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'�� �,, , � � � �• ' Т,! �.���'��• - �. �,, �, 4 � 1 . .у . г' � �' \ е.• � s��} ' i'�L�' � 5 • � �1 • • � • ' "_ ..в 4 � � (�4���� ------ <, ��ьУУi, �• \ r1i � ь. { � i�1 � � .. �' М 1� �У � i�= '1 �I .�= �t..�M r;J1, ь }�-,_ DEVELOPMENT IN PRACTICE Improving Women's Health in India Other Recent Development in Practice Books Sustainable Transport: Priorities for Policy Reform Priorities and Strategies in Education: A World Bank Review (also available in French and Spanish) Better Urban Services: Finding the Right Incentives (also available in French and Spanish) Strengthening the Effectiveness of Aid: Lessons for Donors Enriching Lives: Overcoming Vitamin and Mineral Malnutrition in Developing Countries (also available in French and Spanish) A New Agenda for Women's Health and Nutrition (also available in French) Population and Development: Implications for the World Bank East Asia's Trade and Investment: Regional and Global Gains from Liberalization Goverance: The World Bank's Experience Higher Education: The Lessons of Experience (also available in French and Spanish) Better Health in Africa: Experience and Lessons Learned (also available in French) Argentina's Privatization Program: Experience, Issues, and Lessons Sustaining Rapid Development in East Asia and the Pacific Improving Women's Health in India THE WORLD BANK W A S H I N G T 0 N, D. C. @ 1996 The International Bank for Reconstruction and Development / THE WORLD BANK All rights reserved Manufactured in the United States of America First printing May 1996 The Development in Practice series publishes reviews of the World Bank's activities in different regions and sectors. It lays particular emphasis on the progress that is being made and on the policies and practices that hold the most promise of success in the effort to reduce poverty in the developing world. This report is a study by the World Bank's staff, and the judgments made herein do not necessarily reflect the views of the Board of Executive Directors or of the governments they represent. Photo credits Cover: UNICEF (three young girls); Tejbir Singh (woman and baby); Maurice Asseo (old woman) Text: pp. 14, 44, 86, Curt Carnemark, World Bank; pp. xii, 68, Jorgen Schytte. UNICEF Library of Congress Cataloging-in-Publication Data Improving women's health in India p. cm. - (Development in practice) Includes bibliographical references. ISBN 0-8213-3602-9 1. Women-Health and hygiene-India. 2. Women's health services-India. I. World Bank. II. Series: Development in practice (Washington. D.C.) RA564.85.I47 1996 613'.04244'0954-dc2O 96-13117 CIP Contents FOREWORD vii PREFACE ix ACKNOWLEDGMENTS xi SUMMARY 1 1 The Dimensions of Female Mortality and Morbidity 15 Mortality Patterns and Differentials 17 Overview of Causes of Morbidity and Mortality 23 Maternal Mortality 26 Maternal Morbidity 30 Fertility 31 Other Female Morbidity 34 2 The Sociocultural Context 45 Status of Women 45 Consequences of the Female Disadvantage 48 Traditional Health Systems and Their Significance for Women's Health 59 3 Health Services and How They Are Used 69 Government Services 69 Private Services 75 Utilization and Coverage of Health Services 78 V vi IMPROVING WOMEN'S HEALTH IN INDIA 4 Strategies for Change 87 Program Strategies for Providing Services 88 Meeting Clients' Needs 101 Supporting Women's Health through Action Research 106 APPENDIX 109 NOTES 141 GLOSSARY 145 BIBLIOGRAPHY 149 Foreword The health of a country's female population has profound implica- tions for the health and education of children and the economic well-being of households, as well as for the women themselves. The most direct effects of poor health and nutrition among females in countries such as India are high mortality rates among young children and women of childbearing age and high morbidity rates throughout the life-cycle. The effects of pervasive ill health extend beyond the woman herself. A woman's health and nutritional status influence her newborn's birthweight and chances of survival, her capacity to nurse and nurture her child, and her ability to provide food and care for other children and family members. In households that depend on the labor of their women, whether on family land or for wages, income falls when ill health prevents a woman from working. The World Bank, recognizing the far-reaching consequences of high fe- male mortality and morbidity, especially in poor areas, supports the efforts of governments and concerned organizations to work toward improving women's health. World Bank lending for reproductive health has increased steadily over the past few years and now totals about $450 million a year. The Bank's overall approach to women's health is described in A New Agenda for Women's Health and Nutrition, published in 1994. This Development in Practice book, Improving Women's Health in India, is the product of a collaborative effort by the South Asia Region and the Vice Presidency for Human Capital Development of the World Bank. The book examines, within the broad context of women's lives, the health problems of India's women and the programs designed to meet their needs. Together with the recently published India's Family Weljare Program: Moving to a Repro- ductive and Child Health Approach, it provides background for the World vii viii IMPROVING WOMEN'S HEALTH IN INDIA Bank's discussions with the Indian government on further developing public, voluntary, and private sector capacity to address these problems. There is broad agreement that fundamental changes in the health status of Indian women will require greater opportunities for schooling and employ- ment. But the dimensions and consequences of the health problems of Indian women also argue urgently for changes in the health system: the strengthen- ing and expansion of existing services-public, voluntary, and private-and communication initiatives to increase the demand for services and women's ability to use them. Gender issues must be an integral part of the Bank's business. In India, as in other developing countries, the World Bank supports governments' efforts to widen women's access to health services, improve the quality of care available, and increase the opportunities open to them. This report, and the research and day-to-day work that underlie it, testify to our commitment to ensuring that development assistance helps bring about better lives for women. D. Joseph Wood Vice President South Asia Region The World Bank Armeane M. Choksi Vice President Human Capital Development The World Bank Preface The broadest consideration of women's health issues is based on a life-cycle approach, starting with birth and taking into account the cumulative effects of past health events at each stage of life. Given the excess female mortality in India during childhood and in the prime childbearing ages and the high levels of maternal mortality, this