Interview

The SDGs have set a broad agenda of advancing health and achieving equity by 2030, with SDG 3 calling for promotion of healthy lives and wellbeing for all. Achieving this is impossible without SDG 5 which is achieving gender equality and empowering all women and girls and SDG 7 that seeks to ensure access to affordable clean energy and household energy access alone is insufficient and must include all health facilities and community institutions. 

Maternal and newborn morbidity and mortality are persistent challenges despite increasing rates of deliveries within health care facilities, especially in low resource contexts, with improved infrastructure facilities with greater protection and care to the mother and newborn. But with all the high investments in infrastructure, with power outages such infrastructure is of little use and unsustainable. Skilled health care professionals are constantly challenged and perhaps lose motivation too, to work in such areas adding to the many challenges of access to maternal health. Basic lighting for delivery, basic heating and cooling or perhaps to run the incubators, operation theaters and ICUs are very essential. This need was more than evident during the pandemic too.

While policies and programs have led to an increase in births in health care facilities, due to unreliability of energy, they have not translated into better mother and neonatal  health indicators. Maternal Mortality Ratio(MMR) of India for the period 2016-18,  as per the latest report of the national Sample Registration system (SRS) data is 113/100,000 live births, declining by 17 points, from 130/ 100,000 live births in 2014-16. 

The budget 2022 too failed to provide an assurance of a continued power supply to all rural health centres or budgetary allocations for a continuous power supply. The parliamentary standing committee report on energy (lok Sabha) has no recommendation either to ensure continuous energy security to ensure women and child health. Lack of access to continuous supply of electricity can significantly impact the quality and quantity of healthcare services in rural areas

In this podcast, Bhargavi Rao and Dr. Sreeparna Chattopadhyay  discuss some of these issues and more that highlight the need for better access to energy for women, particularly for maternal and neonatal health.

Bhargavi: From your many  years of experience in the gender and maternal health space, how important do you think access to energy- clean energy is for women, (including adolescent girls, girl children, senior women) and reproductive health at different levels?

Sreeparna: Energy access to reduce time poverty and energy poverty – has impacts on access to education for adolescent girls in several countries where adolescent girls and young women may be tasked with the energy requirements of the household, specifically collecting firewood.

1. To combat indoor population
2. For less physical effort collecting firewood – walking long durations with heavy weights clearly has impacts
3. Belmin et al (2021) found that after controlling for other variables, access to electricity and modern cooking fuels, along with education, reduced fertility. The effects were most pronounced in areas with high fertility levels. They conclude, “ expanded access to modern energy and education would accelerate the demographic transition”.
4. A study in Afganisthan by Palnsky and Ladjabaev (2021)  came up with the following conclusions, “Women in grid-supplied communities are on average 27% more literate and complete more years of schooling compared to women in off-grid communities. Households in grid-supplied communities reported a lower incidence of diseases, lower child mortality, improved access to ante-natal care, and higher vaccination rates, but they also endured a higher incidence of respiratory diseases due to cooking indoors. The study found that switching from off-grid to grid-supplied electricity would allow households to power either 4,200 hours of LED light, 1,340 hours of TV, or 55 hours of hotplate usage at no additional cost. Access to grid-supplied electricity also enables economic opportunities, which is reflected in the average higher income by a factor of 5.9 compared to households using solar panels. Moreover, households with grid-electricity save time on the collection of biomass fuel, e.g. for households using firewood, the daily time saving potential amounts to 5 hours. Consequently, men spend on average more time with their children and are more likely to provide help with household tasks that are typically in the female domain in grid-supplied households. Nonetheless, we find that access to grid electricity has mixed effects on education, health and economic outcomes, especially with regard to gender dynamics. Therefore, we challenge the assumption of a linear relationship between electrification and associated impacts, and stress that structural, institutional and power dynamics exert greater influence on education, health and economic outcomes than access to electricity alone.
5. Energy use helps with income generation which in turn can help improve reproductive, maternal and child health outcomes by reducing poverty and enabling women’s access to social protection mechanism.
6. If you take the example of electricity –  Dinkelman observes that for rural South African women employment increased by a significant 9 to 9.5 percent within 5 years after electrification, while male employment raises insignificantly by 3.5 percent. . Van de Walle et al.  also find a significant, but small increase in women’s non-farm self-employment in rural India. Finally, Chowdhury, shows that the availability of public infrastructure has a significant impact on women’s participation in paid work in rural Bangladesh. On the other hand, Costa et al. find that the availability of electricity in a community does not influence women’s participation in market activities, but it increases the working hours for those already engaged in paid work. 
7. Decreased fertility, adverse gestational outcomes, reproductive system cancer, low vitamin D and immune system alterations), current experimental evidence, and possible molecular mechanisms involved in the impairment of the reproductive health and gestation associated with exposures to common urban air pollution.

