intermediate pass-out when she started working as an ASHA, however she completed her graduation later, while on the job. She used to bring test papers and study at nights 5-6 months before exams after registering for exams. She says she went ahead with graduation despite having a job (as ASHA), as being a graduate increases her chances of getting something better; she says there are many posts better than ASHA like ANM, etc. There are many posts but they should open those posts for us as these days they have started going for MBA degree holders only. On being asked if getting a BA has made her job as an ASHA any easier she says she already knew how to do the tasks meant for ASHAs like filling up registers. The graduation is meant to clear eligibility criteria and not to make our jobs easier - "we will be able to do ASHA work even without a graduation. For example, in Satmalpur out of the 10 ASHAs only two are graduates, rest are only middle school pass-outs. The other graduate lives in Satmalpur, there are 16 wards in Satmalpur GP and 10 ASHAs and 2 ANMs and I am not sure about the number of AWCs in the GP. This village is Balahi Dakshintola, there are many villages in Satmalpur GP but I cannot name all the villages, ANM can, I can only tell wards and GPs".

She agrees to call the team if there are any deliveries taking place. She also agrees for the team to accompany her to the PHC on ANC day on 9/3/19. SMA05 then describes a day when after getting back home from RI day hoping to get some sleep, she would get a delivery call and she is expected to leave, if she doesn’t go with the patient or ask the family to go on their own they won’t go at all; (after a long day), it gets hard because there is no place for the ASHA to sleep at the PHC; however there is one room at the Sadar Hospital where ASHAs can rest on such delivery visits. Also, if the ASHA doesn’t accompany the woman in labour, they write NO ASHA in the registration form resulting in ASHA missing out on her incentive despite the work she put in, it was not like that before; "If we have an emergency at home, instead of understanding and starting for the PHC on their own, they don’t go at all unless we accompany them. They trust us and feel that as long as they have an ASHA they will receive all the benefits they are supposed to receive at the PHC".

A.1.7 Ante-natal Care (ANC) Day with SMA05

Place: Balahi Village + PHC, Warisnagar Block, Samastipur District

Date: 09/03/19

The research team reaches SMA05’s house. She serves food to her husband and waits for him to finish, washes his plate before getting a plate for herself. It is ANC day at the PHC and she is trying to reach her beneficiaries on their cell-phones who are supposed to attend. After the husband finishes lunch, she sits down with hers and says "the food doesn’t taste too good today". SMA05 is supposed to take three pregnant women to the PHC, two of whom are waiting for her and calling her on her phone. ASHA speaks to them while at the same time tries to reach the third woman whose number is not reachable at the moment. While she eats, she gets two calls but the reception isn’t very clear. She has to get up twice in the middle of her lunch to go out in her backyard for better reception but fails to hear the other side nevertheless. SMA05 expresses concern about a pit in the courtyard (inside) of her house, where they do the cooking, that collects stagnant water which is a source of Kala Azar disease. The pit has been made by her sister-in-law, for water to collect when she washes utensils. This pit collects stagnant water and exposes the family to its harmful effects. She is concerned about the health of her children. She adds that the relative doesn’t bother to put kerosene in the pothole despite her requests which acts as a deterrent to breeding mosquitoes. SMA05 rushes to finish her lunch and gets ready for her day on field. She prepares her plastic bag with the documents of beneficiaries who haven’t received their birth certificates yet and carries a pen and her phone before leaving for field.

SMA05 carries INR 50 with her before leaving the house. When asked if the patients ever pay for her commute, she says if she asks them to pay they will stop going to the PHC altogether. She says for them to pay for their own commute back and forth is good enough. The research team accompanies her in the vehicle. Three pregnant women are waiting for her on the road. The group then leaves for the PHC in the vehicle. SMA05 instructs one of the pregnant women who was a minor to tell her age as 21 when asked by the medical staff. The girl got married right after her metric exams and had the child two years after that.

On reaching the PHC, SMA05 ushers the pregnant mothers to the registration desk and asks them to get their slips issued. The slips cost INR 2 each. One of the women did not have any money; RA helps her with INR 5 so she can get the registration done.

SMA05 takes the three pregnant women to the examination room. The MOIC, ANM and a nurse are present. There are other ASHAs with their patients - their registration slips are submitted and their return slips come after a long time. After waiting for a long time, they are called in one by one by the nurse. The pregnant women are asked if there were any health related issues they were facing. The pregnant mother says she feels physically weak and the nurse replies, "Anything else?" The patient says no. Pregnant mothers are being prescribed IFA tablets by a nurse at the time of preliminary examination without determining whether they are anemic or not. They are then being sent to get their weights checked. MOIC is also prescribing supplements and checking LMP dates. His work is getting interrupted several times by the accountant who would come in with administrative work files for him to sign; MOIC is thus not able to examine all the patients who are coming in. The nurse is also examining the feet of some patients and is referring the more severe cases to the MOIC. SMA05 takes the woman to the weighing machine but she wasn’t able to read the machine properly. The patient weighs 58kg but the ASHA says 55kgs and that’s what gets written in the slip. Then her BP is checked by the ANM and after all three are done SMA05 takes them to the medicine counter and gets them the prescribed Calcium and IFA tablets.

After getting the tablets, they go to the lab room for tests. Because of the heavy rush at the lab room they have to wait for about 2-3 hours. A lot of women that day had come by themselves since the MR campaign was going on in their villages which kept ASHAs tied up because of which they were unable to be at the PHC. After that the slip is submitted at the lab room and the women are seated waiting for their turn, SMA05 proceeded to the PHC office to submit the Aadhaar document for another beneficiary (required for the birth certificate of child). She is told the DM is busy with other work and her work can’t get done today. ASHA complains that this has happened before - the last time she was told they were busy with MR work. The person insists she comes again and that her work will surely get done the next time.

From there, SMA05 goes into the accountant’s room where other ASHAs are also sitting. When a few other ASHAs arrive, they start speaking to each other. One of the ASHAs narrates the story about how her daughter has eloped with another guy a few days before she was supposed to be getting married, to her colleagues. The dowry had been paid and all the wedding shopping had been done and then this had happened. The other ASHAs, including SMA05, were consoling her and trying to make her feel better by telling her that these things happen and that she should let it go/get over it.

SMA05 goes back to the lab room where the women are still waiting for their turn. ASHA confronts the lab worker about the delay saying people who had come after her are done with their tests whereas her patients have not got their turn yet. The lab worker assures her their turn will come shortly and that he is following the order of how the registration slips were submitted. He also tells her in jest that she is overly suspicious about it. [On a subsequent visit to SMA05’s home, researchers enquired about this and she reluctantly mentioned that a number of ASHAs had backdoor means to ensure that they wouldn’t have to wait in queues for long, basically they would have paid off the lab technician. This is what typically happens but on this day the technician assured her that her turn would come next and they resolved the issue amicably, so not much of a fuss was made over it.]

While waiting for their turn at the lab room, SMA05 waits with her beneficiaries. She notices an informative banner about Prerna Scheme and reads it out and explains it to them. According to the scheme, that started in 2018, a family is paid INR 5000 to keep a gap of three years between children. While talking about Prerna Scheme to her beneficiaries SMA05 does not seem to know (or be concerned about) the health benefits for the mother of keeping a gap between pregnancies but understands well enough the monetary benefits of the particular scheme. This also reflects her community’s concern or greater interest in the allowances received from such schemes rather than the overarching health benefits. She adds that since she can read, she is able to take this kind of information to the women in her field who then listen to her. She says that there are people who cannot read or write and are thus (in absence of a liaison like ASHA) missing out on such information and benefits from the government.

SMA05 tells the research team about her interaction with a family who were visited earlier by on an HBNC visit on 01/03/19 (the wealthy, educated couple where the mother was not breastfeeding – described on page 26 of this document). She says that on her seventh day HBNC visit after delivery, the family behaved very badly with her. They told her to keep her advice to herself as they are aware of the measures they are supposed to take after delivery. They said that they got their information through YouTube videos. ASHA says they were nice in the presence of the research team but the family (and the new mother) was rude to her despite being less educated than her. [When the researchers had asked about her qualifications on their visit, the husband had mentioned that she was a graduate. But the ASHA says that she has only completed Class 10, and therefore, less educated than the ASHA.] She says it’s not the caste (as they belonged to the same caste as the SMA05) but their financial status in the village that determines how they behave with her. She says that she is hurt by the incident and that she only visits them because it is her job, however, now she would stop going back to this family altogether. She again adds that if she stops her visits, the family will then complain about how they are not benefitted by the ASHA and AWW at all. However, when they need information about events like vaccination camp dates they turn to the ASHA - after the incident, the mother approached her requesting she lets them know about upcoming vaccination dates.

Coming back to discussing incentives, SMA05 says that her incentive of INR 100 on ANC day is regardless of the number of pregnant women she is bringing to the PHC. The incentive is not on a per patient basis.

The research team meanwhile meets SMA01’s husband who has brought a pregnant woman to PHC for ANC day. SMA01 could not come as she has to go for door to door campaigning for MR. The husband, who works as a courier between the PHC and AWC, says that he has already finished his work in the morning and has to only go back after 2 PM. In this free time window, he decided to help out his wife, and has brought this woman to the PHC for her ANC check up. The pregnant woman is accompanied by her husband as well because according to the husband, his wife is scared of going out alone. He adds that they would not have come to the PHC had the SMA01’s husband not accompanied them.

The beneficiaries of SMA05 return after their blood and HIV tests are done with their receipts in hand. The HIV test is done by the same lab person who does the blood tests for anemia. There is no extra charge for these tests. The HIV test is negative - "None" written in the field against it and the blood report consists of the Hb count. SMA05 is surprised to have received the test reports the same day since, as per her knowledge, the reports took at least a day’s time. She says this must be as part of some new regulation by the government.