book emphasizes women's reproductive health and the factors underlying excess female mortality at early ages. Other concerns, such as the diseases and conditions common to men and women and the health of older women, are given less attention than would be required in a comprehensive consideration of women's health issues. Gender-based vio- lence and occupational health issues for women are also noted. but many of the measures required to address these issues are beyond the scope of this report. The book emphasizes the situation in the northern "Hindi belt" states of Bihar, Rajasthan, Madhya Pradesh. and Uttar Pradesh, which account for almost 40 percent of India's population and which exhibit well-documented unfavor- able demographic trends, in comparison with the rest of India. The book also points out the needs of women in rural areas, where mortality levels are sub- stantially higher than in urban areas and access to care is limited. The report focuses on the measures necessary to address existing policy and implementation constraints and improve the quality, acceptability, and utilization of services essential to women's health. It does not deal specifically with financing issues; a separate study on that topic, "India: Policy and Finance Strategies for Strengthening Primary Health Care Services," was recently is- sued by the Population and Human Resources Division of the South Asia Country Department II (World Bank 1995a). It is also generally acknowledged that many of the constraints affecting the provision of public sector health and nutrition services for women are not financial and that in this regard the ix x IMPROVING WOMEN'S HEALTH IN INDIA government's current emphasis on more efficient and effective use of existing physical and human resources is amply justified. The report has as its main focus the public health sector, although it recog- nizes the increasingly important roles played by both the private voluntary and for-profit sectors in the delivery of health care services in recent years. How- ever, the provision of family planning, preventive health, and nutrition services to the majority of India's vast rural population-and its most needy females- will of necessity remain primarily a public sector responsibility for the foresee- able future. Acknowledgments The principal author of this report was Anne Tinker of the Human Development Department. In the World Bank's South Asia Country Depart- ment II Catherine Fogle managed the report's preparation, and Heinz Vergin and Richard Skolnik provided overall guidance. The report benefited from an issues paper by Frances Plunkett. In addition we would like to thank Edna Jonas for her contribution to the report, as well as the following individuals: Susan Brems. Meera Chatterjee, Monica Das Gupta. Kirrin Gill. Marcia Griffiths, Rama Lakshminarayanan. Wilma Lynn, Saramma Mathai, Anthony Measham. Torn Merrick, Nandini Oomman. Indra Pathmanathan, Joanne Salop, and Gita Sen. Emily Chalmers edited the final version. and Amy Brooks was the proof- reader. The government of India was very helpful during the preparation of this report, drafts of which were discussed with them on several occasions in 1995 and 1996. We particularly wish to thank officials of the Ministry of Health and Family Welfare for their advice. xi ”馬塾 巨N多” 鼠＿■ Summary India has made considerable progress in social and economic devel- opment in recent decades, as improvements in indicators such as life expect- ancy. infant mortality, and literacy demonstrate. However, improvements in women's health, particularly in the north, have lagged behind gains in other areas. India is one of the few countries where males significantly outnumber females. and its maternal mortality rates in rural areas are among the world's highest. Infectious diseases, malnutrition, and maternal and perinatal causes account for most of the disease burden. Females experience more episodes of illness than males and are less likely to receive medical treatment before the illness is well advanced. Because the nutritional status of women and girls is compromised by unequal access to food, by heavy work demands, and by special nutritional needs (such as for iron), females are particularly susceptible to illness, particularly anemia. Women, especially poor women, are often trapped in a cycle of ill health exacerbated by childbearing and hard physical labor. Women's health and nutritional status is inextricably bound up with social, cultural, and economic factors that influence all aspects of their lives, and it has consequences not only for the wornen themselves but also for the well-being of their children (particularly fernales), the functioning of households, and the distribution of resources. This report examines the indicators of women's health status in India, analyzes the factors affecting wornen's well-being, and identi- fies workable strategies for improving the health and nutrition of India's girls 2 IMPROVING WOMEN'S HEALTH IN INDIA and women. The report's conclusions-that focused efforts to improve the health and overall status of females will provide substantial benefits in terms of human welfare, poverty alleviation, and economic growth-mirror the consen- sus found in the growing body of literature in the field. An Overview of Women's Health Since the turn of the century. India's sex ratio has become increasingly favor- able to males. This is in contrast to the situation in most countries, where the survival chances of females have improved with increasing economic growth and declining overall mortality. In India, excess female mortality persists up to the age of 30-a symptom of a bias against females. But there are wide dispari- ties in fertility and mortality among states and, within states, between rural and urban areas. The substantially unfavorable levels of these indicators in the northern states of Bihar. Madhya Pradesh, Rajasthan. and Uttar Pradesh in relation to most southern states reflect marked social and demographic con- trasts between the "Hindi belt" and the rest of India. The southern state of Kerala, for instance, has achieved fertility and mortality levels approaching those of industrial countries. Infant and Young Child Mortality Although young child mortality has declined significantly over the past two decades, over 30 percent of all deaths in India occur among children under 5, and, despite their innate biological advantages, more girls than boys die. Dur- ing the past decade the gap between the mortality rates of young boys and girls even widened. Maternal Mortality Maternal mortality in India, estimated at 437 maternal deaths per 100.000 live births, results primarily from infection, hemorrhage, eclampsia, obstructed la- bor, abortion, and anemia. Lack of appropriate care during pregnancy and childbirth, and especially the inadequacy of services for detecting and manag- ing complications, explains most of the maternal deaths. Morbidity Reliable data on mortality and morbidity in pregnancy are scarce, and for female morbidity in general, they are almost nonexistent. The limited studies available report high morbidity and malnutrition among girls and women. Emerging evidence indicates that the prevalence of reproductive tract infec- SUMMARY 3 tions is considerably higher than previous figures suggested and that the spread of HIV/AIDS is a concern. Iron-deficiency anemia is widespread among Indian girls and women and affects 50 to 90 percent of pregnant women. Fertility Female mortality and morbidity rates are linked to overall fertility levels-in India. 