In 2000, the UN’s Millennium Development Goals 4 and 5 set out to reduce the world’s mortality rate of children under the age of 5-years by two thirds by 2015, and to reduce the world’s maternal mortality ratio by three quarters by 2015. This focus on maternal and child health has been seen in India through continuous investments in government schemes such as Janani Suraksha Yojana, and in public private partnership models such as Karuna Trust, a CHMI profiled program that manages government health facilities in 7 states in India. Despite these efforts, maternal, neonatal, and child health (MNCH) conditions in specific communities are still not well understood. An example of such a community is that of female sex workers.
Efforts to improve awareness about HIV and to curb its spread have often overshadowed the need to understand some of the other key challenges female sex workers face in the context of MNCH. Global Health Promise, a US-based not-for-profit, is dedicated to understanding the needs of these women and their children, to create awareness about their issues, and to assisting mothers who are trafficked or in sex work, and their children. Global Health Promise is conducting regional meetings with sex workers in 7 countries, to represent theses voices at Women Deliver 2016, a global level conference focused on adolescent girls and adult women.
The series of regional meetings started in India in May 2015. Global Health Promise along with Swasti Health Resource Centre conducted regional meetings across 7 states in India- Karnataka, Tamil Nadu, Andhra Pradesh, Telangana, Maharashtra, West Bengal and New Delhi. Around 13 focus group discussions (average of 8-10 participants in each session), 20 individual interviews and 14 key informant interviews were conducted across these states. Interviews and meetings broached the questions: Do these women receive timely medical care during pregnancy? What kind of health facilities do they access? What kind of barriers do they face while seeking health care? Do they deliver in hospitals? What is the health status of their children? What kinds of discrimination do these children face?
“It is very rare that anyone talks to us about our pregnancy, our health besides HIV and STIs and the well-being of our children.” said one of the sex workers. The health seeking behaviour of these women, predominantly from urban and peri-urban areas, varies from state to state. While the women in Tamil Nadu and Maharashtra understand the importance of healthcare during pregnancy and thus frequent health facilities during their gestation period and post-delivery, about Many of the women in Karnataka do not access health facilities during their pregnancy. The women have the tendency to postpone their visits to the doctor for a number of reasons including lack of time, low awareness about health and health care, lack of family support, opposition from partners, the fear of being exposed (as sex workers) and being ill-treated by the hospital staff. Besides these, multiple abortions, addictions such as alcohol, tobacco and marijuana and continuing sex work upto the 7th month of pregnancy, are some of the revealing trends reported. Though health-seeking behaviour is low (may be lower than among other groups of pregnant women, many of the women ensure that they deliver in medical facilities. Except for some sex workers belonging to the Bedia tribe of Rajasthan, who choose to have institutional deliveries only in case of complications, most sex workers reported access to health facilities and reported that the use of midwives is not common.
Adding to this is the challenge of living with suspicious partners. Husbands/partners very often suspect the pregnancies of the women and are thus not willing to take care of the woman or the child. The situation often gets worse when families come to know of the women’s professions and refuse to provide any form of support. Favouritism towards male child, discrimination and bribery in hospitals are all key to issues that reportedlyaffect the health seeking behaviour of the women. “We never reveal our identities when we go for check-ups during pregnancies because there are chances that services get delayed and hospital staff treat us disrespectfully. But when we go for delivery we are forced to reveal our identity and place of stay in order to get our children’s birth certificates. Some of the health workers when they know about our profession even ask us to leave our kids for adoption,” says one of the women.
Sex workers’ children face discrimination in schools and society. They often do not get enrolled, as schools demand that the child’s father comes for their enrolment. If enrolled, they frequently have to hear teachers and students speak ill about them and their families. Even in their residential areas, these children are often ostracized and other parents refuse to let their kids play with these children . It is due to lack of care and attention from their mothers and families (which often do not exist) that these children frequently fall ill and are often malnourished.
What can NGOs do for the well-being of these sex workers and their children? Organizations such as Swathi Mahila Sangha (Karnataka), ApneAap (Kolkata), Durbar Mahila Samanwaya Committee (Kolkata) and Prerna (Maharashtra) are of great support to these women; they have helped them immensely with access to information, access to health care and social protection. But many times basic needs such as support, peace and happiness, which these women value above all other needs, are denied to them by their families and society. The support that these women seek includes better care and attention of their children, crèches, financial support for education and hostel facilities and these they believe will help their children grow up in a healthy environment. In addition, counselling and vocational training are crucial for these communities. The youth have high potentials but end up in daily wage work or sex work due to lack of resources and guidance.
“Above all, we are happy that you spoke to us about our children. They face the brunt of what we do. We want them to be healthy, well educated, have good jobs and lead respectful lives and we are ready to do anything to give them a good life” says one of the women. Sexworkers and their children are truly marginalized - they are not the priority of those who work on women’s issues, and their reproductive health is not the priority of those who work on HIV prevention. The million plus women in sex work in India and their children are only a small fraction of those who truly have not been reached in the efforts to achieve MDG 4 and 5. When these women and their children have access to quality health care, education and employment, only then will we begin to address the equity, gender and poverty issues of this millennium.
 Janani Suraksha Yojana (JSY) is a fully centrally sponsored government initiative under The National Rural Health Mission (NRHM) launched in April 2005 that works to reduce maternal and infant mortality through skilled care by promoting institutional delivery among poor pregnant women. JSY scheme provides financial/cash assistance for antenatal care during the pregnancy period, assisted institutional delivery, and immediate post-partum care by field-level workers.