On seeing the reports, SMA05 is concerned about the low Hb levels of one of her beneficiaries. It is less than 8. She advises her to have healthy dietary practices (like making a habit of having one pomegranate every night). The pregnant woman says that though she has tried to maintain the habit every night, she is surrounded by other children in her family (nieces and nephews) whom she ends up giving it to. ASHA insists she shares the fruit with the kids, ensuring that she consumes part of it herself, instead of giving it all away. She then takes the pregnant woman to the examination room again where the nurse and the MOIC are examining patients. The nurse looks at the blood report and prescribes another tonic for the patient to buy from outside. She also advises her to be on a healthy diet. The woman who is supposed to buy the additional health tonic says she cannot buy it right now as she is not carrying any money. She requests the SMA05 to get it on her next visit. ASHA says her next visit will take four days and that she should get the tonic before that. The woman finally decides to ask her husband to buy the tonic for her.

Once the women finish all their check-ups at the PHC, the team leaves for home with SMA05 and the pregnant women.

A.1.8 Interview with Dai

Place: Balahi Village, Warisnagar Block, Samastipur District

Date: 27/03/19

The research team meets with a dai residing in SMA05’s catchment area (the same dai who was at the wealthy family’s residence in an earlier visit). She talks about her interactions and working relationship with SMA05. She refers to a delivery that happened eleven days back where the d_ai_ was called for by the family. She examined the woman at 5PM in the evening and told them that it won’t happen before next morning. She was called again at 10PM in the night – she enquired if the ASHA is also there and why do they want her when she is already there, the family insisted she goes nevertheless – she left with them for the PHC. She says she was the one to remind the SMA05 to call the research team (as we had requested them to) which she did. The child was born the next morning at 4.10 AM at the PHC. She says she is always called to houses where SMA05 has to go for deliveries. She says SMA05 usually suggests the family to call the dai to examine the woman in labour as the ASHA herself does not have the know-how. [This was however not confirmed to us by SMA05 when the research team asked her about it later. It could either be that the dai’s version was an exaggeration of what actually happens or that SMA05 did not feel comfortable revealing this to the research team since they, the dai and the ASHA, are meant to be on opposite ends of the spectrum (of healthcare service providers) and there ought not to be any official collaboration between them.] She says while she examines, the ASHA does the documentation work and this way work in coordination with each other. She says d_ai_ does not receive any money for examining the pregnant woman though she is paid some goodwill money (bakshish) on the day of chhatti. She adds that sometimes when some other dai is called, she gets a part of the amount too but that SMA05 usually calls her over other _dai_s because of her age and experience. Dai refers to the family visited on 01/03 and says that the baby needs to be suckling for proper milk production and that instead of breastfeeding the baby is often just given a bottle. She says the mother is lying about not producing enough milk and that sometimes due to the drugs the mother is on there might be some issue with the amount of milk produced but often it gets better if the child is made to suckle irrespective of whether there is milk or not. She says instead of having the child nursed by the mother, they give him baby formula. She says the same happened with their first child as wel,l where the mother did not breastfeed (even on chhatti) - she knows because the family used to call her for massages when the child got cramps in their neck (sikri) after the mother got back after delivery from Muzaffarpur. The dai says nowadays, educated women refrain from breastfeeding as it is increasingly becoming ‘fashionable’ among them to not breastfeed. On being asked if mother’s milk was preferred back in the day when she was pregnant, she says she always fed breast milk to her children and that breastfeeding is very important. Her daughter-in-law, who is sitting nearby, is asked if she breastfed her children and she says that she started breastfeeding right after the birth of her children. On being asked if they ever consulted a pandit after the birth of their children, dai’s husband adds that in those days they would visit the pandit with the child’s time of birth for everything from the time the child should start breastfeeding, direction the mother should be facing when taking the child out for the first time, to the time when the mother should take the child out for the first time. He says that when they had their children, he visited the pandit with INR 21 as goodwill money and the pandit opened his books. The pandit asked for details such as who was present at the time of the delivery and the time of the delivery to suggest a name of the baby. Dai’s husband says that now people do not follow what pandits say. Dai is not able to remember the exact time that the pandit had given her to start breastfeeding her children. She however says that earlier they would give the child goat’s milk until the pandit would give them the exact time to start breastfeeding. She says if the child is born in the morning then he is fed goat’s milk in the evening (while waiting on the pandit) as he needs to be given something to wet his throat. Sometimes the child is also given honey mixed with milk or water. She says the sweet helps the child to start feeding soon. On being asked why goat’s milk is preferred over cow’s milk, dai’s husband says that goat’s milk is in many ways (nutritious) like mother’s milk. Dai refers to an incident from when her mother used to work as a dai. She says that a child fell sick when he was given cow’s milk right after birth. After the incident, everyone blamed the dai for what happened. The child was then taken to a doctor as the child had developed a rash on his stomach. At the doctor’s the dai wasn’t blamed but the family was. Dai says she was about 10 years old at the time. Dai’s daughter in law says that her first child was born at her natal house. Her mother also works as a dai. She says they did not consult a pandit at the time she gave birth and started breastfeeding half an hour later. The child was not given anything else. She and her child were bathed two days after coming from the PHC. On being asked if the pandit visits them or they visit the pandit, dai says that her husband used to go to the pandit. She says the pandit is visited by people from all around the place. Pandit can tell which planets are important (for the newborn). She refers to her grandchildren’s births and says that the pandit had suggested they do mahadev pooja (for one of her grandchildren) where they have to build an idol using black soil, beetle leaf and earthen lamps. She says that the pandit was consulted at the birth of all three of her grandchildren. She mentions sattayisa (or, ritual done on the 27th day of birth when the child is supposedly born at an inauspicious time) that requires them to do pooja using wood from 27 different trees, water from 27 different wells and 27 earthen pots. She says that mahadev pooja is very difficult and requires a lot of things which they, due to their limited means, could not do completely. She says that the father of the child is supposed to look at the child through a perforated earthen pot. The dai is asked about the routine things she does when called for delivery at home. She says that if the woman is in labor already, she tells the family to call for a doctor. The doctor gives her shots and puts her on a drip. When the pain increases and the child is born, she wipes the child clean and cleans the area. The cord is cut with a sterilized blade. She says that usually the wound heals and the button falls off on its own, if not, she applies some medicine on the remaining wound. She says the placenta is disposed off in areas such as bamboo groves and that the cord stump is also disposed off the same way. She adds that if it’s a boy, the stump is buried in a bamboo grove. It’s not necessary in case of a girl; if it does not fall off on its own, it is then buried in a bamboo grove. She says that the bamboo grove signifies the longevity of the clan (lineage) hence it is buried there. She says that the newborn child is given oil massages with mustard oil and is handed over to the mother before coming back. She visits the child and the mother twice a day for six days after the delivery. On being asked if her daughter-in-law also works as a dai, she says she is not, as of now. She also says that she has never received any training for what she does. She says that when her mother-in-law used to work as a dai, one day when she was not home, the dai was called to attend a delivery in their neighbor’s house. She did not have a lot of information so she took the help of her husband’s aunt who told her what needs to be done. They tell the name of the pandit they have been visiting from the time of the birth of their children and grandchildren. The daughter-in-law says that she also has the know-how of what the dai does. The dai says that sometimes she accompanies pregnant women to Samastipur and Muzaffarpur, if the woman wants her to come along. Speaking of the charges of having a delivery at the PHC, she says that at the time when her grandson was born, she had to distribute all the money she had with her on the day as bakshish or goodwill money. At the PHC, the Mamta took away the child from her and did not return him until she was paid INR 60. She says, ANMs also charge INR 500 at the PHC. On being asked whether a PHC delivery is better than home delivery, the dai says that, it is easier to get a birth certificate for a PHC delivery as compared to a home delivery. Dai’s daughter-in-law however says that at PHC, nurses come and touch them repeatedly, check for dilation, whereas there is more privacy at home where it’s all family. She says that at home one can stay in parda (covered with curtains) and that home has a very different atmosphere and is better than PHC.

Just before leaving, the research team is told about a lamb with deformed hind legs that was running around in the courtyard of their home. The dai’s husband narrates the story of how the dai was called by a neighboring family to help in their goat’s delivery, and as bakshish she was gifted this handicapped goat.

A.1.9 Monthly Meeting of Satmalpur ASHAs and SMF03 & Delivery with SMA10 at PHC

Place: Satmalpur Health Sub-centre (HSC) + PHC, Warisnagar Block, Samastipur District

Date: 28/03/19

SMA08, SMA09, SMA10 are at a meeting with their facilitator - SMF03, along with other ASHAs from the area who are supervised by SMF03. While waiting for the meeting to commence, as everyone had not arrived yet (only SMF03 and SMA08 were present), the research time asks about the velbal altercation they had with the MOIC of Warisnagar PHC on the last ASHA day on 14/02/19. SMA08 says when the workload is high, we all lose our temper. With regard to a comment made by the MOIC during that meeting where he said ‘If ASHAs die because of lack of payment, they should die!’ SMF03 says ‘He never blesses but always curses us. We feel bad.’ (‘Dua toh detey nahin, shraap detey hain, bura lagta hain’)

SMA08 refers to an incident in her field where a male beneficiary who hadn’t received his Ayushman Bharat card accosted her to get him the card. She told him the card has not arrived yet to which he says he knows that the ASHA is keeping the card from him. He started arguing loudly with her. The ASHA stayed quiet and asked him to go and inquire at the PHC.