3.4 children per woman. Childbirth closely follows marriage, which tends to occur at young ages: 30 percent of Indian females between 15 and 19 are married. Childbearing during adolescence poses significantly greater health risks than it does during the peak reproductive years and contributes to high rates of population growth. Indian women also tend to have closely spaced pregnancies. Some 37 percent of births occur within two years of the previous birth, endangering both the health of the mother and the survival of the infant and older siblings. Occupational and Social Influences on Health Women in India, especially in agricultural areas. are expected to perform a variety of strenuous tasks within the household, on family lands, and, in some regions, for wages. These occupations often have serious consequences for undernourished females, including adolescents, whose bone structure is not yet fully developed and who may be required to carry heavy loads or to adopt unnatural postures for prolonged periods. Another problem is exposure to heavy smoke from kitchen fires, which causes a variety of respiratory difficulties. Women are also susceptible to unusually high rates of physical assaults such as rape, burning, and beating. The poor health of Indian women is a concern on both national and indi- vidual levels. It affects the children who will be India's next generation of citizens and workers. It reduces productivity, not only at the household level but also in the informal and formal economic sectors. Improving women's health is integral to social and economic development. In addition, it is eco- nomically efficient, since interventions to improve women's reproductive health are among the most cost-effective available. The Sociocultural Context of Health Poverty underlies the poor health status of most of the Indian population, and women represent a disproportionate share of the poor. Women's relatively low status (particularly in the north) and the risks associated with reproduction exacerbate what is already an unfavorable overall health situation. 4 IMPROVING WOMEN'S HEALTH IN INDIA The Status of Women The position of women in traditional Indian society can be measured by their autonomy in decisionmaking and by the degree of access they have to the outside world. By these measures, Indian women, particularly those in the north, fare poorly. Girls are typically married as young adolescents and are taken from their natal homes to live in their husbands' households. There they are dominated not only by the men they have married but also by their new in- laws, especially the older females. Women are frequently prevented from work- ing outside the home and traveling without a chaperon, and this has profound implications for their access to health care. The money they earn, the dwellings in which they live, and even their reproductive careers are not theirs to control. In addition, the work they perform is socially devalued. This inherently inequi- table social system is perpetuated through a process of socialization that ratio- nalizes and internalizes the female disadvantage. The consequences of women's unfavorable status in India include dis- crimination in the allocation of household resources, such as food, and in access to health care and education. as well as marriage at young ages. The loss of a husband usually results in a significant decline in household income, in social marginalization, and in poorer health and nutrition. (Over 60 percent of women aged 60 and above are widows.) Education The female disadvantage in India is also evident in education. Although signifi- cant gains have been made in female literacy since independence and the benefits of educating females are widely recognized, population growth has meant that there are more illiterate females today than a decade ago. According to the 1991 census, only 39 percent of Indian females above age 7 are literate, compared with 64 percent of males. In some northern states, the percentage of literate females is as low as 21 to 26 percent. A variety of socioeconomic factors are responsible for women's lower educational attainment, including direct costs, the need for female labor, the low expected returns, and social restrictions. Because women's educational level and improvements in their health status are closely linked, increasing female education is key to improv- ing their health. The Preference for Sons Daughters are generally considered a net liability: they often require a dowry, they leave their natal homes after marriage, and their labor is devalued. The SUMMARY 5 result is a strong preference for sons. In its most extreme form. this preference leads to female infanticide and, more recently, to sex-selective abortion. The preference for sons is readily apparent in the relative neglect of female chil- dren, who are weaned earlier than males, receive smaller quantities of less nutritious food and less medical care, and are more likely to be removed from school. This inequitable treatment continues into women's adult lives. Women eat after men, and even during pregnancy their diet is typically inadequate. A high proportion of women receive no treatment for illness; many use home remedies or traditional healers, while men are more likely to receive modern medical and institutional care. Women and Work Beginning in childhood, most rural women fulfill multiple productive func- tions in addition to bearing children and performing household labor. Ironi- cally, recent agricultural innovations have not benefited rural women, who still perform primarily manual labor. The strenuous physical tasks allocated to women, combined with limited food intake, exacerbate malnutrition among Indian women. Productive responsibilities are hardest on childbearing women, who typically work until late in their pregnancies without needed rest or addi- tional food. New mothers resume work before they have fully recovered from childbirth and have their children in relatively close succession, resulting in a cycle of matemal depletion that saps their physical strength and undermines their ability to function effectively. While poverty tends to exacerbate a woman's lot, it may result in better treatment of female infants and children at the