The government of India released a new National Health Policy in March of 2017. It was the first update in 14 years, and it was based on a government assessment of how effectively the previous policy had addressed a number of concerns. According to that analysis, a number of concerns — such as malnutrition and adolescent deaths – had improved. But when it came to assessing policies affecting the reproductive and sexual health of women, there was no clear picture. That’s because India does not focus specifically on women’s health – and the 2017 policy update did nothing to change that.

Issues that affect women’s health such as HIV/AIDS, access to health care and family planning are addressed throughout the new policy but the actual section titled Women’s Health and Gender Mainstreaming is short and says that a package of services covered in previous paragraphs in the report will be put towards women’s health. It doesn’t specify what those services are. The approach to women’s health is a patchwork, made of bits and pieces from different parts of the policy.

Aspects of women and children’s wellbeing – including their health – is also addressed by the Ministry of Women and Child Development. Even so, most of the resources are invested in children, who are regarded as being most crucial to the country’s future. In fact, the 2017 national budget allotted more funding – about two trillion rupees (38 billion Canadian dollars) more – towards children’s welfare compared to women’s.

In 2016 – about one year before the new National Health Policy came out – the Ministry of Women and Child Development released a draft policy of its own, and called it a “vision for the empowerment of women.” While the policy noted that the Constitution of India has a mandate for the equality and rights of women and that the discourse on women’s empowerment has evolved for the better in terms of legal policies, it also made a point to show that “a lot still needs to be done” to give women equal access to basic rights.

One of those rights is health care, which is highlighted as a priority area in the Ministry of Women and Child Development policy. It suggests focusing on issues such as reducing maternal mortality, focusing on women’s reproductive rights, family planning, and adolescent sexual and reproductive needs – among other things.

Some of the fixes to these issues flagged by the Ministry of Women and Child Development were already being dealt with in the National Health Policy under a program called the National Rural Health Mission (NRHM), which began in 2007. After the program was introduced, there was an increase in the number of health care centres and health workers in rural areas that were operating under the NRHM program. A free ambulance service for rural communities was also established so people could have better access to emergency services. This ambulance could benefit women who need to travel to a hospital in order to give birth.

The rural program also inspired the creation of what are called ASHA (accredited social health activists) workers. In Hindi, the name Asha means hope or desire but in this case, it’s used as a title for government health activists. It’s their job to visit rural areas and educate people – most often women – about proper health care, including aspects of reproductive health care, hygiene, post-partum routines and basic infant care. Even so, the 2017 health policy noted that progress was slow when it came to HIV/AIDS prevention and care, infant and maternal mortality rates and population control – all issues that greatly affect a woman’s health and livelihood.

Many sexual and reproductive health complications can be avoided with proper education about things such as family planning methods, safe sex, hygiene and pre- and post-natal care. Some of these subjects can be taught to individuals when they are young, but studies have shown that both adolescents and adults aren’t getting the education they need.

A 2015 study done by the Indian Journal of Psychiatry found that the sexual reproductive health needs of adolescents in India are being overlooked or not understood by the country-wide health care system.

The study says that many legislators in states such as Gujarat argue that sexual health education “corrupts the youth and offends ‘Indian values,’ leading to promiscuity, experimentation, and irresponsible sexual behaviour.” Sexual health education has therefore been banned in public schools in Gujarat and five other states. The impact of this is enormous.

Since sexual health is not openly discussed due to cultural norms, the study says that the sexual histories of adolescents aren’t always recorded by their doctors. It also notes that sexual health education could help prevent or decrease rates of sexual abuse, pregnancy complications, unsafe abortions and HIV/AIDS.

According to a United Nations AIDS report, there were 2.1 one million adults and children living with HIV in India in 2016. Of those, two million were adults aged 15 and over. Eighty thousand adults and children were newly infected with HIV and 71 thousand of them were over the age of 15.

The most recent National Family Health Survey conducted by the government of India in 2015 and 2016 reports that 10 per cent of women between the ages of 25 and 49 had sex before they were 15 years old. Thirty-eight per cent had sex before the age of 18 and 58 per cent by age 20.

Contraceptive use by married women is just under 50 per cent with the most common form being female sterilization – also known as tubal ligation or in some cases, hysterectomies – followed by male condom use and then oral contraceptives. The numbers in the state of Gujarat vary only slightly from the national averages.

The study showed that most women were going to public health institutions like government hospitals, primary health centres and community health centres to access different methods of birth control. Oral contraceptives, however, were more often acquired from private doctors, not funded by the government.