When SMA08 told her husband about it, he wanted to go to this man’s house and fight on behalf of his wife, for the way he had treated her. SMA08 said to her husband that he will not be affected by it as he will leave after the fight but she will have to stay and continue to work in the same community with the same group of people. So instead, she decided to go to the man’s house alone to have a word with him. The man had threatened to file a case against her accusing her of keeping his card from him. SMA08 told him that she had distributed all the cards she had to the names and addresses she was aware of but there were some that she did not understand and had given to her facilitator to figure out. She tells him if he wants to follow up he should go to the PHC. The man asks her why she is so agitated and that he was on his way to the PHC to inquire about the same. The ASHA then tells him that he can go wherever he wants to but she will not stay quiet if he accuses her again. She says that after that incident the man has stopped speaking to her.

More ASHAs from Satmalpur arrive by now. Some ASHAs are coming in late as they are busy with Muskaan (older name for what is now called RI) work. SMF03 says if one has to do two tasks, it cannot be helped, both have to be done as they are both important. SMA10 did not have a blank page to jot down her monthly task figures so SMA08, sitting next to her, provided her with one. They are approaching SMF03 one by one with their data on polio day. SMF03 asks them if they have filled up their RCH registers. SMA09 says she has lost hers and that her requests at the PHC to look into the matter are not being heard. RCH register has information like details of pregnant women - her name, family details etc. All ASHAs are noting down details from their register on a piece of paper for the facilitator. The paper has details like ANC report, RI report, Kala Azar, Tuberculosis, Leprosy, home and institutional deliveries, and details of pregnant women. SMF03 takes down the following details - number of home deliveries, number of CuT surgeries, number of PPIUCDs, number of malnourished babies (weighing less than 2.5 kg), number of pregnant women, number of children (between 0-5 years), number of Filaria and Kala Azar patients. They are also taking down details from their survey register on the newborns in their area. SMF03 asks the ASHAs if they are using Mobile Kunji. She says that she is getting complaints from the PHC that they are not using Mobile Kunji in the community. All ASHAs are given a mobile sim from the government which they need to keep active and use for the Mobile Kunji. She informs them that it is very important for them to keep this sim active since, in future, these will be linked with their ASHA ids and that requisitions for vaccines and contraceptives will have to be done directly from it. The government also recharges these phones and the ASHAs do not have to fill balance on it.

At the meeting, SMA09 has left her due register with the AWW at her AWC on the last RI day on 27th March for the AWW to copy the beneficiary details. The AWW had said she would return it by evening but she did not. SMA09 calls the AWW from the meeting and asks her to have the register sent to her. The AWW has her neighbor’s son (arrives on his motorbike) brings the register to SMA09. She then goes on to say that she has to cater to two wards (Wards 7 and 8 – Ward 7 is her own) because the ASHA who was recruited for Ward 8 had quit. SMA09says Ward 8 includes a Muslim tola (hamlet) and that not everyone can understand the area like she does, being from the community herself.

ASHAs were putting their signatures on a PHC document when one SMA08 stops SMA09, asking her to give the document a read before signing. SMA09 jokes she does not have any land that she should be scared of writing it away. SMA09 says the document is for the facilitator’s incentive but SMF03 says it’s for their own incentives that they are signing, and that she is signing her own document.

SMA05 calls the SMF03 to tell her she is in Samstipur with a patient and asks whether it is important to attend today’s meeting. She wants to know what is going on at the meeting. SMF03 tells her it is important to attend the meeting as her share of work would be pending if she doesn’t attend it.

SMA10 asks the SMF03 about the procedure to correct a spelling error in the name of a beneficiary on his Ayushman Bharat card. SMA09 tells her to go to the PHC to have it corrected

SMA08 calls her niece to get in touch with an SMA11 who lives next door to her. She had not come to the meeting and they were wondering whether she knew that the meeting was taking place. She asks her to give the phone to SMA11 as she must be home. The niece tells her to call after ten minutes.

SMA09 calls SMA12 asking her to come quickly with her registers to submit her reports. She says SMA12 is not able to complete her paperwork because she is less educated than the others and she often wonders what to say in meetings. SMA09, however, adds that she is very active in the field and good at her work, especially during deliveries and surgeries. She says they tell her to come to these meetings nevertheless as they are there to help her out with the documentation work, something they are not able to at meetings that are held at the PHC.

SMF03 then tells all the ASHAs that the report on Kala Azar is zero, to which the ASHAs say they will not do that work as they have not received any money for it so far. They tell SMF03 that Kala Azar staff (Mr Mishra) had given incorrect information in the field that the families would receive incentives for taking Kala Azar medicine, so that they would be more compliant with the protocol, and now people have been approaching the ASHAs for that money and they are facing a lot of pressure.

While at the meeting, SMA10 receives a phone call from the family of a pregnant woman that she has started labour pains and that she should be taken to the hospital now. She calls the ambulance and gives directions for where to reach. ASHA is anxious to leave the meeting as she is worried they might have to have the delivery at home if the ambulance does not reach on time. The patient’s house was half a kilometre away from the Health Sub-centre (where the ASHA was at the time she got the call). In absence of the research team’s vehicle, SMA10, in her frantic state, would require to get to the patient’s house on her own either by foot or in a rickshaw. The cost of this conveyance is not compensated and comes out of her own pocket. Upon reaching the pregnant woman’s house, the ASHA asks the pregnant woman how long she has had these pains. The mother replies since morning. The ASHA then supervises the arrangements - she makes sure they carry the required items - Aadhaar card (photo ID) of the pregnant woman, her bank passbook, a packed bag of clean cloth of different sizes and a bottle of mustard oil. SMA10 makes them carry an extra saree and asks the mother to take more mustard oil than she has taken. She enquires about the Mother and Child Protection card which the woman says has not been made. She had come to her mother’s house for delivery a month back because of which she could only get one ANC done. The second ANC could not happen because the AWW was on a sick leave on that particular RI day. The mother of the pregnant woman says that they had called a dai on the birth of the first child of the woman who was in labour but they did not this time as they will need to pay her some amount to go to the PHC. The brother of the pregnant woman steps in and says that if a dai is called and she does work then she of course must be paid for it. The family serves tea to the research team and the ASHA despite the rush. The ambulance arrives shortly after and the family prepares to leave - the ASHA, the mother of the pregnant woman and her aunt leave in the ambulance along with the woman. The brother follows behind on his motorcycle. The ASHA asks the driver to drive carefully as the jerking was bothering the pregnant woman. The ASHA calls her oldest daughter (who is visiting from her in-laws) to meet her on the way. She wants to hand over her plastic bag of registers to her as she will be spending the night at the PHC and might lose it in all the running around. The daughter arrives and the bag is given to her. Soon after, the ambulance driver notices a facilitator from another panchayat on the way and stops the vehicle. He tells the SMA10 to ask her to get inside as she is also going the same way. The facilitator gets down at a square and the ambulance continues to the PHC. SMA10 goes up to the registration counter to get the slips made. They want the details the husband of the pregnant woman such as his name and address which the ASHA does not know. She takes the in-laws’ number from the pregnant woman and takes down the required details. She then takes the pregnant woman to the delivery room and requests the ANM to examine her. SMA10 then brings the pregnant woman out of the delivery room to the waiting area after the ANM asks them to wait for further dilation. The ANM asks the ASHA to bring the pregnant woman to her room where her BP is checked. She then tells her to inform the doctor about the woman’s blood pressure. The doctor comes soon after to check the pregnant woman’s feet and asks the pregnant woman about the duration and frequency of the labour pains. SMA10 goes out with the pregnant woman’s mother to buy cord clips and medicine (Sinto - oxytocin to induce labour) as asked by the ANM. After coming back and while waiting she asks the woman to eat or drink something hot as that will help induce labour and the child will come out easily. Once the pain increases, SMA10 takes the pregnant woman back to the delivery room and helps her up onto the delivery bed. She helps her place her feet on the stands and adjusts her saree. SMA10 is standing next to the bed getting interrupted by a number of phone calls.

By this time, the woman’s water has broken an hour back and the ANM examines the woman every now and then. They put her on a drip as the saline gives the strength she needs to push. The woman is in a lot of pain and her mother asks the ANM if the baby is aligned in the right direction (head first). The ANM is constantly asking the woman to push, and asking her not to cry. Apart from the mother and the aunt, the delivery room has two Mamtas and one dai (hospital employee) present. The patient is made to turn to her side to ease the delivery. The ANM gets called by someone from outside the delivery room but she asks the person to come in instead. She soon leaves the room to speak to the person and does not return for some time. The ASHA gets a call again and she leaves the room to take it. The ANM asks the mother if they had got an ultrasound done to which the mother replies yes but that they are not carrying the report. The ANM says they should have brought the report as it has important information such as the weight of the baby. The woman gets a third wave of pain which is higher than the last few. The woman is tired and sleepy and the Mamta tells her this is no place to sleep. Her feet are slipping from the stands next to the bed but no one is paying attention to that. The woman urinates and gets very strong waves of pain. (There are also a lot of flies in the room.) The woman is made to lie down on a strip of cloth which the dai, ANM and the ASHA are using to cover her lower body. The ANM uses the soiled strip of cloth to wipe the woman. The Mamta and the d_ai_ asks her to use a different strip. By this time the ANM is able to see the head of the baby and asks her to push hard.

The baby comes out and the ANM puts him on the mother’s stomach, wipes the baby with another strip of cloth and blows into his nostrils with a pipe. The baby makes a crying sound. The cord is cut by the ANM (after 3 minutes) with the help of the dai and the stump of the cord which is attached to baby’s belly releases the excess blood. The family is concerned but the ANM assures them that this is normal. The baby is put on the weighing machine and the Mamtas further cleaned up the infant. When the ANM asked who whould hold the baby both elderly family members of the new mother were reluctant so SMA10 went up to the baby and took him in her arms. While this happened, the dai cleans the woman’s lower body and helps the ANM deliver the placenta. The ANM leaves the room once the placenta comes out leaving the Mamta and the dai to clean up the area.