lowest socioeconomic levels, where females are valued as productive workers. The gap between male and female children in feeding and care is often less in very poor families than in wealthier households. However, these girls are under pressure to begin earning at very young ages. They may be taken to work beside laboring parents in the field or may participate in home-based enterprises. with adverse consequences for their health and physical growth. Traditional Health Systems and Their Significance for Women's Health A complex array of medical systems is practiced throughout India, including several traditional text-based medical systems and modern allopathic medi- cine. Ayurveda, the classical Hindu system, is concerned with an individual's total health. Today, ayurvedic practitioners often utilize not only natural rem- edies but also allopathic treatments. Other medical systems in use include 6 IMPROVING WOMEN'S HEALTH IN INDIA Unani, favored by Muslims, and homeopathy. Another set of beliefs that un- derpins health practices concerns the nature of illness, the role of food, and supernatural forces. While some of these traditional beliefs are not incompat- ible with Western medicine, they often complicate the delivery of modern medical services. For this discussion, views about pregnancy and childbirth are of particular importance. Efforts to deliver antenatal services to women are hindered by the prevail- ing attitudes toward pregnancy, which is not generally considered a condition that requires special treatment. Pregnant women receive little (if any) addi- tional food and often no medical attention, even when complications arise. In rural areas, over 80 percent of deliveries occur at home, assisted by older household women and traditional birth attendants (dais). The unhygienic con- ditions in which rural deliveries often occur lead to infection in many mothers and newborns. Women frequently turn to traditional practitioners for abortions; the proce- dures used are usually unsafe and may lead to infections and other complica- tions. Women may also consult these practitioners for help in dealing with infertility-which is almost always deemed to be the woman's problem and is considered a disaster for women in Indian society, where women's main role is believed to be reproductive. Health Services and How They Are Used A variety of services are available from the Indian government, the not-for- profit sector, and the for-profit sector (which includes modern allopathic and traditional practitioners and local healers). Although the private sector provides about 80 percent of health care in India, the government is the primary source of preventive services such as immunization and family planning. Government Services Overall, government spending on health represents only about 1.3 percent of the gross domestic product. In addition to general health services provided to all people, public sector services to meet the specific health and nutritional needs of Indian women are provided through the Family Welfare Program of the Ministry of Health and Family Welfare and the Integrated Child Development Services (ICDS) Program of the Ministry of Human Resources Development. THE FAMILY WELFARE PROGRAM. The Family Welfare Program adminis- ters family planning and maternal and child health services that are provided through subcenters (which serve a group of villages), primary health centers, community health centers, and district and subdistrict hospitals. The Family SUMMARY 7 Welfare Program has evolved from the National Family Planning Program, the oldest in the developing world. In recent years it has focused primarily on sterilization. The program has come under criticism for its prescriptive meth- ods, narrow scope of services, and inadequate outreach. In response, the gov- ernment is developing a more decentralized approach, and specific method targets have been abolished. There is increasing commitment to a broader approach to reproductive health, as well as a multisectoral perspective that recognizes the importance of addressing related issues such as female educa- tion and women's status. The Child Survival and Safe Motherhood Program, initiated in 1992, is designed to improve the health status of women and children and reduce mater- nal, infant. and child mortality rates by addressing the main causes of morbidity and mortality. The initiative builds on services provided by the Family Welfare Program but is more targeted. The child survival component of the program, particularly the efforts to expand immunization coverage, has received the most attention. The safe motherhood component has developed more slowly, primarily because implementing the program's ambitious goals requires a sig- nificant expansion of the existing maternal care services. Current facilities for providing care of obstetric complications (a key program goal) are inadequate. and it is difficult to recruit trained female personnel for posts in remote areas. The Intensified Training of Dais Program is designed to provide training for dais, who are present at many births in rural areas. The women are given hands-on training that stresses antenatal care, safe delivery practices, including hygiene, and detection and referral of complications. They are also provided with kits containing essential items for hygienic delivery. THE INTEGRATED CHILD DEVELOPMENT SERVICES PROGRAM. The aim of the ICDS Program is to improve the nutritional and health status of pregnant and lactating women and of children under 6 and to enable mothers to look after their children's health and nutritional needs. Services such as supplemental food for children, preschool programs, and nutrition and education programs for women are provided by female workers (anganiwadis) at village health centers. The program currently covers over 50 percent of the development blocks in India and is being expanded throughout the country. The ICDS Pro- gram is working to strengthen community-based services through improved linkages with the health system. Private Services Private care is offered in the not-for-profit, organized, and informal sectors. The private sector provides 80 percent of health care in India and is the princi- pal source of curative care. While the not-for-profit and organized health sec- 8 IMPROVING WOMEN'S HEALTH IN INDIA tors are largely concentrated in urban areas, rural areas support a wide range of private health care providers, from allopathic and traditional medical practitio- ners to faith healers. THE NOT-FOR-PROFIT SECTOR. Nongovernmental organizations (NGOS) run some of the most effective programs providing family planning, health, and related services for women. The success of these organizations lies in the flexibility of their operations, their communication skills, and their ability to elicit community support and participation. Their strategies often cut across sectors and