The community health workers protecting pregnant women from dangerous heat in Delhi

BBC News

3 days ago

In one of the world's hottest capital cities, a specialist team is working to help pregnant women survive the scorching temperatures.
On a scorching June morning, when temperatures hit 43.9C (111F) in Delhi, Baby Kumari fainted, while rushing to a routine check-up at the nearby health centre. Pregnant with her fifth child and struggling to cope with Delhi's scorching temperatures, for a moment she thought she was having a miscarriage.
Fortunately, Kalyani Karan, an Accredited Social Health Activist (ASHA), was by her side. ASHAs are part of India's million-strong network of female community health workers, trained to provide medical aid in emergencies. They provide doorstep health services in rural and suburban areas to reduce maternal and infant mortality and have significantly improved healthcare access for low-income communities in India.
"When Kumari fainted, I knew I had to quickly do something because her fluids and electrolytes were depleting, making it harder for her body to cool down through sweating," says Karan. "I took her aside, dabbed her face with a wet piece of my scarf, and fanned her with a punkha [a hand fan]. She regained composure after a few minutes, and I gave her some water mixed with oral rehydration solution [ORS], which I always carry," says Karan. She then quickly took Kumari to a district hospital.
There a doctor confirmed Kumari was suffering from dehydration and heat exhaustion, conditions that could have escalated into life-threatening heat stroke if not for Karan's timely intervention with ORS – a mix of water, electrolytes and carbohydrates used to treat dehydration.
After these interventions, Kumari recovered. She cleans homes and works as a cook in the crowded and chaotic neighbourhood of Najafgarh, on the outskirts of Delhi. Last summer, temperatures reached 47.8C (118F) in Najafgarh, making it the hottest area in the capital.
"I've never experienced anything like this in my last pregnancies," Kumari says. "I often feel lightheaded and find myself getting irritated easily."
In Delhi, Karan and hundreds of other ASHAs are helping thousands of pregnant women navigate the growing risks that heat poses to maternal health in a warming world.
Extreme heat poses a risk to the majority of India's population, according to a recent report by the International Institute for Environment and Development. Delhi recorded 4,222 days with temperatures above 35C (95F) over the past three decades, more than any other of the world's 20 most populous capital cities.
India is expected to be among the first countries where temperatures exceed safe limits for healthy people by 2050, even while resting in the shade, which could impact labour productivity, economic growth and the quality of life for 310 to 480 million people.
The number of extremely hot days and nights in India – when the body cannot adequately recover from daytime heat – could quadruple by 2050 if emissions continue to rise unabated.
Pregnant women like Kumari are particularly vulnerable to extreme heat. Increased heat exposure during pregnancy has been linked to a higher risk of several serious health conditions, including hypertension, preeclampsia, cardiac events and gestational diabetes. Studies also show that heat can lead to increased rates of miscarriage, stillbirth and reduced birth weight.
"Being pregnant in a warming world is a double whammy," says Deepali Rana, a gynaecologist in Delhi. Pregnancy is a thermogenic condition, Rana explains, meaning the elevated hormone levels during this time cause the body to generate more heat than usual. This not only leads to significant discomfort for women but also impacts their ability to eat and stay hydrated – especially for those with high-risk pregnancies. "So pregnant women are more likely to get heat-related illnesses than those who are not [pregnant]," she says.
Each 1C (1.8F) rise in temperature is associated with a 5% increase in the risk of preterm birth and stillbirth. With Earth's average temperature projected to rise by nearly 3C by the end of the century compared to pre-industrial levels, the World Health Organization has warned of "an existential threat to all of us", with pregnant women facing "some of the gravest consequences".
Despite the increasing evidence of the danger heat poses to pregnant women, scientists and physicians still lack a comprehensive understanding of the physiological mechanisms involved, says Adithya Pradyumna, an environmental health researcher at Azim Premji University in Bangalore. A report by the United Nations Population Fund found that only 20% of the 119 countries that have made climate change pledges include maternal and foetal health in their plans.
There is no universal threshold for what constitutes dangerous heat levels for pregnant women, nor is there international guidance on how to protect these women, particularly those working in extreme heat.
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Karan was working as a primary school teacher when she realised that expectant mothers in her area were struggling with oppressive heat. She decided to educate herself through YouTube videos about heat-related dangers and signed up as an ASHA worker in 2019.
Launched in 2005 as part of the Indian government's National Rural Health Mission (NHRM), the ASHA programme has become a vital service in India's rural and suburban healthcare system as this army of one million women connect a vast majority of India's 1.4 billion people to its public health services.