The mother of the woman says that the child is very weak and checks if he is able to open his eyes properly. Mamta washes the woman’s breast with warm water and after five minutes hands her the baby to breastfeed. She also uses the oil the woman’s family brought with them to massage her, to provide some relief after the ordeal of the delivery. She then helps her sit up on the bed and puts the baby in her arms. The milk is not coming out and the Mamta massages the breast and the baby is made to have the colostrum. The ANM asks the mother’s family for her card to put in the birth date.

Once the baby has been removed from the mother’s breast, the Mamta, dai and SMA10 helps the mother wearn a fresh saree and takes her to a room where 6-7 beds were kept. She is made to lie down on one of the beds with her baby who is carried to the room by SMA10. The Mamta comes in a while and tells the woman to feed the baby every half hour. The Mamta asks the family about her previous children – they tell her she has a son and a daughter. The Mamta then starts telling her about family planning and that she should get the surgery done. She then asks her how the bleeding is and to let her know if she faces any difficulty. She tells her to keep taking the IFA tablets after meals. The baby’s grandmother asks SMA10 to check if the child is able to open his eyes. She uses her fingers to make the child open his eyes and tells the grandmother that the room is too bright for him to open his eyes. She assures her that the child is crying, which is an indication that the child is fine. The mother of the woman then asks SMA10 to come with her to have tea and bring some back for the new mother. The dai brings the child to the next bed where the woman’s aunt is sitting. The aunt asks the dai if she can switch on the fan. The dai says the child has just come out of the mother’s womb and needs time to adjust to the outside environment and for that he needs to stay warm.

The ANM comes and talks to the research team – says when they go for RI to the field, some of the women who they have helped deliver recognize them and covers their face with their ghoonghat (viel made out of the lose end of the sari) out of shyness. They say "this didi (sister) has done our delivery and has seen us naked". She says that it is not possible for her to remember so many faces so she often fails to recognize them.

After a while, the second ANM comes in and records the new mother’s blood pressure. She checks the cloth put under her for bleeding, in case she is having postpartum hemorrhage. Mamta is cleaning the baby’s mouth with her finger wrapped in a piece of cloth. The research team asks the ANM when the child will be vaccinated. The ANM says it will be given before the child is discharged the next day. That’s because one medicine vial has enough for 14-15 children and once opened cannot be reused later. The new mother’s mother (child’s grandmother) says that when the woman’s older daughter was born, the dai had made them stay back for a long time saying the delivery will easily happen at home. But the woman was in a lot of pain and they brought her to the PHC eventually. The delivery happened normally but they had to do an episiotomy ("chota operation" - minor surgery). That time the ASHA had told them if they had tried to do the delivery at home the dai would not have been able to manage it.

About to leave, the research team asks SMA10 if she will be staying – she says yes, she will need to stay with the family the entire night, until they leave for their home the next morning. She says that she had eaten in the morning, before leaving for her meeting, and has not eaten anything since.

A.1.10 Interview with SMA10’s Beneficiary (Delivery Case)

Place: Satmalpur Village, Warisnagar Block, Samastipur District

Date: 01/04/19

The research team reaches the beneficiary’s house where she has been staying with her newborn. It is her natal home where she currently lives with her newborn and her mother, father, sister, brothers, sisters-in-law, nephews and nieces. As the research team enters the house and asks where the woman is, they are shown a cordoned off area in the passage (room-like) through which one enters the house. There is a board draped with plastic sheets, across the centre of the room, which acts as a partition separating a small section of the area. The board is about 3 feet high and is covered with empty nylon bags used to store cement. On the other side of the partition, on the floor, sits the new mother with her child sleeping next to her. There are a few pots and pans and a small dug up pit on the floor next to the mother. There is also a pile of burned down wood and ashes in the area. The team speaks to the family and asks them what they did after bringing the woman and her child home from the PHC. The mother (of the woman) says that the woman was bathed in hot water and the child was wiped with a wet cloth. The child was then wrapped in a piece of cloth and given to the mother. She is asked about the problem in child’s eye and if they did something about it. She says they took him to a private doctor who prescribed eye drops – two drops to be given 3-4 times a day. She adds that there is a dai who comes to give massages and she just left for the day. On being asked if they put any medicine on the child’s belly button, the mother doesn’t say anything. She says that the child won’t be dressed in any stitched clothes till chhatti (celebrated on the sixth day of birth) and the child’s mother is not given any food other than milk and sweets. She is asked if the child and mother were given anything else to eat after coming home to which she says they were not given anything else. Answering a question about the dug-up pit located next to the woman, the mother says that is where the new mother relieves herself when she needs to use the toilet. She points at the pile of ashes and says that when the dai comes she makes fire to heat up the oil for the massages. She says that the woman will stay in that area till the sixth day of birth when chhati is celebrated and won’t come out until then. She also tells that they are having the chhati ceremony tomorrow at 9 PM. She says that they will be doing the pooja on their own and haven’t called any pandit. The pooja will be done using rice, sweets, kohl and vermillion powder. The woman’s sister adds that the woman will be fed whatever is cooked at home. The research team asks if they add anything to the fire that is lit in the section the woman is staying with her child. The mother says they don’t add anything to it and the fire is only used to give hot compress to the child. She says that they belong to the Kurmi (OBC) caste. The woman says that SMA10 visited her yesterday and asked if she and her child were doing okay. On asked about if they knew when the shots are scheduled for the child, the mother says that the child has already received his shots at the hospital. She says they haven’t been told about the subsequent shots yet. When the research team asks for their permission to take pictures of the new mother and child, the father says they have their permission as long as it doesn’t run them into trouble. Sinjini assures him there will be no trouble and offers to give her phone number to which he says they are foolish village people (and are scared of repercussions) before agreeing to let them take the pictures. They are asked if they are farmers, they say yes and that they grow vegetables and wheat. Coming back to the topic of consent for pictures, the father says he only hesitated so that later they do not run into any trouble to which lead researcher says it’s their right to ask those questions. The research team shows interest in attending the chhati ceremony and the mother says the preparations will begin at 8 PM and the ceremony will be at 10 PM. On being asked if there is any ceremony planned for the morning, the mother says they will clean and mop the house, cook for guests attending the ceremony. The father of the woman says that he had gone to a pandit after coming back from the PHC who said there is nothing wrong with the child’s (horoscope?) and everything is fine. The pandit told him that if the birth had happened after 1.15 PM, the child would have been born under sattayisa (an inauspicious period) but he was born at 5.31 AM and is therefore fine. The father says that the pandit lives in Satmalpur and is an elderly person.

On being asked why mustard oil is preferred over other kinds, the researchers are told that the dai uses mustard oil to massage the baby because that’s the oil they have seen it being used by their elders and that’s what is used in villages and jungles. The father of the woman says that mustard oil warms the body while coconut oil cools it down and therefore mustard oil is preferred over coconut. While in the middle of the conversation, a woman who lives near their house enters. She says her child is sick but she cannot afford to take him to a "big" doctor as that would cost about INR 2000-3000 which they cannot afford. There is loud noise coming from the house next door and the neighbor says that they are having a weekly SHG meeting and the members are having a fight among themselves. The woman’s mother says that the fight is around the loan taken by the group. The neighbor says that the CM or the Community Mobilizer had taken a bribe of INR 2000 when the group received their loan amount (of INR 100,000) and a second bribe of INR 1,000 when the group received another amount of INR 15,000. The neighbor says that the CM is getting an honorarium of INR 600 from the government but she charges INR 100 from each of the member of the SHG- this way she makes INR 1200 from one group. Now that it has come to making up for this amount, she is making the members pay up again which they are refusing to do. When the mother of the woman is asked if she is also a member of this group, she says yes and that she is also in the fight against the CM. On being asked what the fight is about, they say that the chairperson and the secretary of the group withdrew the loan amount of INR 1,15,000 from the bank account without anyone’s knowledge. The treasurer who is supposed to keep a record of transactions did not have any knowledge about this. The sister in law of the woman had gone to attend the meeting who after learning about the embezzlement tells the woman’s mother (and her mother-in-law). The mother goes up to the "group leader" (the chairperson of the group) and asks if she knows anything about this. By that time a woman came, and told them to take up the matter with the CM. The mother says that the fight is happening between the CM and Rani Devi (neighbor). The mother says that there are three people who deposit money with the group but they will not get any money if they need it.