Half of the women who underwent sterilization procedures for family planning had the operation by age 26. Sterilization is permanent. The women who are sterilized are unable to get pregnant again.

The Indian Journal of Psychology study included findings from an NGO in New Delhi called TARSHI – talking about reproductive and sexual health issues. The NGO monitored a helpline it runs to give people sexual health information and found that it received more than 60 thousand calls from people “seeking information about sexual anatomy and physiology, counseling and referrals regarding sexuality and reproductive health issues.” Seventy per cent of those callers were below the age of 30.

The study found that even in states where sexual health education was part of the curriculum, it was failing to fully address main health issues that adolescents may face including early pregnancies, not waiting long enough between pregnancies, unsafe abortions, sexually transmitted infections, HIV/AIDS and sexual violence.

When it comes to health education for adolescents, the new National Health Policy says it recommends expanding adolescent and sexual health education. One method of doing so is by investing in school health and adding health education to the curriculum to promote hygiene and safe health practices. It also makes note of using schools as primary health care sites.

But in states like Gujarat, or the five others where sexual health education is banned in the education system, expanding the scope of it won’t be possible in schools.

When asked about the health policy, government officials in various offices did not respond to e-mail requests for interviews or said they could not comment.

Dwarka is the nearest city to Chamadiya’s village and is a well-known tourist and pilgrimage destination. It is known for its ancient Dwarkadeesh Temple, where it is said one of the Indian Gods, Lord Krishna, ruled. Within the Dwarkadeesh gates, line-ups of devout visitors fill the temple grounds. Outside the gates are lines of beggars, some missing limbs and others with children, waiting for alms from temple-goers.

Many visit Dwarka to pray and bathe in holy waters of the rivers that empty out into the sea. In the morning and evening, sounds of drums, bells and prayers permeate the streets as the many temples in the city hold service for locals and visitors.

As the sun sets over the water, single lights begin to switch on along the horizon. They come from fishing boats preparing to float in place for the night.

The main industries for the area are farming, fishing and tourism, although there is an industry for pearl harvesting along the shores of Dwarka as well.

The city has all of the trappings of a tourist destination, with money going towards beautifying and maintaining the temples, beaches and walks along the sea.

There is only one hospital, two gynaecologists, and no paediatricians in the entire city. There are three primary health care centres, one of them serving as Jotnigiya’s base, and 25 sub-centres like the anganwadi that Chamadiya goes to for Mamta Day each month.

Compared to other large cities in Gujarat, Dwarka has a much smaller population of almost 39 thousand according to the 2011 census.

Dwarka lacks the hustle of a large, urban city. Instead, people laze about their days as they combat the heat and humidity that comes from the sea.

There are 45 villages surrounding Dwarka, with Chamadiya’s Shivrajpur being one of them. The rural population outside Dwarka is a little over 51 thousand people.

The total literacy rate for the area is about 58 per cent, which is significantly lower than the national literacy rate of 74 per cent.

In Dwarka, about 60 per cent of the males are literate compared to approximately  41 per cent of females.

Illiteracy can make life especially difficult for women; it can contribute to their inability to take power over their own health. If they are given health pamphlets with extensive writing on them, many will struggle to read and fully understand what they say.

In rural areas like this, being pulled out of school early to help out with work at home or on a farm is common.

Chamadiya’s brothers and father work in the fields while the women in her household tend to the family farm, livestock and homestead. Chamadiya spends her days cleaning and cooking alongside her mother, a younger sister and two sisters-in-law but said she sometimes ends up doing more of the work, despite being eight months pregnant.

“That’s just how it is,” Chamadiya says as she takes a seat on the ground.

Meals must be cooked for the men before they head out for the day and hot chai should be at the ready for the family in the mornings and whenever they take their tea breaks. The grounds must be kept tidy as well.

“There is always something to do,” says Chamadiya.

She left school in grade seven and quickly learned the responsibilities that were waiting for her on the farm and at home.  At the age of 20, Chamadiya got married and moved to a nearby village to live with her husband and in-laws.

Chamadiya’s mother, Nakhu Nayani, says she is worried about what will happen to her daughter now. She is uneducated so getting a job will be difficult and she has no husband to care for her.

“We are trying to call her husband back to her now that she is pregnant again,” says Nayani. She sits on the floor of their garage and leans against the cool wall to stay out of the sun’s rays that are pouring in through the doorway. She sips on a cup of hot, sweetened milk from their cow.