Over the past two decades, ASHA workers have taken on many responsibilities. These include supporting pregnant women during pre- and post-natal check-ups, administering immunisations, and educating communities on nutrition and sanitation.
They counsel women on safe childbirth, breastfeeding, contraception and provide guidance to teenage girls on menstruation, while working to prevent common infections in mothers and children. The ASHA workers also file daily reports, conduct surveys and collate health-related data.
Karan provides antenatal care to about 24 women in her area, 15 of whom have high-risk pregnancies. To support women like Kumari, she has created a list of dos and don'ts for pregnant women, advising them how to stay cool and hydrated, both indoors and outdoors.
This includes simple tips to stay hydrated, such as drinking homemade beverages like lime water, buttermilk, lassi (a yogurt-based drink) and shikanji (lemonade), while strictly advising them to avoid exposure to the Sun. "If they can't avoid it, I tell them to always carry an umbrella, cover themselves with a cotton scarf, wear light-coloured clothes, and carry water mixed with ORS. Sometimes I even ask them to send me a photo to check if they are following my instructions," Karan says playfully.
In 2023, Karan created a WhatsApp group for expectant mothers in her area and began sharing informative, evidence-based videos on heat-related dangers in Hindi to help them understand the impact of heat on their bodies and learn how to cope with it.
"That's how I discovered Kumari was struggling unusually with her current pregnancy. She often complained about feeling extremely hot and anxious. At first, I thought it was normal – until I realised it wasn't," Karan says.
"I started by counselling Kumari, insisting that she increase her fluid intake, avoid going out in the Sun, and reduce exertion while working," Karan says. "I couldn't ask her to stop working altogether, even though it would have made a huge difference. It just was not practical. So, we discussed it and decided she would take up work as a house help in the early mornings and evenings to avoid the peak heat."
Karan says she quickly learned her solutions had to align with her patients' priorities, which, for most, meant being able to work and earn money. For Kumari stopping work is not an option – she already struggles to feed her family with her monthly income of £85-90 ($114-121).
Rana believes that these simple measures taken by ASHAs can significantly benefit pregnant women. "ASHAs have extensive on-the-ground experience and work closely with their patients. Solutions such as keeping patients hydrated, maintaining a nutritious diet and taking precautions in the sun can greatly reduce the risk of heat-related illnesses."
"I think the efforts and potential of ASHAs, if properly harnessed, can contribute to the broader strategy for addressing the health impacts of climate change," she says.
Indeed, studies show that the ASHA programme successfully connects marginalised communities to maternity health services.
"Given the limited understanding of heat's impact, I believe we need more hyper-localised intelligence, like what ASHA workers bring through their work," says Ajay Chauhan, a physician at Delhi's Ram Manohar Lohia Hospital, one of the largest hospitals in Delhi. The hospital set up a special heat stroke unit in May 2024 after the general ward struggled to manage the influx of heat stroke patients.
ASHA workers tell the BBC that challenges are abundant. Despite being expected to handle a staggering number of tasks daily, they are still called "volunteers" in official records and do not receive a fixed salary. In most Indian states, they are paid a small honorarium of 3,000 rupees ($35/£26) per month, along with task-based incentives. For years, ASHA workers and their unions have been advocating for better recognition and fair pay.
"Our work demands that we are on call round-the-clock because illness or childbirth doesn't follow a schedule, and we can't refuse to help. But it's no secret that we are overworked, underpaid and unrecognised," says Dalal.
Their demanding job involves frequent field visits, regardless of the weather, making them, too, vulnerable to heat. "I fainted from the heat last May while on my way to weigh a newborn," says Karan, adding that a passer-by recognised her by her uniform (a pink coat) and helped her get home.
"Though we attend countless training sessions, we have never been taught how to protect ourselves from the heat, let alone how to safeguard pregnant women. We once requested umbrellas from the authorities, but I've never received one," she says.
"Ambulances meant for pregnant women are supposed to have air conditioning, but in reality, they only have a small fan, which is barely enough for the patient. So, I always carry a hand fan when accompanying a woman in labour because we have no one to complain to," Dalal adds.
India's Ministry of Health and Family Welfare and the National Health Mission, which leads the ASHA programme, did not respond to the BBC's request for comment.
Back in Najafgarh, both Karan and Dalal remain committed to helping pregnant women cope with the dangers of extreme heat. "A safe and successful delivery – that's all I work for," Dalal says with a smile.
Kumari safely gave birth to her fifth child last December and says she recovered faster than her previous pregnancies. "For the first time since I moved to Delhi, I had the support of an ASHA worker," she says. "I was able to return to work after four months of rest, and whenever there's a health issue with me or the baby, Kalyani didi is just a phone call away."
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