[Rest of what was said is unclear]

A.1.11 Interview with PHC Mamtas

Place: PHC, Warisnagar Block, Samastipur District

Date: 01/04/19

The research team meets SMM01 and takes her consent for the interview. SMM01 says that she has been working as a Mamta since 12/7/2010. She is 33 years old and has four children – two boys and two girls (including twins). The first child was born in 2001 and the youngest in 2006. Three were delivered at home and one at the PHC. She talks about her first delivery that happened at home. She says that it was normal and she did not face any difficulty. She was given tea and biscuit to eat after and the child was also breastfed. She says that bleeding started soon after and she was fine after the nurses put her on a drip. She was in consultation with a doctor who also examined her. She says that the child had received all his shots – Vitamin K at night and BCG next morning. She does not remember the weight of the child at the time of birth and says she needs to check the card as that’s where the weight is noted down. She talks about her second delivery when she was expecting the twins. This delivery had also happened at home and was a normal delivery (happened "without needles and medicines"). She says she was not working at the time and she became a Mamta after her children were born. She is asked about her recruitment at the PHC as Mamta and she says that she used to visit PHC for shots and medicines for her children. She started getting to know the people working there. She says that six months after her youngest was born, she fell sick. She had diarrhea and she came to the PHC (for treatment). It was then she was asked if she would like to work there and she said yes. She says her house is located very close to the PHC and she has been working here and giving (patients) shots and medicines ever since. SMM01 is asked if there is anyone working as a dai in her family. She says at her natal home, her grandmother (on her father’s side) used to work as a dai. She says that now no one does that in her family anymore and she does not know why no one has taken it up either. She says that she has to work in her fields as well. She lives with her husband and four children. She says that back in the day when she was pregnant, it was common to have deliveries at home. In serious cases, people would go to private hospitals. She is asked since when has she seen this transformation and she says that she did not know anything before she was recruited and it is only after (she started working as Mamta) that she got access to this kind of information. She says nowadays everyone comes to PHC for deliveries. She says that there were no ASHAs at the time of the birth of her first three children. On being asked why are people preferring to come for PHC deliveries, she says that there are facilities here that ensures the delivery happens properly. Mothers receive INR 1400 which is why most people come to PHC and birth certificates are issued without any hassle. She says when a woman comes to the PHC for her delivery and goes back and tells others, others also come to the PHC. SMM02 is also on duty and seated here. She tells that she has studied till 7th standard and is also from Ram, (SC) community. SMM03 has studied till 8th, is from Ram community and has four children. SMM02 says her mother in law is also a dai. She says money is not that important- as they not receive it on time and only get it later. She says the ASHA program started when she was pregnant with her last child. Her ASHA was the one who brought her to the PHC after telling her about the facilities one gets there. They used to say it’s dangerous to have a delivery at home as there is no provision of getting the right medicines and "needles" on time. SMM01 had received INR 1400 upon having her delivery done at the PHC. She says in those days they used to get cash in their hands. She says people now come to the PHC because the newborn gets BCG, hepatitis and polio shots right away. She says women who come to PHC are very aware and they even go back and tell others. ASHAs also go around in the community and tell people (about the benefits of coming to PHC for delivery). She is asked what her job is inside the delivery room when a woman is giving birth. She says one of the things that she does inside the delivery room is to wash the new mother’s chest and help her feed the child. She is asked who the child is given to after the ANM pulls him out and cuts the cord. She says after the delivery is done, the child is given to the "cleaning woman" who then hands him over to the Mamta who then cleans the mother’s chest and helps her feed the baby. SMM01 says that she does not go inside the labor room except in emergency when she has to help carry a pregnant woman inside. They say that they have been at the PHC since 8 o clock last night and are supposed to stay till 2 PM. They are asked where they sleep when they feel sleepy. They say that they don’t sleep and they usually spend the night sitting around talking to the patients which keeps them busy through the night. She is asked if she likes to sleep after getting home. She says that she does if she is feeling too lazy otherwise she has to attend to other household chores such as washing her children’s clothes, working the fields or any other work that may come up. SMM03 says most of her time at home is spent "bathing, cleaning and eating". She says after leaving today at 2 PM her next shift will begin next day tomorrow and that someone else will take their place after they leave today. They say that they all belong to the ram community and their houses are next to each other at a distance of 200 metres from the PHC. SMM02 says that in her family she, her mother and mother in law work as dai. She and SMM01 say that there is a lot of difference between dai’s work and the work that they do now as Mamtas. SMM02 says "home is home and a hospital is a hospital, there is definitely a difference". SMM01 says that earlier when children died (during birth), people would say (the child was) "touched by tetanus" they did not know it was tetanus (that killed the child). Earlier those cases were very common but now they are not heard of anymore. On being asked if there has been a reduction in the number of infant and mother mortalities, SMM01 says yes, there has been a lot of reduction. SMM03 says that sometimes during home deliveries the mother would get a "tear" during childbirth but there was no facility to give her stitches. SMM02 says that she had done about 10-12 deliveries as a dai before becoming a Mamta and she never faced any difficulty and no children were lost. On being asked about recruitment, they say that the notification was published in the local newspaper and the applicants belonged to all castes – _mestar, chammar, koyari, brahmin, ravidas, dom_and ram. They say that (at the time of application) they had changed their castes to ravidas as otherwise they would not have got selected.They say that a lot of people from faraway places had also applied but only those who lived nearby were recruited so they can do emergency visits at the hospital. They say they did not have to give any money, as bribe, for being selected for the opening. They say that they have received two trainings in Samastipur. They were trained in how to hold a newborn, how to bring the mother to the delivery bed, what to instruct mothers such as telling them to carry money, bring family members and to bring their husbands. They ask them to bring clean clothes and tell them to dry their clothes in the sun if they are dirty. They say (after some confusion and discussing among themselves) that they have received three trainings so far. They say that they received the money for two trainings and one is still pending. They received INR 500 for each of the first two trainings and nothing so far for the third – their account numbers were taken but nothing has happened after that. SMM01 says that the ANM and doctor have asked them not to enter the delivery room except when there is an emergency when they have to help carry a woman inside. But they leave immediately after as there are ANMs (didi) present inside already. She says she enters after the child is born and the mother is unconscious to bring them out. She says that at the time of delivery, there are two ANMs and one dai present – the dai is there to do the cleaning. SMM02 says that once the child is born they go inside and wrap the child in a piece of cloth. SMM01 says that if the patient does not have any family members accompanying her they go inside. Their husbands wait by the entrance of the room; he does not enter. SMM02 says that they wash and clean the woman’s chest and help her feed the baby. They say that when the pregnant mother is in labor waiting for the delivery, the Mamtas get together with the ASHAs and chat with each other and the patient. Then one of the Mamtas says that sometimes the pregnant woman starts running around out of pain and fear and the Mamtas have to catch her and bring her back to the delivery room. They tell her that if they try to do a delivery at home, it might harm the child, that she might bleed a lot and there would be nobody to take care of them. They convince her and bring her back to the delivery room with four Mamtas holding her. They say that if the doctor asks them to go inside the delivery room, they do that especially when a mother develops complications. They say often when a patient is running around frantically she delivers outside the labor room in the PHC premises. Mamtas say that sometimes the woman wants to go home and have the baby there. SMM02 says that there are times when the mother is running around even when the child is crowning. They say that usually when their husbands are around, they throw tantrums and we have to ask the husband to leave the building. She says sometimes while the woman is in the toilet and about to deliver, she is made to come back to the delivery room. They refer to one such case where the woman had delivered on her way back to the delivery room; the child came out and was stuck in her saree underskirt. The Mamtas took her inside the delivery room. On being asked if the woman is accompanied by a dai, SMM01 says that nowadays _dai_s don’t come with pregnant women. Earlier during home deliveries _dai_s were needed but now at the PHC, they have doctors, ANMs, and Mamtas so _dai_s are not needed. SMM02 says ever since she became a Mamta she has not done any deliveries at home and she brings them to the PHC. SMM02 adds that during home deliveries, they would cut the cord; SMM01 says that she has never done deliveries at home. . On being asked if there are rituals associated with cord-cutting, Mamtas say yes. They say that earlier during home deliveries they would wait for the dai to come to cut the cord. If the delivery happened at night they would for the dai to come and cut the cord and clean the placental remains. SMM02 says that her mother used to say this but it does not happen anymore. They say that now dai goes to new mothers to give massages to them and their newborns. They say that the mothers are given proper instructions about how to take proper care of themselves and their babies before they leave PHC. They say that people listen to them now; SMM01 adds that at least 75% of those who come to PHC listen to them and follow their instructions. The Mamtas say that they advise the families to not bathe the mother and the child (for the first few days) and that the doctors and the ANMs also advise them. They say that about 50% of the people actually follow their advice. SMM01 says that sometimes the child falls sick after bathing and is rushed back to the PHC. The other 75% who don’t bathe the child do not face this problem. They say that by seeing and learning from each other nowadays they do not bathe their newborns. SMM01 says that initially she used to see a lot of cases of sick children at the PHC who were brought because they fell sick upon bathing but now it does not happen anymore. She says that in such cases the sick child would stop eating and cry all the time. The ANM and doctor would ask the parents what happened and they would say they had bathed the child and then get scolded by the doctor. The doctor would try to explain that the child comes out from the warmth of the womb and is thus needed to keep warm wrapped in sheets. SMM03 says that earlier every woman would have one or two miscarriages but now it doesn’t happen anymore. Their consent is taken for taking their photograph for the study. They are asked if they think the state of public health in Bihar has seen any improvement and what needs to be done according to them. Mamtas say that earlier people used to lose children because they did not have the right information. They say that people were stupid and they did not come to the PHC for deliveries. They say that now they do and they also tell their neighbors to go to PHC. They advise other pregnant women in their neighborhood to not have more than two children, and to visit their AWC in their first trimester. They advise mothers even six months after the child is born – when to feed the child, how to feed the child, and how to have add nutritional supplements to their diet. They tell pregnant women to have green vegetables, vitamins and fruits in her diet. The Mamtas say that such advice makes the neighbors very happy. SMM02 concludes that she is a member of a SHG in her village and she is always made to stand in the front. She says that (the women in her SHG say that) she is from the hospital and let her speak (give her more importance than other members in the group). She says she has been with her SHG (name – Akanksha Group) for three years now.