“He just left her here and didn’t come back for her,” says Nayani. “His parents think she will be expensive and a waste of money because they already had to pay for her abortion. They blame her for the baby and think this other one will be a problem too.”

While Chamadiya’s mother speaks about her daughter’s situation, Chamadiya shifts to squat on the ground. She says it is more comfortable for her to sit that way.

At the mention of her husband, she looks down, and lets her mother speak for her.

“What can we do?” says Nayani. “We have to convince him to take her back.”

Bavna Nayani, the anganwadi instructor, in Shivrajpur, Gujarat. | Shalu Mehta

Bavna Nayani is the anganwadi teacher who helps out on Mamta Days in Chamadiya’s village.

Nayani said that more often than not, women know little or nothing about their own sexual health. She says they speak about it in secret with family members who are typically equally uneducated about the subject and only learn what is absolutely necessary to know from their doctors.

“It’s taboo,” says Bavna. “People are shy. Nobody feels comfortable talking about it.”

Nurses, also referred to as “sisters” since many are missionaries, run from one end of the hospital to the other. The space is not very large, but still easy to get lost in.

At the centre of the hospital is a round foyer with a murti — a small statue or shrine — dedicated to Lord Ganesh in the middle. He is the elephant-headed Hindu God who is supposed to be the mover of obstacles — a reminder to those that are religious that there is a God watching over them and giving them strength to overcome their struggles.

Standing guard outside Chandrana’s office was an ASHA worker who did not want to give her name. She brought these women to the hospital and would get paid depending on how many of them underwent a family planning operation. She stood in front of the heavy wooden door separating the doctor from his patients and tried to stop others from entering the office.

From inside, Chandrana summoned one woman at a time to discuss their family planning options.

An older woman nearing 60 years of age, who wanted to remain anonymous, sat nervously in a chair beside him. He looked over her charts, remarking that she had high blood pressure and was not taking the medication necessary to control it. He said her high blood pressure combined with her age made her a poor candidate for tubal ligation or a hysterectomy.

“I don’t know why you need any of this at this point because of your age,” said Chandrana.

“She told me I needed it and brought me here,” said the woman, looking over at the ASHA.

Chandrana said if she really wanted some form of family planning, he’d give her an intrauterine device and then sent her back into the waiting area.

“Right now we don’t have an issue of not getting enough funding,” says Chandrana. “There’s plenty of funding for health care here.”

Chandrana says the issue is how funding is distributed and how aware the public is about the services offered to them.

He argues it’s up to people in rural communities to learn about – and actually take advantage of – the health care that is offered to them.

“If people in rural areas aren’t educated about it, then they won’t know what we’re offering them at the hospital in the city,” says Chandrana.

Speaking from his own experiences, Chandrana says he sees a high rate of HIV/AIDS among men as well as sexually transmitted infections and reproductive tract infections among women. He also says that he assumes many women have HIV/AIDS but are not willing to speak about their sexual health with doctors due to the taboo associated with it. But these are his own observations, since he says the local government does not keep track of those numbers.

“It is hard to really tell, “ says Chandrana. “Since many ladies don’t talk about it.”

He says that many infections and illnesses women face are also due to high rates of malnutrition and anemia. He says it is up to ASHAs and female health workers to communicate the importance of being healthy and taking iron pills.

Chandrana says that despite efforts from health centres to provide services to rural communities, if the public isn’t educated about why they should talk about their sexual and reproductive health, they won’t take advantage of them.

But cultural barriers and illiteracy rates means it can be difficult for rural women to learn how to take charge of their own health.

In the city of Vadodara, there are hundreds of hospitals serving a population of about two million people.

The streets of Vadodara buzz with the bustle of people who are busy at work, trying to get through their daily grind without being sidetracked by the many vendors and beggars who line the roads. Vadodara is an expanding city, with new developments encroaching into the farming towns and communities around it.

Construction workers and their families are mobile, moving from building site to building site and setting up tent cities near masses of cement that are waiting to be turned into high-rise apartments.

Cows still roam here the same way they do in Dwarka, but instead of grazing on grass they are grazing on garbage and litter that turn the sides of roadways into colourful mosaics of plastic and paper.

Side streets and alleys take residents away from the business of the main roads and shelter them and their homes from the noise that persists through all hours of the day.