Bhargavi: Can you share some thoughts on how lack of energy at the household level is affecting reproductive/maternal health? 

Sreeparna: Walking long hours and carrying a burden clearly has an impact on women’s reproductive and maternal health. Lack of electricity also means that access to important messages around reproductive health, family planning, media etc is likely to be interrupted or absent. Education will also be impeded in the absence of electrification. 

Bhargavi: What are the impacts on maternal health when women bear the brunt of collecting firewood, water and more and are exposed to toxic fumes from cooking?

Sreeparna: Direct and indirect impacts- A 2019 study found Prenatal air pollution may be associated with diabetes, which in turn has impacts on maternal and birth outcomes.

1. Prenatal air pollution may be more critical for certain at-risk populations
2. Prenatal air pollution among those with diabetes may increase risk of preterm birth
3. Oxidative stress has been identified as the most relevant with evidence from increased levels of lipid peroxidation products and inflammatory cytokines in response to air pollution exposure
4. One study found a positive association between maternal exposure to ambient air pollution and Autism Spectrum Disorder in children, there is some evidence for PM2.5, 
5. A chinese study found that NO2 concentration was positively correlated with term low birth weight and preterm birth for over 21,00o women. Each of PM2.5 and PM10 concentration was also associated with preterm birth 

Bhargavi: Can you also highlight the need for access to continuous supply of energy at the PHCs, Hospitals in rural areas and other community centres? Will be great if you can share anecdotes of how maternal health suffered due to lack of energy at PHCs or other tertiary care centres?

Sreeparna: Lack of electricity can affect a range of procedures from doing x-rays or ultrasounds to blood storage for c-sections. The problem with interrupted electricity and no back-up is that cases get referred from CHCs to Tertiary facilities and their load increases. Also vaccines cannot be stored safely for children, pathological tests cannot be done. Everything that is needed to provide a good quality ANC cannot be provided. OT facilities won’t be there neither will be ways to sterilise equipment. Anecdote about woman who was sent to a Tertiary facility because of no blood despite the fact that the majority of women end up with anaemia in India when they are pregnant. 

Bhargavi: Are there studies that have focussed  or reviewed access to energy at health facilities and hospitals and highlighted the impacts? Can you share a few examples?

Sreeparna: A systematic review by Irwin et al. (2019) found that electrification was generally associated with positive health outcomes, such as reduced mortality, lower rates of disease, and improved quality of and access to care, while poor electricity reliability was associated with negative health outcomes, including increased morbidity and mortality, lower quality of care, and reduced utilisation of health services. Although the overall quality of the evidence was weak, given the many potential pathways through which electricity may affect health, efforts should be made not only to increase the number of connected households globally, but to improve the reliability of the electricity supply as well.

Jyotigram Yojana in Gujrat JGY implementation (electriifcation) significantly improved the operational capacity of health facilities, in particular primary health centers (PHCs), by increasing the availability and functionality of a wide range of essential devices and equipment. JGY also significantly increased access to health information through television. JGY increased utilization of health services; in particular, it increased the probability of children receiving critical vaccinations and pregnant women receiving antenatal care. 

