- NL Sena
Bhil women from the Dhadgaon region in Maharashtra's Nandurbar struggle with stigma, social exclusion and a rural healthcare system that fails to provide effective treatment for infertility.
On a hot afternoon in Akrani taluka in the Dhadgaon region, Shevanta Tadvi runs after her small herd of goats, head covered with her saree pallu. When a baby goat ventures into the bushes or tries to enter someone’s farm, she bangs her stick on the ground, bringing it back to the fold. “I have to keep a close eye on them. The little ones are more mischievous. They run off anywhere,” she smiles. “Now they are like my children.”
She has walked towards the forest, about four kilometres from her home in Maharajapada, a hamlet of Harankhuri village in Nandurbar district. Here she is alone and free amongst her goats, the chirping birds, and rustling trees. Free also of the taunts of vanzoti (barren woman), dalbhadri (accursed woman) and dusht (wicked) that have been flung at her through the 12 years of her marriage.
“Why is there no such derogatory term for men who cannot have a child?” asks Shevanta.
Now 25, Shevanta (not her real name) was married at the age of 14. Her husband Ravi, 32, is an agricultural labourer, earning around Rs. 150 on days when he finds work. He is also an alcoholic. They belong to the Adivasi community of Bhils, in this predominantly Adivasi district of Maharashtra. The previous night, Shevanta says, Ravi (not his real name) had beaten her again. “Nothing new," she shrugs. "I cannot give him a child. The doctor said my uterus is flawed so I cannot conceive again.”
A damaged uterus is how Shevanta describes the polycystic ovarian syndrome (PCOS) she was diagnosed with in 2010 at the Dhadgaon Rural Hospital, when she had a miscarriage. She was only 15 years old at the time, and three months pregnant.
PCOS is a hormonal disorder among some women of reproductive age that causes infrequent, irregular or prolonged menstrual cycles, elevated androgen levels and enlarged ovaries with follicles surrounding the eggs. The disorder can lead to infertility, miscarriage or premature childbirth.
“Besides PCOS, anaemia, sickle cell, poor hygiene and sexually transmitted diseases are also responsible for infertility among women," says Dr. Komal Chavan, Mumbai-based chairperson of the Federation of Obstetric and Gynaecological Societies of India.
Shevanta recalls that day in May 2010 vividly – when she had the miscarriage and was then diagnosed with PCOS. The sun was beating down on her head as she tilled the land. “I had a pain in my abdomen since the morning," she remembers. "My husband refused to come with me to the doctor, so I ignored the pain and went to work.” By afternoon, the pain had become unbearable. “I started bleeding. My saree was soaked in blood. I couldn’t understand what was happening,” she says. When she lost consciousness, the other agricultural workers took her to the Dhadgaon hospital about two kilometres away.
After that diagnosis of PCOS, her life was never the same.
Her husband refuses to accept that Shevanta has a physiological problem that causes the infertility. “How will he know why I am not able to conceive if he won’t even see the doctor?” asks Shevanta. Instead, he subjects her to frequent unprotected intercourse, and sometimes to sexual violence. “He gets frustrated if I get my period even after trying so much and that makes him more aggressive [during sex]," Shevanta says. “I don’t like it [intercourse]," she confides. "It hurts a lot, burns sometimes and itches sometimes. It has been going on for 10 years. In the beginning I used to cry, but eventually I stopped crying.”
Now she believes that infertility, and the social stigma, insecurity and isolation that accompany it, are her destiny. “I used to be very talkative before I was married. When I first came here, the women in the neighbourhood were very friendly. But when they saw that I could not conceive even after two years of marriage, they started avoiding me. They keep their newborn children away from me. They say I am paapi [a sinner].”
Exhausted and isolated within the family's one-room brick house with its few utensils and brick-lined chulha (stove), Shevanta also lives with the fear that her husband will marry again. “I have nowhere to go," she says. "My parents live in a thatched hut and work on other people's farms for Rs. 100 a day. My four younger sisters are busy with their own lives. My in-laws keep showing my husband prospective brides. Where will I go if he abandons me?”
