It has been less than three months since Vanthala Pramila was forced to deliver her baby on the hill adjoining her hamlet of Y Gonthupally, a remote settlement in Andhra Pradesh’s Visakhapatnam district..The small hamlet of Y Gonthupally is a 25-km ride from the nearest town of Chinthapalle and a 2-km trek on foot across a mountain from the nearest motorable road. Set in the Eastern Ghats of Andhra Pradesh’s tribal region, for locals to access even the basic facility of a motorable road requires trekking through a rocky terrain..When Pramila went into labour, locals had to make a makeshift stretcher with sticks and pieces of cloth to carry her to an ambulance. But she was forced to deliver on the way. And all she had for help was from K Susheela, a community health worker under the government’s Accredited Social Health Activist (ASHA) scheme..While Pramila’s situation may seem shocking, this is a common ordeal for women in the Agency area which covers parts of Visakhapatnam and Vizianagaram district near the Andhra-Odisha border..Holding her 3-month old infant in her arms, Pramila says that a proper road would have ensured that she would have got the most basic maternal healthcare facilities required during a delivery..Susheela, who is the ASHA worker for the hamlet, agrees. “Whether it is a pregnant woman or even someone who is down with fever, it is very difficult to take them to a hospital. It’s very difficult without a road. Walking is tough, it is a ghat and the terrain is full of rocks.”.\r\tSusheela and Pramila.Painful ordeal for pregnant women.In September last year, a group of adivasis belonging to Maasika Valasachintala, a hilltop hamlet with no road connectivity in Vizianagaram district, decided to document their ordeal on camera. 24-year-old Mutthaiama was forced to deliver her baby on a treacherous dirt path while being carried on a handmade stretcher..A relative of the woman is seen saying in the video, “This is the situation we are in and this is how things are. No one cares for us and even at the time of death, we don’t know where to go and whom to approach. Please see this video and do something to help us... look at her, she is delivering on the way only. Our life and death is on the road only. Though we have been telling our elders and higher authorities, things haven’t changed.” .A resident of the village, which only has a path for two-wheelers, told TNM that they were pulled up by authorities for circulating the video to the media, and refused to comment further. .\r\tScreenshot from the video.This hamlet and Y Gonthupally, however, are just the tip of the iceberg. Locals point out that there are several hamlets, nestled deep in the hills, some of which require at least 4-5 hours of trekking to reach. For the women living in these hamlets, dealing with pregnancy turns into a nightmare, with most of them delivering babies within their homes. And for them, change is still far away. A testament to this ordeal is data suggesting that the state of maternal healthcare in the tribal belt is dismal..One too many deaths.There are two indicators as far as maternal healthcare of a region is concerned – Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR). MMR is defined by the government as the number of maternal deaths per 100,000 live births while IMR is the number of infant deaths per 1,000 live births. .According to the Integrated Tribal Development Agency (ITDA) office at Paderu town, the MMR under its jurisdiction for 2018 up to January 2019 was 204. This is shocking when compared to Andhra Pradesh’s rate between 2014 to 16, which stands at 74 or India’s rate which stands at 130. Officials seem to have been able to maintain a better standard when it comes to the IMR – 305 infants have died between 2018 and January 2019 compared to the 2017-2018 figure of 370..Government support for expectant moms.Sandhya Kumari is seven months pregnant and has come down to the village of Gudem, where the motorable road ends, close to GK Veedhi, the mandal headquarters. The closest road from the hamlet she comes from is around 30 km, she says, after which only two-wheelers can go. Either way, a 5-km walk is unavoidable..“Even when pregnant, we walk and come since it is difficult for a vehicle to reach us, we have no choice. Just going to the hospital or even to visit a health centre for a basic check-up, we have to travel very far,” she says..Sandhya is one of the more fortunate mothers-to-be as her maternal home is in Gudem, where an ambulance can reach and where she can safely deliver her child before heading back to her hamlet..\r\tSandhya.As far as ensuring safe deliveries in concerned, the state government relies on two things, ASHA workers and Auxillary Nurse Midwives (ANMs)..While ASHA workers are picked from the same villages, ANMs are more trained at handling such cases. The government has insisted that deliveries should happen only in a healthcare facility and while both these groups are working towards the goal, it remains a formidable challenge..This is because some ANMs are in charge of at least 25 to 30 hamlets and can manage to visit each hamlet only once or twice a month..Apart from providing ASHA workers and ANMs, on the 9th of every month, women in the region are asked to assemble at different points from where they can be picked up and brought together either to an anganwadi centre or another government building for a check-up..“We inform them in advance to come to one place. From there, we take them to the hospital in an ambulance once a month. Despite that, we can drop the mother only to a certain point. Even after they deliver their child, they need to trek back to reach their homes,” says K Kameswari, who is the ANM for 31 villages in the GK Veedhi region..Kameswari also points out that a major part of her job is to ensure and convince women to come to the health centre and take the medicines prescribed to them..