include a range of services, of which health care may be only one. However, the services NGOs provide are relatively small in scale and are avail- able to only a small proportion of the rural population. THE FORMAL AND INFORMAL PRIVATE SECTORS. Privately provided modern medical care has become more widely available in India, although data on the exact number and coverage of practitioners and facilities are incomplete. In general, modem allopathic care is more prevalent in urban areas, while rural residents tend to call on traditional practitioners and faith healers. Many rural practitioners are unlicensed; some practice an eclectic form of medical care that combines allopathic medicine and one or more traditional or supernatural sys- tems. Drug sellers and phanrmacists are another major source of health-related information and medicines. Utilization and Coverage of Health Services Many patients are pluralistic in their choice of treatment, utilizing a variety of allopathic and traditional practitioners. The widespread utilization of tradi- tional practitioners suggests that they are more trusted, more accessible, and more affordable than public sector or formal private sector practitioners. In choosing between government and private services and practitioners, better-off Indians tend to favor private sector treatment, since competence is often associ- ated with cost. Patients are frequently dissatisfied with the government services they receive, for reasons that include the cost of nominally free services and drugs. rude and improper behavior on the part of health staff. staff shortages, a lack of supplies and drugs, and long waiting times to see a doctor. The avail- ability of female doctors. nurses, and midwives affects women's use and choice of health services. Because of cultural constraints, women are not encouraged to consult male health providers. Yet unsuitable accommodations in rural ar- eas, cultural restrictions on women working away from their families, and the need to seek employment near their husbands all act to suppress the number of female health care providers in rural areas. SUMMARY 9 MATERNITY CARE. The number of women who receive antenatal and post- partum care through the Family Welfare Program is still relatively low. Only about half of all pregnant women receive any antenatal care, and far fewer receive the recommended three contacts. Problems exist on both the demand and supply sides. Pregnant women are often unaware of the need for routine care, and the program has not generally been successful in communicating the importance of receiving care from early pregnancy to six weeks after delivery. Furthermore, many women are not aware that maternity care is available from female health workers at subcenters. The anemia prophylaxis program that provides iron and folic acid tablets to pregnant women is a key component of antenatal care, but the scheme has met with bottlenecks at the field level because of supply and demand problems. Only 51 percent of women have been receiving tablets. Supplies have been erratic, and some women have refused or discontinued using the tablets . More- over, the quality of the tablets has been poor and their effectiveness question- able. The Child Survival and Safe Motherhood Program is attempting to address these problems, and coverage levels are reported to be improving, although they remain low in states with high maternal mortality. The number of deliveries that take place in institutions or are attended by trained providers remains low. Overall, only one-quarter of deliveries occur in health facilities. Among deliveries that take place at home, 48 percent are attended by a traditional birth attendant, 40 percent by relatives or others, and only 11 percent by a doctor or nurse-midwife. A primary consideration is the lack of emergency obstetrical services, including blood banks for transfusions. especially in remote areas with poor roads and transportation. However. just as antenatal care is often considered unnecessary. so is medical care during child- birth. The cost of nominally free government services is an additional barrier, since women can deliver their children at home at minimal cost. FAMILY PLANNING. Since 1970. the use of modern contraceptive methods has risen from about 10 percent to 40 percent. Again, the figures vary widely by state, from 53 percent in Maharashtra to 20 percent in Uttar Pradesh and Bihar. The most striking aspect of contraceptive use in India is the predominance of sterilization, which accounts for more than 85 percent of total modern contra- ceptive use. Female sterilization accounts for 90 percent of sterilizations. The lack of knowledge about and access to other contraceptive methods reflects the Family Welfare Program's historical emphasis on sterilizations. Increasing con- traceptive choice, particularly temporary methods for delaying and spacing pregnancies, is now seen as a high priority. Since the leealization of induced abortion in India in 1971, the reported number of legal procedures has reached about 600,000 annually. However, 10 IMPROVING WOMEN'S HEALTH IN INDIA estimates suggest that at least twice as many illegal (and unsafe) abortions take place. and some estimates place the number at ten times that of legal proce- dures. The primary reason for this situation is the limited availability of provid- ers and facilities that offer legal abortions. Only about 10 percent of eligible facilities actually have a trained provider and the necessary equipment. The financial difficulties involved in obtaining legal abortion services, whether from a government or a private facility, and concerns about confidentiality also make local, unsafe alternatives more common, particularly in rural areas. Strategies for Change Improving women's health requires a strong and sustained government corn- mitment, a favorable policy environment, and well-targeted resources. The government's strategy should include balancing the roles of the public and private sectors to maximize resources and to extend care to women whom government programs do not reach. The public sector will continue to play a key role in providing services such as family planning, maternity care. and control of infectious diseases that promote equity and economic efficiency and confer widespread benefits. However, not all health services-even those that are publicly funded-need to be provided by the state. The challenge for the government is to help direct and improve privately provided services through appropriate regulatory arrangements and by encouraging an expansion of their scope to include promotion and prevention, in addition to curative care. The expansion and strengthening of existing services will reduce the dis- ease burden and the associated costs. including productivity losses. For these improvements to be sustained and the female disadvantage decreased, health systems must be more