Shevanta manages to find work as an agricultural labourer for roughly 160 days a year at a daily wage of Rs. 100. She is lucky if she gets Rs. 1,000-1,500 a month, but she has little control over even those meagre earnings. “I don’t have a ration card," she says. "I spend around Rs. 500 a month on rice, jowar flour, oil and chilli powder. My husband takes the rest of the money away...He doesn’t give me any money even for household expenses, forget about medical treatment, and beats me if I ask. I don’t know what he does with his occasional earnings besides spending on alcohol.”
There was a time when she had 20 of her beloved goats, but her husband has been selling them off one by one, and now there are only 12 left.
Despite the financial stress, Shevanta managed to save up for infertility treatment from a private doctor in Shahade town, 61 kilometres from her hamlet. She paid Rs. 6,000 for clomiphene therapy to stimulate ovulation for three months in 2015 and another three months in 2016. “There was no medicine in Dhadgaon hospital then, so I went to the private clinic in Shahade with my mother,” she tells me.
In 2018, she was able to get the same treatment free of cost at the Dhadgaon Rural Hospital, but it failed for the third time. “After that I stopped thinking about treatment," says a resigned Shevanta. "My goats are my children now.”
Treatment differs from case to case, explains Dr. Santosh Parmar, gynaecologist and rural health officer at the 30-bed Dhadgaon Rural Hospital, which sees patients from 150 surrounding villages and registers about 400 patients at the outpatient department every day. “Drugs such as clomiphene citrate, gonadotropins and bromocriptine work for some. In other cases, advanced assisted reproductive technologies such as in vitro fertilisation (IVF) and intrauterine insemination (IUI) are required."
Basics such as semen analysis, sperm count, blood and urine tests and genital examinations are possible at the Dhadgaon hospital, Parmar notes, but no advanced infertility treatment is available here, or even at the Nandurbar Civil Hospital. "Therefore, infertile couples are largely dependent on private clinics where expenses run into thousands of rupees,” he adds. Parmar is the only gynaecologist at the hospital, handling everything from contraceptive services to maternal health and neonatal care.
In India, evidence on the prevalence of infertility, says a 2009 paper in the journal Health Policy and Planning, is “sparse and dated.” The National Family Health Survey (NFHS-4; 2015-16) records 3.6 per cent of women aged 40-44 as never having given birth or childless. With the focus on population stabilisation, infertility prevention and care has remained a neglected and low-priority component of public healthcare.
Shevanta drives this point home when she asks, “The government sends condoms and pills to control birth; can't the government also provide free treatment for infertility here?”
A 12-state 2012-13 study, published in the Indian Journal of Community Medicine, found that most district hospitals had the basic infrastructural and diagnostic facilities to prevent and manage management, but the majority of community health centres (CHCs), primary health centres (PHCs) did not. Semen examination was not available at 94 per cent of PHCs and 79 per cent of CHCs. Advanced laboratory services were available at 42 per cent of district hospitals but only 8 per cent of CHCs. Diagnostic laparoscopy was available at only 25 per cent of district hospitals and hysteroscopy at 8 per cent of them. Ovulation induction with clomiphene was practised at 83 per cent of district hospitals and with gonadotropins at 33 per cent of them. The survey also revealed that none of the staff at the surveyed health centres had received any in-service training on infertility management.
“Access to treatment is an issue, but more important is the absence of specialist gynaecologists in the rural health set-up," notes Dr. Chandrakant Sanklecha, former president of the Nashik chapter of the Indian Medical Association. "To treat infertility, trained and qualified staff and high-tech equipment are necessary. Since the government’s priorities are maternal health and neonatal care, providing affordable infertility treatment at the PHC or civil hospital level is financially difficult.”