A.1.12 Interview with SMA01’s Husband

Place: PHC, Warisnagar Block, Samastipur District

Date: 01/04/19

The research team meets SMA01’s husband and takes his consent for the interview. He is asked about a delivery case that happened yesterday, for which he is at the PHC. His wife was unable to come to meet the family so he was here to ensure that they were alright and that the mother and child would be discharged soon. He says that when they received the call the evening before, they called the ambulance but at the time it was busy and could not come. So they brought the pregnant woman (to the PHC) in an auto. She was admitted after her blood pressure was checked when the ANM said the delivery can happen any minute. He says that the family lives very close to their house and they did not face any difficulty getting there as the roads are also fine (between the woman’s house and the PHC, unlike the road from his house to the PHC). When the family had called, SMA01’s husband had gone to their house and advised them to take her to the PHC in advance and rest there as the condition of the road (between their house and the PHC) was quite bad and the weather was also not right and that there might be a hailstorm. He says then they both, him and SMA01, brought the pregnant mother to the PHC as it was night and the road is also quite bad and he didn’t want to let her (SMA01) go alone. He says that he had taken his bicycle while SMA01 walked to the PHC and they stayed till the child was born. He says they reached the PHC at 9.20 PM and the child was born at 10.07 PM and that the delivery went well. The mother was taken to the ward when the bleeding began; SMA01 was still here at the time. He says that she was taken back to the delivery room on a wheelchair to stop the bleeding and put on a saline drip. The bleeding stopped after some time. He left for home at 1.00 AM with SMA01. He says that the patient was accompanied by her mother and mother-in-law. She stays with her in-laws in this village and had called her mother who lived elsewhere. Her mother had come down from Kashipur to look after her. On being asked about his work, he says that he works as a courier between PHC and other centres and has a contract with the hospital directly. He says he does not get any salary and his work is incentivized based on the boxes he delivers in a day. It used to be INR 75 per box but since October, he says he has heard that it has gone up to INR 90. He says he does not get any other payment over and above this amount. He says the number of boxes in a day depends on the site – on Wednesdays he has to visit three sites, on other days it’s only one or two sites and one site means one box. He adds that he gets to work about 22 days in a month. He says he has to carry boxes only to AWCs on RI days. He mentions that he has been doing this work from before his wife became an ASHA in 2005 and that she was associated with PHC for pulse polio work even before she became ASHA. He says that his father also worked at the PHC who retired in 2002.

A.1.13 Interview with SMA11 (Infant Mortality Case)

Place: Satmalpur Health Sub-centre (HSC), Warisnagar Block, Samastipur District

Date: 01/04/19

ASHA says the woman who lost her child was at her in-law’s place which falls under her catchment area. She says that the woman had received all ANC check-ups during her pregnancy. She says that the child did not cry at the time of birth; he cried for a bit after he was put on oxygen and hit on his butt. She says the mother had two USGs done and had all her shots from a private clinic (from someone called Manjula). She says this happened despite the fact that both the woman and her husband were examined. She says the child could not be weighed at the time of birth but from what she saw, he must have weighed around 2 kg. She says the delivery was normal and they had rushed the child from PHC to the private hospital. The child died on the way. SMA09 and SMA13 are also standing there. SMA09 says that the child weighed very less. She says that when a child weighs less, he cannot bear the pain during delivery as when the mother pushes, the child also exerts force to let itself out. She says that’s the reason why mothers are asked to eat properly so that the child is "bold" and able to take this pressure. SMA11 says that this is the first time something like this is happening for her. She says that she is feeling extremely sorry. She says the woman had had three miscarriages before that she was not informed of. She has heard that she had once had a miscarriage in the eighth month and this time both the woman and her husband had undergone physical examination. She says that the woman belongs to Mahtotola. SMA11 says that after the incident some families in the communities have put the blame on her and said that ASHAs should be sent to the private sector. She says that they had got all their tests done at a private hospital – USGs and other examinations were done in a private hospital. She says she had even brought her to get all her all shots on RI days. She says she also lives in the same community and although the family did not blame her, others in the neighborhood have blamed her for what happened. She would just reply saying that she did not know about the complications and that it was a normal delivery. On being asked if she has now lost the credibility to convince people in the community, she says no she still has it in her to do the work she has been doing since 2012 and one case does not change anything. She says it is normal for a child to develop complications at birth and usually "they come back to life" after an hour or two and that this case is first of its kind where the child could not be saved. She mentions that in this case the child did not change color as they usually do in other cases. SMA13 adds that it’s common for a child to not cry at the time of birth and that they would often flick under the child’s feet to make her cry. She refers to a case where the mother had a case of eclampsia at the time of birth and the child was too weak to respond. There was no power in the room so they could not put the child in the baby warmer. The baby could not be given to the mother as she was not in the state to hold him and give him her body warmth. So, the ASHA took the baby in her arms and kept him close to her body so he receives the warmth required by his body. She kept flicking under his feet and held him for a long time until the child made his first cry. Soon after the power was back and the baby was put in the baby warmer. SMA09 then says that when things go right they do not get the credit but when something goes wrong it is always the ASHA who gets the blame. She says that if she knew the woman’s history on time, she would have advised them to get the delivery done in a private hospital. She would have said that when they have got all their tests done in private hospitals, they should have the delivery done there as well. She says that nobody wants to see that the ASHA did not have this information but they blame her now that the child was "lapsed". She says that the woman was not accompanied by dai but her husband, aunt, mother in law and sister in law to the PHC. She says the woman’s husband had come to her house in the morning to tell her the woman was having light pains. She told him she needs to be taken to the PHC. The woman was reluctant to come to the PHC but her husband forced her to come. Upon getting there, she was told that her water had broken and that she would deliver any minute. The child was born on 27th March. She says she was eating well during her pregnancy and there were no issues. She talks about the day of the delivery and says that she was on her way to the PHC when she decided to go to the woman’s house. The woman was not home and she was told that she had gone to the toilet. She told her husband to let the woman know that she had come. The husband told her to be on her way and that they would be leaving soon for the PHC. They arrived a while after she reached the PHC. They had hired a tempo and the woman was getting light pains. She says they had not called for the ambulance as they thought this could not be labor and an ambulance is only called when a woman goes in labor. On being asked if the woman had delivered before her due date, she says that it is normal for the due date to vary from what was estimated through an USG. This woman’s due date was April 4th and she had delivered slightly earlier on the 27th. SMA11 says that she also cried with the mother when they lost the baby. She says that (throughout the pregnancy), she would go visit her every time someone came to call her and that the family had a lot of trust in her. She says that she did not eat for two days for the mother. SMA09 empathizes and says that such incidents can get very tense. SMA09 also says that crying is natural (after such an incident). She says that a healthy child is also a kind of incentive for ASHAs and that if the child passes away it nullifies the hard work they had put in through the course of nine months. SMA11 says (talking about SMA09) that she is also worried that now since it was her first time with this family, people might not want to call her and that an incident like can affect (ASHA’s credibility) a lot. When an ASHA does 2-3 deliveries without any problem, people call her often and say that "this ASHA is very good at her job" and "she can get our work done very effectively". SMA11 talks about an incident where she was at training in Patori when she gets a call from a woman in her area. ASHA told the woman that she is in Patori and she can call her a vehicle and she should go on without her. The patient said she would go only if the ASHA goes with her. So the ASHA attended the second day of training and took the woman to the hospital that night. The woman had received shots that day. She did not have anyone with her when the labor started except the ASHA. The woman’s mother was sitting outside (the delivery room) and crying. She says this delivery happened properly but the other was fated to go down that way. It’s all a game of fate, she says. She says that she has put in a lot of her own money during deliveries. She says that when a patient runs short of money she sometimes helps out so she can get her medicines. SMA09 says that sometimes "normal" families have about INR 250-500 on them and if they run into any extra expenses, she pitches in. She says that they are also from the same village and they are not going anywhere and that at least they are getting the help when in need. She says she anyway always carries INR 500-1000 with her. SMA11 says that sometimes when they need medicine, she goes out and buys them with her own money and after when the child gets better she gives them an account of the money spent by her which is paid back to her. She says that she has given them the account of the money that she had spent on March 27th (on the day of the child’s birth). She says that she made the payment so they can later, if need be, get medicines on credit. She says that she expects her money back in a few days as people do not keep her money (that she spends on their medicine) for long. SMA09 says that it is hard to estimate the amount that one might need during a delivery. It could be anywhere between INR 1000-2000. Sometimes, the woman might bleed a lot and she is prescribed injections which are not available at the PHC and that they have to get from a private hospital. SMA11 says that the money that they spend on a patient is paid back to them sooner or later. She talks about her family and says that she has a son and a daughter. The daughter is married and stays with her in laws. The son is also married and has a wife and a son. She says that her grandson was also born at the PHC whom she had brought herself. ASHA then refers back to the case where the child had passed away and says that the woman’s family (from her natal house) had also landed up when it happened and threatened to file a case against the ASHA. On being asked if in such a situation they receive any support from the PHC, ASHA says that she did not talk about this at the PHC so much because the husband of the woman told her that they are his in laws and to let them say what they want. He assured her that they won’t be taking any such action against her. ASHA says after that she left the issue there. She says the whole episode was just a big trouble. While concluding the conversation SMA11 says that she was extremely sad by the incident and when the PHC asked the couple to get a physical examination done, the ASHA took them to a RMP who told them that they both had negative blood groups.

A.1.14 Interview with ANM, SMF01 & SMA01 (Infant Mortality Case)

Place: Satmalpur Village, Warisnagar Block, Samastipur District

Date: 02/04/19

The child was born two months premature on 22/3/19 to mother, Juhi Khatun and father, Md. Israr, residents of Mohuddinpur (Musalman tola) from village Rohua Paschimi, Warisnagar block, Samastipur. According to the first information letter- format to the State Health Society, Bihar, the cause of death is given "weak infant child". The death took place on 28/3/19 at the house where the family resides. The first information report is brought to the PHC by the concerned ANM. The research team meets the facilitator and the ANM at the PHC. The facilitator says that the woman had faced no problems during her pregnancy. She had received proper check-ups and injections through its course. She says the child was born too weak to survive. She adds that the mother was eating properly during her pregnancy though they did not have anyone to supervise whether she was. She says that she was told to have a good diet when she would come in for ANC check-ups but whether she was actually eating or not is not known. When prompted, she says that her weight records can tell whether she was eating or not and that she needs to check the mother’s card to find out if her weight record was normal. The facilitator says the child weighed 1600 grams at birth which was very low and the child was immediately referred from there. They say that there was no USG done as not everyone gets it done. They say this family resides in the Musalman tola of the village. The ANM says that the delivery was normal but they don’t remember if it was the woman’s first issue. She says the first information report is filled up by the ASHA which is then given to the ANM who submits it at the PHC. They say these reports used to be submitted to the facilitators but now they are submitted directly to the ANMs. She says after the report is submitted at the PHC, their staff visits the family to investigate cause of death (type of diseases etc.) and prepare their report.