gender sensitive, and education and employment oppor- tunities must be expanded. Both demand- and supply-side considerations need to be taken into account. although efficient, high-quality services will generate their own demand in the long run. The government of India has recently taken important steps toward moving from a target-driven, demographic approach emphasizing female sterilization to a decentralized approach that helps individuals meet their broader health and family planning goals. The progress that has been made under the Family Welfare Program needs to be continued and expanded to place more emphasis on reducing female morbidity and maternal deaths. The ICDS needs to sharpen its focus on women and to coordinate with other health services. "Action" re- search should be used to investigate and test alternative approaches to improv- ing the delivery of services and showing greater responsiveness to women's needs. SUMMARY 11 The Family Welfare Program Changes need to be made in the allocation of resources so that funding is linked to states* performance in implementing the new approach. as well as to popula- tion size and funding needs. New indicators of performance will be necded to replace method-specific targets. IMPROVING EXISTING SERVICES. Specific steps by the government are needed to improve the quality of India's health care services. These include integrating family planning and maternal and child health services: prioritizing needs at the field level; training fieldworkers, including auxiliary nurse-midwives (ANMS) and traditional birth attendants; protecting at-risk female children; accelerating anemia prevention and control efforts; making temporary contraceptive meth- ods widely available; and increasing the availability of medical termination of pregnancy. PROVIDING ADDITIONAL SERVICES. Existing health services are not adequate for meeting women's needs in the key areas of non-pregnancy-related morbid- ity and maternal mortality. N Non-pregnancy-related norbidirv. Increased attention to female morbidity throughout the life cycle. including more gender-sensitive approaches, are needed for the control of common problems such as diarrheal diseases, respiratory infections. malnutrition, intestinal parasites, malaria, tuberculosis, and repro- ductive tract infections. These problems are amenable to cost-effective preven- tion and treatment. Reproductive tract infections, in particular, have been gen- erally neglected, yet they represent a substantial disease burden for women and can increase susceptibility to HIV/AIDS. ANMs and other health staff need to be trained to identify and treat (or refer) gynecological problems: laboratory diag- nostic capacity needs to be strengthened, and outreach efforts are needed to make both men and women aware of the symptoms and seriousness of sexually transmitted diseases and other reproductive tract infections. m Maternal mortalurv. The existing health system does not adequately meet the needs of pregnant women, particularly for complications of pregnancy and obstetrical emergencies. Three major problems need to be addressed: an absence of links between communities, subcenters, and referral facilities, shortages of equipment and trained staff at referral facilities, and a lack of emergency transport. 12 IMPROVING WOMEN'S HEALTH IN INDIA The Integrated Child Development Services Program The ICDS Program has many of the same problems as the Family Welfare Program. Women tend to receive less emphasis than young children, even though it is well understood that maternal health and nutrition are critical to ensuring a good start in life. The ICDS needs to improve technical and infor- ination, education, and communication (IEC) training for fieldworkers, make supplemental nutrition programs for women a priority; improve targeting in its supplementary feeding program for children; and expand initiatives that will increase adolescent girls' knowledge of health and nutrition before marriage. Coordinating Services The Family Welfare and ICDS programs share some common objectives, pro- vide complementary services, and often target similar populations. Coordina- tion between these two programs needs to be improved in several areas: plan- ning. work routines, supervision, informal training, and curricula for formal training. Increased coordination is particularly necessary at the field level if the efficiency. effectiveness, and coverage of health services for Indian women (including adolescents) are to be improved. Meeting Clients' Needs The government can take several steps to meet women's health needs, in addi- tion to strengthening services. Through legislation, legal enforcement, and IEC, harmful practices such as domestic violence and gender bias can be curbed. Working closely with civil society, particularly NGOs and women's groups, will make services more responsive to women and improve utilization and impact. INFORMATION, EDUCATION. AND COMMUNICATION. If demand is to be ef- fectively created or enhanced, IEC strategies must be consonant with the per- spectives of the community. Therefore, careful qualitative research will be needed as a basis for designing messages to convey knowledge and modify behavior. Mass media and interpersonal communication should be used to improve knowledge and practices related to contraception, safe sex. safe moth- erhood practices, nutrition, HIV/AIDS prevention, and gender relationships. Ef- fective strategies include targeting specific households. providing information on the importance of health care and the availability of services, promoting dialogue with women's groups, and encouraging men to involve themselves in family planning and women's health. Such strategies must be decentralized in order to respond to local sociocultural variations. In addition, fieldworker train- SUMMARY 13 ing should emphasize that communication is a two-way process and that work- ers should take into account the beliefs and traditions of clients when offering health and family planning information and services. PRIVATE SECTOR INVOLVEMENT. Several steps can be taken to increase the private sector's role in improving women's health. Both nonprofit and for- profit organizations can be encouraged through training of private practitioners who provide essential women's services, subsidized commercial marketing, and incentives for employment-related insurance policies. In particular, the government should support efforts byNGOs, whose flexibility, innovative meth- ods, and field experience allow them to design and implement services with objectives and components that cut across sectors, thereby addressing broader development concerns. PARTICIPATION BY COMMUNITIES AND WOMEN'S GROUPS. Community sup- port and participation are essential to facilitate the planning and delivery of health care services. Involving women's groups is especially effective in in- proving women's access