Bhargavi: From the many protocols for maternal health by the WHO and other agencies, are there protocols that focus/mandate on access to energy?

Sreeparna: WHO published a 115 paged report where it investigated the links between energy use and Universal Health Coverage. WHO’s “Sustainable Energy for All (SE4All) initiative, which aims to achieve universal access to energy by 2030 as well as double the rate of improvement in energy efficiencies and the share of renewable energy in the global energy mix.” The report was directed towards SE4ALL’s new High-Impact Opportunity (HIO) on Energy for Women’s and Children’s Health, which aspires to improve availability and quality of essential maternal and child health care through the scale-up of energy access in health facilities

Bhargavi: What would be your recommendations to improve and ensure 24×7 access to energy for maternal health.

Sreeparna: At the very basic level – Within India’s health systems, PHCs need to have uninterrupted electricity so they can do the work they are supposed to do.  Mobile phones are used to deliver health messages and with uninterrupted electricity it would be possible to send messages so that women can receive them. The work of ASHAs and Anganwadi workers will become easier and go long ways in improving maternal and child health. Digitalisation of health including telemedicine, health records and data will remain a dream unless this is done

Bhargavi: The union budget is perhaps a done and dusted document. But it did promise that Two lakh anganwadis would be upgraded under the Saksham Anganwadis scheme which aimed at a new generation of anganwadis that will have better infrastructure and audio-visual aids for early child development as per the budget 2022. The budget 2022 also had major commitments in the area of mental health. And this is certainly possible. With all the transition to clean energy as promised by the PM at Cop26 and as we move forward with the transitions to solar, wind, tidal and more we sincerely hope we will ensure no one is left behind in the energy access. And as the world celebrates the International women’s day this month, I sincerely hope some of the ground realities will be comprehended and the basic demands will be considered and met with.

Thank you for your valuable insights and your time for this important conversation.

Sreeparna Chattopadhyay is an Associate Professor of Sociology at FLAME University, Pune. She received an AM and a Ph.D. in Anthropology with a focus on medical anthropology, demography, and South Asian studies from Brown University. She holds a Bachelor’s Degree in Economics from St. Xavier’s College, Mumbai. Her research over the last sixteen years has been attentive to questions of inequalities – both gender inequities as well as intersectional inequities that shape life trajectories including its deleterious impacts on health, education, and life chances. Her work has been supported by the Harry Frank Guggenheim Foundation, the National Science Foundation, the Mellon Foundation,  the Vera Campbell Foundation as well as more recently by the World Health Organisation. Her research has been published in several international and national journals and has also been covered by the national press in India, as well as internationally by the BBC. She has worked for the government, academia, and non-profits in India, the US, and Europe. Her first book The Gravity of Hope makes explicit the links between domestic and structural violence and will be published in 2022.

Bhargavi S. Rao works at the intersections of community action with law, policy, planning and governance. She currently works as Deputy Director, Center for Financial Accountability focussing on Energy & Infrastructure Finance and Capacity Building. She has 25 years of experience across research, advocacy, campaign and teaching on a variety of human rights, governance and people-centered efforts in areas of environmental and social justice. She has worked with the Public Health Foundation India, Azim Premji Philanthropic Initiatives, Environment Support Group (ESG), United Way, Department of Microbiology and Cell Biology, Indian Institute of Science, Bangalore. She was Co-Director, International Honours Programme, (Boston University and SIT World Learning) & Minnesota Studies in International Development, University of Minnesota implementing experiential educational programmes. She has taught on a variety of faculty-led programmes of the University of Washington, Seattle, Acara College, Minnesota and a few others. She enjoys engaging with student communities, developing and designing research tools, working with local communities and co creating new ideas to address environmental and social justice challenges. With her multidisciplinary background, she pursues her interdisciplinary approach to research in environmental decision-making processes, agroecology, biodiversity, renewable energy, infrastructure, public health, climate change, cities and local governance. She writes regularly in leading dailies and has contributed research papers in science journals, chapters to books and articles in magazines. 

Listen to this interview here.

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