A.1.15 Interview with ASHA (SMA01) (Call recording)

Talking about a delivery, SMA01 talks about an infant mortality case that happened in her area. She describes the case to the team. It happened in a family in the Musalman tola. Their house is situated behind the sub-centre. On being asked if the mother had received proper attention during her pregnancy, SMA01 says this case has a story in the background. She says that the woman’s husband was married before and has five children from his previous marriage. After the 5th child was born, the doctor had warned the family that another pregnancy could be dangerous for the mother. ASHA says that she had tried to convince the family to let their daughter-in-law have the sterilization surgery done and that she already has three daughters and two sons. The husband (Israr Khan’s) family refused and said that it is deemed to be a sin in their community and that they would like to have another child before getting the surgery done. The woman got pregnant again and passed away at her mother’s house while giving birth. The ASHA says that they found out much later and now it has been more than a year since the incident. The woman who lost her child (Juhi Khatun) now is the second wife of that man (whose wife died last year). The ASHA says that the second wife was also married before and has two daughters from her last marriage. Her first husband had a second wife in Bengal which she had no knowledge of. She found out about the second marriage after a year and was at her mother’s place for another year and half after the divorce was done. She was supposed to get her things back that her parents had given her on her wedding but she refused to go back for them saying let him return the things if his conscience makes him. ASHA had this information however she had no knowledge of Israr Khan’s second marriage to Juhi at the time. She was informed by her sister in law that Israr Khan’s has gotten married again and his wife is now pregnant. She thought she should bring the woman to her centre on RI day and get her shots. She got her fist shot on Februrary 22nd. The second shot was supposed to be given on March 22nd but the centre was closed on account of Holi. A night before (on the 21st March), the husband of the pregnant woman came over to her house. He said that his wife is having a lot of pain and she should come and see her. ASHA said it can’t be possible as the woman had just entered her seventh month of pregnancy. The husband said they had taken the pregnant woman to a traditional healer called "Satbhamadidi" who said the child will not "stop" anymore. ASHA scolded the husband and said that "you only go to places where there are no doctors". She told him that he should have come to her or consulted with a ladies doctor. They would have done some treatment to stop the baby or given her medicine or done an ultrasound. She says she had only gotten her one shot and Kamladidi (ANM) had said at the time that she will get her RI card made when she comes in for her second shot as they had run out of cards that day. She says the husband had brought a tempo that night and insisted she goes to see his wife. She says the child was born in the tempo on their way to the PHC at 5 AM. The tempo was parked near the gate of the hospital near the gate of the labor room when the child was born. The ANM asked if the child was breathing and the ASHA replied yes. The child was crying and the ANMs who were sleeping at the time were woken up. The ANMs cleaned the baby and put him on oxygen. He was immediately referred to district hospital in Samastipur. ASHA says that she had to go and wake up the ambulance driver herself. She was also scared as she was alone and sick and without her husband but then she thought these men are from her village and they won’t do any wrong. She went up to the ambulance driver with the pregnant woman’s husband to wake him up. She told him they have to take a child to Samastipur who was referred to the hospital. The cord was cut after the patient was taken inside and a cord clamp placed on the child’s belly button. The child was crying but he was not given any shots at the PHC (no BCG, no OPV or hepatitis). The PHC staff was rushing them to take him to district hospital. They instructed the mother and her sister in law to stay back and leave for home after resting for some time. ASHA left with the child, his grandmother, grandfather and father on the ambulance for Samastipur. They reached at 5 AM. There were two ANMs present in the child care section who examined the child and asked them to take him to DMCH in Darbhanga. Upon ASHA’s insistence, the ANMs agreed to keep the child till 10 AM until the doctor’s arrival who can then examine and refer the child to DMCH. After putting on a diaper, he was given to the ASHA and kept in childcare. ASHA says she could not wait till 10 as her husband was sick and there was no one to give him food or medicine. ASHA told the child’s father that the child will be referred to Darbhanga and the ambulance will be there. She says that the child’s mother’s family also lived nearby who had all gathered at the hospital. She left for her home on a tempo and was constantly in touch with the father. The father informed her on call that the child has been referred to DMCH and that they are on their way. Upon reaching DMCH, it was found that there were no beds available in child care and that the child will have to be kept in the general ward. They said that the child will not get the care he needs in the general ward and was referred back to Samastipur hospital. The father called ASHA and told her that he will not be taking his child back to government hospital and that he is taking him to a private hospital in Samastipur. The child was kept there for two days and a total of INR 14,000 was spent. The doctor advised them to keep the child admitted for another 12 days but the family said they cannot afford it. The father informed the ASHA that they have brought the child home and the ASHA went to see him. The ASHA asked the family to wake the child up but they said that the doctor has advised them to let him sleep for long. She then asked if he was able to have mother’s milk and they said that he is too weak for that. She suggested to take the breast milk in a bowl and to feed him with a dropper. She then asked them when the next injection was and they said it will be given next Friday. She went back to see him on Thursday evening and then again on Friday morning before the child was supposed to get his shot. She says the child was not in a good shape on Friday morning and that she was scared to even touch him. She says he seemed as feeble as a kitten and his hands were too weak to show any movement when she tried to move them. She says he seemed lifeless but he did not say that to the family. She came back to her house and thought in that condition it might be too risky to give him a BCG shot. She says she thought if anything happens because of that, she would eventually get the blame as it usually happens in Musalman tola. Next morning she called the father and asked him to bring the child for his BCG shot and told him that she will also come with them and that they will get his card prepares as well. The father then informs her that the child had died the previous night at 11 PM. She later received a call from CARE personnel Aryan who wanted her to visit the newborn (with "low baby weight") with him. The ASHA, who was at home at the time, informed him that the child had passed away. He asked her to come to Centre No. 26 (AWC) so they can go visit the family together. She called him from Centre No. 26 but Aryan said he was at Centre No. 19 and cannot make it because the road was too bad. The ASHA went to visit the family on her own and saw that a crowd had gathered. They were in mourning and the child was dressed as a bridegroom. ASHA asked them when the burial was but they said it was Jumma (Frida) and they had an event in the evening. ASHA called the CARE personnel again asking him to visit the family. He said he won’t be able to make it as he was at Centre No. 16 and the roads were in bad condition. He asked her for their mobile number which the ASHA already had with her. She left for the hospital where she ran into the CARE personnel again. He took the family’s mobile number from her and also took a picture of the first information letter she had brought to submit. She says that they are told in their trainings to report any beneficiary death within the first two hours. The call should be made to the BHM. She says she had called the BHM who did not receive her call. She had then brought the first information letter to the PHC herself. When she took it to the data operator, he asked her to take it to the BHM. BHM then sent her to submit the report to the BCM. The BCM asked why she was giving the report to her as it needs to be given to the ANM. So, today, the ASHA says, she goes to the ANM’s house with her husband to hand her the letter. On being asked why the woman got her first TT shot so late in the sixth month, the ASHA told her that in December they were on strike and in January they did not have any medicine except MR. February was when she could get her the shots. She had said that she had got the information through her sister in law when the woman was in her first trimester. On being asked if the woman was taking a good diet, she says that the woman was pregnant so she must be taking a good diet. Then it was asked her if she had received her ANC check-ups to which the ASHA replied that she had and only received the first TT shot. She says that the ANM has a weighing and a blood pressure machine but she never uses it but that she writes it down based on her experience. She was asked if that’s how all ANCs are done and she says that the weighing machine is always dysfunctional at the time at the AWC. She says that the centre does not even have a proper chair and a table when they even received funds for that. She asks not to tell the ANM that she had said these things about her. She says that the ANM even has a Haemoglobin machine which she does not use. The ASHA says if she did not have these difficulties, she would have got all the examinations done by herself.