to services and increasing sensitivity to women's needs. Supporting Women's Health through Action Research Action (or operational) research includes a variety of formal and informal research projects that can be used to introduce. test, or modify program strate- gies and activities and measure their impact and cost. Given the difficulties of introducing changes in large, well-established programs, action research can play an important role, particularly if an existing approach is not working orIEC efforts are needed. Because India's central and state governments often lack the capacity to carry out such research, NGOs. academic institutions, and other private sector groups with the requisite expertise should be utilized to carry out action research. Action research on service delivery and tEC projects is sug- gested for the following: safe motherhood messages; anemia prophylaxis and treatment; increased contraceptive choice: reduction of unsafe abortion practices: management of reproductive tract infections- referral of and transportation for obstetric emergencies; nutritional supplementation for adolescent, pregnant, and lactating women: quality of care; and public-private collaboration. - - - - -�-- �:�� " � � `� � д i� .:; � _ �"� ° � � - ., �.. � � �� �� _ _ . � .�. � - �„ . _ �: � i у � -�'.Я � . I�� � �- ' д'_ � _ ' R3п- - { ` � ✓ �лйЕ ��� ' �.�- _ � -,` ;,ч,.� �:. - м �� . йr � _ i� . ' � _ � . � � . � �' ь'4т' '.� . -�'�у �wNy�1, , т . . . _ C H A P T E R 0 N E The Dimensions of Female Mortality and Morbidity Human females have a natural biological advantage over males. In Western countries with low mortality rates, men die in greater numbers than women throuohout the life span. Women can expect to live Ionger than met], and there are more females than males in the total population.' However, al- though women live longer worldwide, they are more likely than men to experi- ence poor health (World Bank 1994a). India is one of the few countries in the world where males significantly outnumber females: according to the 1991 national census, there were only 927 fernales for every 1.000 males.2 Furthermore, since the beginning of the cen- tury the sex ratio of the population, calculated from the decennial census, has becon-ie increasingly weighted toward men (figure 1.1). In earlier decades, India's peculiar sex ratio was genet-ally attributed to the undercounting of females in the census, to differential migration, or to singularities in male and female birthrates. Only with the work of Visaria (1971) was it conclusively demonstrated that the increasing imbalance in the ratio of men to women could not be ascribed to any of these factors and in fact reflected certain social characteri sties of Indian society. One way to estimate the extent of the problern is to compare India's actual sex ratio to the sex ratio that theoretically would exist in the absence of gender discrimination. This theoretical sex ratio is then compared with the actual sex ratio to produce a number that represents the girls and wornen (often called 15 16 IMPROVING WOMEN'S HEALTH IN INDIA FIGURE 1.1 POPULATION SEX RATIO, INDIA, 1901-91 Females per 1,000 males 1,000 990 980 970 960 950 940 930 920 910 900 1901 1911 1921 1931 1941 1951 1961 1971 1981 1991 Source: RGI (various years). "missing women") who have died as a result of past and present discrimination. The current estimate is that there are over 35 million "missing women" in India, although other estimates have ranged from 23 million to 42 million (Das Gupta and Bhat 1995: Drze and Sen 1995; Klasen 1994: Coale 1991). It is not difficult to identify the direct demographic cause of India's female- deficient sex ratio. In most other populations-including those of developing countries in Africa, Latin America, and Southeast Asia-age-specific death rates for females are lower than the corresponding rates for males. India, like most other countries of southern Asia, is different. The main reason for the difference is that, up to about age 30, females in India die at higher rates than males (figure 1.2; appendix table 1 .1 ).' Excess female mortality was probably characteristic of most traditional peasant societies in the area stretching from the Mediterranean across Asia to China before twentieth-century socioeco- nomic changes transformed the region's mortality levels (Harriss 1989: Amin and Pebley 1987). The severity and persistence of relatively high female mor- tality rates in India indicate that the social causes underlying this demographic phenomenon are deep-seated and difficult to address. Discrimination is also appearing in new forms as technology becomes increasingly sophisticated- THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 17 FIGURE 1.2 AGE- AND SEX-SPECIFIC DEATH RATES, INDIA, 1989--91 Deaths per 1,000 30 mMale 25 - M Female 20 - J 15 - 10- 5- Source: RG I (various years). for instance, in the spreading practice of sex-selective abortion, which has anl additional (although currently low) impact onl the overall sex ratio. The health differential between females and males is reflected in relative morbidity levels. Although studies of morbidity in India are limited, a recent analysis by Murray and Lopez (forthcoming) indicates that loss of healthy life from nonfatal diseases and pathological conditions is higher overall for females than for males. This is a result of significantly higher morbidity among girls under age 5 and women ages 15-44. Mortality Patterns and Differentials Marked regional variations, the worsening of maleffemnale mortality ratios for children ages 0-4 in a number of states, and the persistence of excess mfortal ity among women of childbearing age highlight the problems that Must be ad- dressed if the health status of women is to be improved. Regional variations are among India's most prominent denlographic char- acteristics. Mortality, fertility, illiteracy, and other demographic indicators are considerably higher in the northern states of Bihar, Madhya Pradesh, Rajasthan, 18 IMPROVING WOMEN'S HEALTH IN INDIA and Uttar Pradesh than in the rest of the country, reflecting underlying socio- cultural contrasts between the "Hindi belt" and the rest of India.' Indicators for the southern state of Kerala are similar to those of many industrial countries. Measures of mortality provide good examples of the north-south demographic differentials. In 1992. the crude death rate in Uttar Pradesh was 13 per 1,000 population), almost twice that in Kerala, with 6 per 1,000 (appendix table 1.2). Regional differentials among females for the basic demographic indicators follow essentially the same pattern as the differentials for both sexes combined. The causes of this disparity in demographic and health indicators between the northern states and the rest of India should be a major consideration in the design of interventions intended to meet women's health needs. Reasons for