In some areas, the homes are large and gated with multiple bedrooms and storeys. Middle-class and upper-class residents own these and keep to their gated communities for the most part.

Lower-class housing consists of row houses that line narrow, rough, unpaved streets. Only scooters, rickshaws and small carts are able to make their way in between the row houses. In the urban slums, shanties made of wood and tarps with satellite dishes hanging precariously off the sides crowd against each other.

Naina Chauhand and her two-year-old son, Shlok. This is Chauhand’s third child and she had to have a caesarian section to deliver him. | Shalu Mehta

Naina, Hetal, Urmila and Sangeeta Chauhand are among her clients. They are all sisters-in-law, living in row houses that are side-by-side and connected on the terraces.

Hetal just delivered her first child and said the ASHA worker, Ashish, helped her in the months leading up to the birth. She said she received nutritional food packets from the anganwadi that provided her with iron-rich items like lentils and green vegetables. However, Hetal took the lead of her eldest sister-in-law, Naina, and delivered her baby in a private hospital.

“Nobody likes the government hospitals,” says Naina.

Naina has three children – two girls and one boy – who were all delivered in a private hospital. Her baby boy Shlok is the youngest and required a caesarian section when Naina was giving birth to him.

“We have a little bit more money for things like this, and there are so many private hospitals so we could go to the one that worked for us,” says Naina.

Since government hospitals are free, many people believe the quality of care is not as good as what they would get at a private hospital. So even if they cost a little more, people will try to deliver in a private hospital if they can.

Naina says she didn’t go to the Mamta Days because she didn’t know about them during her first two pregnancies.

Urmila and Sangeeta are newly pregnant and make sure to visit the monthly Mamta Days. They say receiving the free food is the best part, but go for the injections and medicine too.

However, they are insistent on delivering in a private hospital as well and have told Ashish that they will not go to a government hospital with her. That also means Ashish will not receive any commission for their deliveries because of this.

Although the Chauhands are from low-income families, living in an urban environment gives them more choice when it comes to doctors. They do what they can to get the best care they can afford and have the liberty to shop around for doctors within their price range at private hospitals. Delivering a baby at a private hospital costs around 2000 rupees – 39 Canadian dollars. If the family is living below the poverty line, they are likely making 100 rupees or less a day.

In communities outside of cities, women suffering from complications with their pregnancies have to worry about private hospital costs as well as travel expenses to a private hospital. And the stigma against government hospitals remains, so most people try go private if they can afford it.

Jotnigiya visits many women in rural communities outside of Dwarka who fear having complications or even having to get caesarian sections. If there aren’t any gynaecologists working at the one government hospital in the city, they have to make the drive to Khumbaliya, a city that is about two and a half hours away. They don’t have a choice.

That was the case with Nathi Vinjooda says Jotnigiya, as she paid her a visit at her home. Vinjooda had a miscarriage at six months pregnant and had to rush to a hospital outside of the city to have the baby and placenta removed. Jotnigiya says Vinjooda was fortunate because her family had some savings they could put towards the procedure in the private hospital.

Jotnigiya says that often, doctors won’t perform a procedure or C-Section in private hospitals without being paid up front. For lower-income families, coming up with money on the spot can become a problem.

Now that Vinjooda has had the baby and placenta removed, Jotnigiya says she hasn’t been able to stop menstruating. She visits Vinjooda often, giving her nutritional advice and ensuring that she is taking iron pills regularly.

Bharat Jalla is an administrator in the government of Gujarat’s health department. He works in Gandhinagar – the state capital – and says that a few years ago, a decision was made by the state and federal governments to improve the quality of life of tribal populations in Tapi.

“It’s a 90 per cent tribal population in Tapi district so there was no development before,” said Jalla.

Gamit says that after the government decided to increase funding to the area, changes came into effect quickly. They were given new equipment to use at Mamta Days and more personnel training as well.

A new state budget was passed on February first of this year, according to Jalla. He says now that the Tapi district seems to have improved greatly, the government will be shifting focus to a new area — Dwarka.

In Dwarka, Sonal Jotnigiya is still visiting homes of women who are struggling to take control of their own health. She brings them booklets to teach them about what they should be doing to stay healthy and teaches them about their own reproductive health and hygiene. Jotnigiya checks up on her patients, making sure they are taking their vitamins and are not over-working themselves, despite the domestic responsibilities that so often get thrown on them even when they are ill or pregnant.

“I work so hard to make sure they get the care they need,” says Jotnigiya. “And there are a lot of problems here like not enough doctors. But what can I do? I work for the government but I feel farthest away from it here.”