\r\tK Kameswari, ANM for 31 villages in GK Veedhi region.“We have been telling authorities for a long time that we are struggling without a road and that it is difficult, but they insist that the deliveries should take place in the hospital and that the women should be brought two to three days before delivery. But how is that possible when it takes hours when you call an ambulance and when even basic roads aren’t there?” she asks..A social issue.The ASHA workers and ANMs state that locals are reluctant to travel to the nearest hospital and admit themselves a few days in advance as the government wants them to, because they do not want to lose their daily wages..“Let’s say we go from here. Then there will be no one to work at home. If we go, we need to stay for 2-3 days or even a week, which leaves no one here to earn a livelihood. That is why many don’t want to go,” Susheela explains..Dr Hemalatha, the Superintendent of Victoria General Hospital (VGH) in Visakhapatnam, points out that the problem is a social one. “In most cases, the women are illiterate and so are the husbands. They may already have one or two children. How can one expect her to leave all that and get admitted? They are not willing to do so because it is difficult to manage. If a patient comes, her husband will have to accompany her. If it’s a delivery case, one female assistant, generally a close relative, will also have to come as men aren’t allowed into the ward. There is also a fear as to how uneducated persons like them can come to the town and stay,” she explains..According to DK Balaji, Project Officer ITDA, Paderu, the most important reason is a lack of awareness among the tribal women, with many getting married very early and expecting a second or third child by the age of 19 or 20..“Even the ASHA workers in the area are picked from the same region. Their awareness levels are also quite low. Though we constantly give them training, they still need to rise to the occasion in most of the cases in interior areas. We do conduct a lot of awareness camps, but more work needs to be done,” he adds..Lack of awareness also results in expectant mothers not taking the kind of care pregnancy requires..“As far the cases from Agency areas are concerned, many are anaemic, because variety in diet may not be an option. In the interior villages, they eat only one type of food daily. As a result, they have iron deficiency anaemia or even sickle cell anaemia. We also get cases where patients have high blood pressure. Many women are also multigravida, which means they are pregnant for the third or fourth time,” says Dr K Hemalatha..\r\tDr Hemalatha, Superintendent, Victoria General Hospital (VGH).“Generally, these women come to us at a late stage. By then, septicaemia (a blood infection) would have affected them or the foetus would have died in the womb or they would have got fits because their BP is high. If delivery has already happened, many come to us in shock after heavy bleeding,” she adds..Lack of gynaecologists.Even while authorities insist that women get admitted in advance, the hospitals themselves aren’t equipped to handle all pregnancy cases. Until recently, a local hospital in Chinthapalle had shortage of beds and staff, with two patients having to share one bed in some cases..“There is a hospital in the region but there are no gynaecologists. The doctors conduct as many deliveries as possible or refer cases to hospitals outside the area. If there are gynaecologists in these areas, it will help the region. The closest town outside the ghats is Narsipatnam, which is 50 km away, or Visakhapatnam, which is 150 km away,” says Devudamma, the ex-sarpanch of Chinthapalle..While acknowledging the government’s monthly check-ups, Devudamma says, “Doctors do come from Vizag once a month, but how many people can they check? If there is a resident doctor, the adivasis here will also get more confidence in the system. They will also want to know updates on their child.”.Dr Hemalatha points out that it takes at least 2-3 hours for an expectant mother to reach the closest Community Health Centre (CHC). If it a high-risk case, they are referred to Vizag, which includes another journey of around 4-5 hours. “Within this time, if there is a case with high bleeding or obstructed labour, we may lose the mother,” she explains..\r\tChinthapalle town.One possible solution for this, according to Dr Hemalatha, is having a gynaecologist and an anaesthetist and a blood bank facility in the CHCs. Constructing a maternity hospital or a medical college in Araku or Paderu would also go a long way in improving the situation, she adds..Government hopeful.Despite the challenges, the government says it is hopeful. There are several incentives for expectant mothers, such as the Pradhan Mantri Matritva Vandana Yojana through which a woman gets Rs 6,000 for her first delivery, right from pregnancy until immunisation is done for the child..Balaji also says that an audit review is done every time there is a maternal death to fix accountability. The ITDA, he says, is not only conducting awareness drives, but is also proactively incentivising expectant mothers and their husbands to rid them of the apprehensions of losing their daily wages..“Our only objective is to ensure that maternal health improves and that every delivery takes place in the institution,” he says..While these efforts are on, data suggests that the state of maternal healthcare continues to be dismal, especially for villages located deep inside the hills. With Y Gonthupally in the process of getting its first motorable road ever, tribal people continue to live in the hope of better facilities reaching them soon.