Five kilometres from Shevanta's hamlet, Geeta Valavi is spreading kidney beans out to dry on a khat (charpoy) outside her thatched hut in Barsipada. Geeta, 30, has been married for 17 years to Suraj, a 45-year-old occasional agricultural labourer. He drinks heavily. They also belong to the Bhil community. After a lot of urging from the local ASHA (accredited social health activist) that he should get tested, Suraj (not his real name) was diagnosed with low-sperm count in 2010. Some years before that, in 2005, the couple had adopted a girl, but Geeta’s mother-in-law and husband continue to victimise her for not being able to conceive. “He blames me for not giving him a child when the problem is with him, not me. But I am a woman, so I cannot marry anyone else,” says Geeta.
In 2019, Geeta (not her real name) harvested 20 kilograms of kidney beans and one quintal of jowar from her one-acre farm. “This is to eat at home. My husband does nothing on the farm. Whatever he earns from agricultural labour, he spends on drinking and gambling,” says Geeta, her clenched teeth betraying her anger. “He eats for free!”
“When he comes home drunk, he kicks me, sometimes hits me with a stick. When he is sober he does not speak to me at all,” she says. Years of domestic violence have left her with backaches and chronic pain in the shoulder and neck.
“We adopted my brother-in-law's daughter, but my husband wants his own child, that too a son, so he refuses to use condoms as ASHA tai suggests, and refuses to stop drinking,” says Geeta. The ASHA worker visits every week to enquire after her health, and has advised that her husband use condoms since Geeta complains of painful intercourse, sores, painful urination, abnormal white discharge and pain in the lower abdomen, all indicative of a sexually transmitted disease or reproductive tract infection.
The health worker has also advised Geeta to get medical attention, but she has stopped caring, refusing to get her symptoms addressed. "What is the use of seeing a doctor and getting the treatment now?” Geeta asks. “Medicine might heal my physical pain but will my husband stop drinking? Will he stop harassing me?”
Dr. Parmar says he sees at least four to five infertile couples every month where the low sperm count of alcoholic husbands appears to be the primary problem. “Ignorance about the male factor in infertility leads to brutal treatment of women,” he says, “but most of the time women come alone. It is important for men to understand and get tested, instead of putting the blame entirely on women.”
With the focus on population stabilisation, infertility prevention and care has remained a neglected and low-priority component of public healthcare. Ignorance about the male factor in infertility leads to brutal treatment of women.
Dr. Rani Bang, who has worked on reproductive health issues in the tribal belt of Gadchiroli in eastern Maharashtra for over three decades, describes infertility as more a social than a medical issue. “Male infertility is a big problem, but infertility is perceived only as a female problem. This mindset needs to change.”
In the paper in Health Policy and Planning, the authors observe: “Even though only a small fraction of women and couples are affected by infertility in the population, it is an important reproductive health and rights issue.” The paper notes that while the causes of primary and secondary infertility relate to both males and females, “Infertility is deeply feared by women, their identity, status and security are affected and they experience stigmatization, isolation and a loss of bargaining power and empowerment in the family and society.”
Geeta – educated up to Class 8 and married in 2003 at the age of 13 – once dreamt of becoming a graduate. Now she would like to see her 20-year-old daughter Lata (not her real name) fulfil her dream – she studies in class 12 in a junior college in Dhadgaon. “So what if she is not born from my womb; I don’t want her life to be ruined like mine,” says Geeta.
There was a time when Geeta enjoyed dressing up. “I loved oiling my hair, washing it with shikakai and just looking in the mirror.” She didn't need a special occasion to apply talcum powder on her face, style her hair, and drape her saree gracefully. But after two years of marriage and no sign of pregnancy, her mother-in-law and husband began calling her "shameless" for wanting to look good, and Geeta began to neglect herself. "I don’t feel bad for not having my own child; I no longer want to have my own child. But why is it wrong to want to look beautiful?” she asks.
Eventually, relatives stopped inviting her for weddings, name ceremonies and family gatherings, and the social exclusion was complete. “People invite my husband and in-laws only. They don’t know that my husband has weak sperm. I am not vanz [infertile]. If they knew about him, would they stop inviting him too?” Geeta asks.
Cover illustration: Priyanka Borar is a new media artist experimenting with technology to discover new forms of meaning and expression. She designs experiences for learning and play, juggles with interactive media, and also feels at home with traditional pen and paper.