Her supervisor, Ranjan Gamit, is optimistic that things will improve soon. She thinks that people’s mentalities are changing and that both men and women are becoming responsible for each other’s health.

“We have spent so much time educating people,” says Gamit. “And now they are getting older and will educate their children and so on.”

But Jotnigiya says she feels overworked trying to educate and care for so many people herself. She sleeps with her cell phone set to loud in case any of the women she oversees has an emergency in the middle of the night.

“I will wake up, take them to the hospital, stay with them all night and then go back to work the next morning. I won’t take a day off,” says Jotnigiya.

Some days, she says she wishes she could take a personal day to recuperate but she knows her job is too important to do so.

“But some doctors will take the day off, and when we have so few that is a problem,” says Jotnigiya.

The increase in funding will go towards improving health programs and increasing health personnel so that people like Jotnigiya don’t feel so overworked. According to budget documents received from Jalla, the state and federal governments have put about 42.7 million rupees (almost 840 thousand Canadian dollars) into various women’s and reproductive health centres and services. However, the task of educating women and children about reproductive health will still largely fall to ASHAs and female health workers due to lack of school attendance and the absence of sexual health education in curricula.

The National Rural Health Mission, which is being continued as part of the National Health Policy, is carried out all over the country, but allocation of funds and policies regarding health care and health education are largely based on decisions made by each individual state.

The World Health Organization defines sexual health as a state of physical, mental and social well-being in relation to sexuality and recommends that sexuality and sexual relationships should be approached positively.

Swati Mehta from CHETNA says that sexual health education, especially in rural areas, is hard to monitor. This is because some schools don’t offer it and for those that do, whether or not it actually gets through to children is also difficult to tell since more often than not, students choose not to study it because of cultural taboos.

Mehta insisted that sexual health education for children — especially the basics like anatomy and puberty — is integral to improving their self-empowerment. She says it gives them the ability to take control of their bodies and speak openly about health concerns when entering a sexual relationship with a partner.

Chamadiya’s lack of education and inability to understand her own health and what went wrong with her first pregnancy has affected her life in drastic ways.

Chamadiya says the reason her in-laws and husband abandoned her was because they blamed her for the baby’s deformity, even though the doctor told her otherwise.

Regardless of whether or not Chamadiya agreed with her husband and in-laws, she says she didn’t feel she could reason with them on the subject. Instead, she accepts that the baby’s deformity was her fault and tries to convince them that her soon-to-be-born child will come out healthy.

Chamadiya in Dwarka, and the Chauhands in Vadodara all said they had to rely on limited information from female family members about their sexual health until they met with an ASHA worker when they were pregnant. Just like them, many young women living where sexual health education in schools is banned will have to do the same, waiting until they are married or pregnant to learn about their own health.

The government’s National Health Policy says there will be an emphasis on promoting healthy living but besides using a specific example of teaching yoga in schools, does not elaborate on how this will be done. However, it does mention partnering with NGOs and other organizations to carry out aspects of the policy.

The CHETNA organization is an example of an NGO that works with the government to deliver educational materials to people who need them. But it has limited projects, only working in one or two places at a time.

So while more funding is coming to Dwarka to supply health centres with better equipment and more personnel, it’s still up to women to take their well-being into their own hands. But when they are don’t know why they need to look after themselves in the first place, it is difficult to see how they could be equipped and motivated to care for themselves.

Lack of hygiene, malnutrition and a limited use of protection during sexual intercourse have resulted in numerous health problems for women in India. Sexually transmitted infections, reproductive tract infections and HIV/AIDS, and infant mortality are all consequences of the uneven application of reproductive and sexual health care for women throughout the country. But until fundamental issues such as literacy rates and cultural barriers are addressed in concrete ways, women will not be empowered to take their health into their own hands. And the services that the federal government does fund won’t change women’s health outcomes across the board, no matter how much money is funnelled into them to keep them afloat.

In Hindi, the word mamta means motherly love.

The government’s Mamta Days, in combination with the people running them, give women the help they need to deliver babies in a safe environment and feel motherly love for the first time.

But the guidance many women can receive — if they know about it, are offered it and are willing to accept it — can also give them the opportunity to feel love for themselves and understand exactly what their bodies are capable of.

Mamta means motherly love, but it represents the strength of a woman’s love for herself and her children and the positive effects that can come from loving others and loving oneself.