A.1.16 ANM & Facilitators Monthly Meeting with MOIC, BHM & BCM

Place: PHC, Warisnagar Block, Samastipur District

Date: 02/04/19

It is Family Planning day at the PHC. ANMs and ASHA Facilitators have arrived at the centre for a meeting with the MOIC, BHM and CARE personnel. The meeting is taking place in the same room that doubles up as post-op on family planning days. The MOIC is speaking about MPI (Antara) especially about it side effects. He enquires about the dip in the number of women getting MPI shots and the ANMs tell him that the women are worried about the side-effects of the shot. The MOIC gives an example of Penta shots and how some children develop a fever as a side-effect and are still safe to get the vaccine. The ANMs and the facilitators list bloodshot eyes, excessive menstrual bleeding or no bleeding at all as the symptoms when the MOIC asks about the side-effects the women are complaining of. MOIC further explains that the symptoms could be a reaction to the B-Complex present in the medicine and that the issue is only hormonal. He says that what’s needed is to address the complication and explain the side-effects to the beneficiaries. He adds that counseling is an important step for family planning and the beneficiary must be informed about the complications that may arise due to the side-effects. He says there has been a change in the general thinking among the women who now want to keep a gap of 4 to 5 years between children. To this an ANM sitting next to the research team says that "women do not want to have proper gap between children". The MOIC says after the counseling the names and numbers of the beneficiaries must be taken down so a reminder can be sent to them on the day MPI shots are given as some women in villages who do not go out too much may not have this information. The CARE personnel asks the participants if they remember the grace period of MPI shot – the women reply that a shot can be given before two weeks and after four weeks of the designated date. The MOIC says that one shot is not enough and the women must complete the course. The MOIC says likewise Chhaya should also be done on Mondays and Saturdays at the HSC on family planning days. The CARE personnel then says that reporting has not been proper by the ANMs for example with information like condom usage at the HSC. He stresses the importance of reporting such expenditure as being government inventory if not reported the ANMs would be held responsible to explain the expenditure. An ANM then says that they were told they would be receiving a format for their reports. The BHM then says that the format will be given next month and they can provide the current expenditure details on a piece of paper. The CARE personnel then starts talking about Saas-Bahu Sammelan (a gathering organized once a month, at AWCs, where daughters-in-law and mothers-in-law are brought together and advised on family planning measure, child gap, nutrition, etc) and that earlier the funds had lapsed which is why the events could not happen. But now, he says, there has not been any reporting even though the funds are available. The ANM/facilitators tell him that the micro-plans for Saas-Bahu Sammelan have been submitted but not the vouchers. The MOIC then asks the ANM/facilitators to submit the reports on the same with details like number of planned and actual Saas-Bahu Sammelans in their respective areas. The MOIC asks the BCM (sitting on his left) to take down details about Arogya Diwas (or RI) in her register. The BHM asks the ANM/facilitators to submit their micro-plans as soon as possible. He insists them to make it a thumb rule to submit their micro plans before every Tuesday. Some of the ANMs say that they will be submitting theirs today. The MOIC then talks about an order received from the office of the District Magistrate which instructs them to inspect all HSCs and their medicine supplies. In compliance with that, the MOIC says, he will be visiting all HSCs along with the BHM on Mondays and Saturdays. He asks them to take a stock of their inventory and inform the PHC about the medicines that they need (including Chhaya and Antara). He says they can take the medicine on their own from the PHC or have theirs delivered at the HSC. He tells them that the expired medicines should be wrapped in a red cloth and kept aside. He asks them to also make a list of medicines that are expired, equipment that they need or that are no longer required at the HSC. He asks them to make two copies of the lists – send one to the MOIC and keep the other with her. He then says that as most ANMs have received their RI trainings by District Padadhikari, they should also learn how to fill up the format. He goes on to talk about the importance of vaccination. He says that when he was in college, cases of tetanus and polio were rampant but they are not seen anymore. He says that however there are some other preventable diseases that are still doing the rounds such as chicken pox and measles. He tells them that these cases are present and they must be reported and treated. He talks about having these cases treated on time as they can result in extreme cases leading to death. He tells the ANMs that chicken pox characterized by high fever can be treated by them with the means they have. They can give the patient paracetamol for high temperature, cetrazine for allergies and calamine lotion for the blisters. He says that in villages, people call it "mata maiyya" but (they need to be told that) a shot is important. He says when families call the disease "mata maiyya" and refuse to get the child any medicine; those children must get the right treatment. The MOIC refers to the Leprosy Khoj campaign and asks if the ASHAs are doing house visits. He asks them to ensure their _dai_ly report reaches the PHC even if it says "nil". He tells them it is important those cases are verified and treated at the PHC. The MOIC goes on to talk about Kishanbazar HSC that has not been performing well. He says the owner of the building the HSC is set up at has in that the centre is closed most of the time. He says the last ANM had done a good job and there were no complaints before. He then tells the current ANM responsible to improve the centre’s performance. The MOIC refers to a recent infant mortality case and asks the concern ANM to submit a detailed report on the incident. The ANM says that the child was malnourished and was referred to the District Hospital for treatment. The MOIC says that such incidents won’t be condoned in the new financial year as now if they miss a deadline, they would lose on their payments. He says that with the elections coming up and ministers visiting, the sub-centers must stock up and be up to date as anyone can visit with a problem and they should have the resources. In the middle of the meeting, MOIC enquires about an ANM who was absent and instructs to have a letter issued to her for her "chronic" habit of missing meetings. The MOIC reminds everyone that April 7th is Pulse Polio Day which is also World Health Day and that it is general knowledge and they should even tell their children about it. The BHM enquires about the progress of leprosy/kalazaar/TB work in the field. One ANM informs that the ASHAs are refusing to work as they have not received any money so far. The BHM asks her to submit the names of the ASHAs and their facilitators who are saying that. Another facilitator complains that one ASHA in her area is pregnant and she cannot work. She questions the PHC officials why they cannot appoint new ASHAs? The BHM asks her not to get agitated and put in a request. The MOIC tells her not to worry about recruitment as they can get the work done using volunteers if they have to. He says that despite requesting the village head numerous times he has not called for an aam sabha. The aam sabha would be used to shortlist candidates (after their degrees are checked) and select ASHAs for the required position. He says that the village head is not responding to DM requests so will not listen to PHC officials either and they can’t do anything until then. MOIC says a person at his position and his responsibilities, it is important to know what’s happening on field. He asks if the ASHAs are doing home visits for leprosy, kalazaar and TB. He asks the ANMs and the facilitators to interact with ASHAs gently and with love and to maintain a good relationship with them. He says no work be it RI or anything will be successful without ASHA cooperation. MOIC talks of a controversy regarding ANMs being sent to a panchayat for RI and very few beneficiaries came. The ANMs said ASHAs complained that their facilitator did not inform them about the RI. MOIC asks for names of the ASHAs who said they weren’t informed by their facilitator. He yells at the facilitators for not visiting AWCs on RI days. After that, the MOIC asks ANMs for pulse polio day preparations and that whether it is on schedule. He also asks if all ASHAs have enough medicines at their sub-centres for polio day. He says along with making arrangement for polio day, ANMs are also required to get the vaccine carriers cleaned as the vaccines need to stay in a clean space. The BHM asks them to use VHSND funds for this cleaning before starting polio campaign to which one ANM says she can do it herself. Then, the BHM tells them to update and submit their yearly micro-plans for Saas-BahuSammelans, monthly reports and RCH registers. One ANM says that a couple of ASHAs who are working two areas cannot update RCH registers because there are not enough pages. BHM asks for names of ASHAs who have updated their RCH registers. BCM is taking these names down. He also says that payments will be withheld if RCH registers are not updated on time. Then the MOIC introduces the research team to the participants of the meeting. He then tells the participants that they are all given INR 1000 for their uniform despite which they have not followed the dress code for the meeting today. He says what the take-away of the research team would be when they see women belonging to one institution in colorful sarees. He tells them that next time they should strictly be in uniform and that it should be a matter of pride to them. The BHM then talks about the Saans-Bahu Sammelans and says that since some sub-centres have two ANMs, the money for the work should be divided according to the work done by both. For example, the payment for one centre is INR 1500 and the money should be divided between the concerned ANMs as per the number of centers worked by each of them. He says that the division should be done as per their mutual understanding and that if anyone has any grievances about the same should report to him. A disgruntled ANM sitting next to the research team mutters that all incentives are given to ASHAs and there is no value for ANM’s work. She says how much ASHAs even work for them to receive so many incentives. She then tells the BHM while reporting that ASHAs bring RCH registers to submit at PHC but no one takes it. The BHM tells her to be concerned with completely filling up the registers. The reporting continues and the ANMs and the facilitators give their numbers to the BHM. Satmalpur has 16 sites and 11 ASHAs – the ANMs say that ASHAs are not willing to take new RCH registers. The BHM asks what he should put in the update in his reports. The ANMs seem unsure and take their time to respond. One of them says that the old ones are up to date till March while the other is startled and hits her jokingly with the pen she has in her hand. RahuaPaschimi has seven sites and seven ASHAs of whom four have updated including SMA01. The BHM says there are 37 ANMs in Warisnagar block – 34 at the sub-centres and 3 at the PHC. Some centers have one ANM but most have two ANMs. Then, instructions are given to ANMs to plan their Saans-Bahu Sammelans ASHA-wise and payment will be made in the same way. For Saans-Bahu Sammelans, the BHM asks the ANMs not to make the plan for sites that has no ASHAs. He says they can allocate one ASHA on two sites or two for one site according to need. He asks them to update their records and use untied funds if need be. He says the plan needs to be given to the PHC so the PHC staff can be at the site on the day of the event. He tells them failing to do that they will be responsible for not informing the PHC and if the plans reach PHC on time and the staff fails to show up, it will be PHC’s responsibility. He also asks them to give plans for dates before 31st March only because of end of financial year. The MOIC says that the Panchayat wise cluster meetings need to take place before 24th April. He says that all ASHAs from that panchayat need to be there. They will be given instructions on how to fill up their monthly registers. The ANMs complain that ASHAs are refusing to fill reports as there is no money and they have pending dues.

Once the meeting comes to a close, research team goes to the building that houses the delivery room. The team notices a chart put up right outside the delivery room. It mentions the several food items that an in-patient is supposed to be provided by the hospital. There is an ANM who is asked the reason behind people not opting to eat PHC food. She says it depends on the patient and her family whether they want to eat PHC food or not. She also says that those who prefer to eat outside probably have issues with impurity and untouchability (caste). She adds that they leave the hospital and take a shower before entering the house. Fresh clothes are kept for her outside so she changes into them after the bath. She then washes the clothes that were taken to the hospital with her after which the mother and the child stay in one room. The ANM however says that it is good practice to wash the clothes that are used in the hospital as it reduces the risk of infection but that most people do not see it as infection and they are only bothered by the idea of impurity and untouchability. She is asked referring to the food chart on the wall if the patients are actually receiving what’s mentioned. The ANM says that they do not get any food in the evening but sometimes they are given tea and biscuits as mentioned on the chart. She says besides that they get rice, dal and roti throughout the day. A group of women are sitting in the waiting hall one of whom says that they do not receive anything that’s mentioned on the chart nor do they get tea thrice a day. The woman says they do not get any of the food items mentioned on the chart.