the relatively poor health indicators in some states include higher rates of poverty and illiteracy, fewer resources allocated to health per capita, lower commitment to social development, and inadequate capacity (World Bank 1995; Measham and Heaver 1996). A woman's chance of survival is also affected by whether the area she lives in is rural or urban. As in most developing countries in recent decades. mortal- ity is lower in India's cities than in its rural venues, and urban females are less disadvantaged relative to males. Urban death rates are lower than correspond- ing rural rates at every age: in 1989-91, the urban crude death rate for females was 7 per 1,000 and the corresponding rural rate, II per 1,000 (appendix table 1.1). Indian women have achieved slightly greater proportional gains than men in overall life expectancy over the past several decades. The average life ex- pectancies of men and women in developing countries are 62 and 63. and in industrial countries 73 and 80, respectively (World Bank 1993). Life tables from India's Office of the Registrar General (RGI) show that while in 1961-70 life expectancy for males (46.4 years) was higher than for females (44.7 years), by 1986-90 women were living slightly longer than men-59.1 and 58.1 years, respectively (appendix table 1.3; see also appendix tables 1.4 and 1.5). But while this favorable trend is encouraging for women who stIrvive to older ages, women under the age of 30 do not benefit equally. Infants, girls, and women in their prime childbearing years (ages 0-30) are at a far greater risk of death from preventable causes than older women. Infant and Child Mortality Among children 0-4, the female mortality rate in 1989-91 exceeded the male mortality rate by 10 percent (28.9 and 26.3, respectively; see figure 1.2). This THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 19 differential rose to 25 percent for children ages 5-9 (3.0 and 2.4. respectively) and declined to almost zero at ages 10-14. The less favorable mortality ratio for girls in the 5-9 age group compared with those in the 0--4 group presumably reflects the relatively high rate of male neonatal mortality, which affects the overall ratio of the 0-4 group. The lower ratio at ages 10-14 is to be expected, since girls in this age group have survived the worst hazards of childhood but have not yet had to face the risks of childbearing. Infant and young child mortality rates are among the most sensitive indica- tors of the health status of a population. Over the past two decades, infant and young child (0-4) mortality rates in India have declined significantly. RGI estimates indicate a drop in the infant mortality rate (IMR). wnich fell from over 133 deaths per 1,000 births in 1972-74 to 80 in 1990-92 (appendix table 1.6), and a similar decline in the mortality rate of young children (age 0-4) from 53 to 26 deaths per 1.000 (appendix table 1.7). The rates vary considerably across states (appendix table 1.8). In 1992. Orissa and Madhya Pradesh still had ImRs of over 100, while Kerala's rate of 17 was far lower than that of any other state. Young child death rates follow a similar pattern. INFANT MORTALITY. Given the biological advantage baby girls enjoy when it comes to survival, male IMRs should be higher than female ImRs. However, in India overall. the two rates are currently about equal (appendix table 1.8: see also appendix table 1.9). The expected female advantage appears most clearly in Kerala. The most recent figures available (1992) show that female infant mortal- ity rates are still higher than male rates (with a low of 0.88 in Uttar Pradesh). INiRs mask a basic difference between neonatal deaths. which occur within 28 days of birth, and post-neonatal mortality. Neonatal mortality is attributable largely to causes, such as tetanus, prematurity. and congenital conditions. that are not gender specific. Post-neonatal deaths, however, are by and large caused by infectious diseases. The incidence and severity of most of these diseases are affected by controllable factors such as imntunization, health care, and nUtri- tion. Where gender bias exists, these factors are not controlled equally for male and female children. The disparity will be reflected in excess post-neonatal mortality rates, as the natural female advantage can be expected to appear in the neonatal rates. To examine gender differences in infant mortality, then. it is necessary to consider neonatal and post-neonatal mortality rates separately. The RGI does not publish neonatal and post-neonatal mortality rates by sex. but studies have documented the gender disparity between neonatal and post-neo- natal mortality for a number of rural and urban populations in northern and southern India. In these early studies (1965-84) male/female neonatal mortal- ity ratios were more than 1, but post-neonatal ratios ranged from 0.53 to 0.80 20 IMPROVING WOMEN'S HEALTH IN INDIA (Kishor 1993: Abel 1987; Das Gupta 1987: Ranianujam 1987; Ghosh, Bhargava. and Moriyama 1982; Kielmann and others 1978). YOUNG CHILD MORTALITY. The sex-specific death rates for boys and girls in the 0-4 age range clearly show the difference between male and female mortality at young ages (appendix table 1.10). The extent of the female disad- vantage at these ages becomes evident in state figures (appendix table 1. 11). Only in the states of Kerala. Karnataka, Andhra Pradesh. and Maharashtra were mortality rates in the 0-4 age group higher for males than for females, as they are around the world. But a recent (1994) report on Uttar Pradesh by the Population Research Center (PRC) and the International Institute for Population Science (iips) describes a still more serious disadvantage for young girls. The survey found that during the post-neonatal period, 124 girls die for every 100 boys. The most significant difference was found between the ages of I and 5. when 170 girls die for every 100 boys. If the nationwide male mortality levels in the 0-4 age group are taken as an index of the level of child mortality that can be achieved under existing circumstances in India, it is clear that the number of excess female deaths at these ages-more than 100,000 a year-must be the result of gender discrimination. Even more significant than the current female disadvantage in young child mortality rates are recent relative mortality trends for this age group. Until about 1983, female rates were declining faster than male rates. However, since then, despite a continued decline in mortality rates for both sexeF, the gap in mortality rates for this age group has increased rather than decreased- in other words, instead of declining. the female disadvantage grew. Between 1982-84 and 1990-92, India's overall male-female mortality ratio for the 0-4 age group declined from 0.93 to 0.90. This unfavorable trend is evident in six of the fourteen major states and in the south as well as in the north (figure 1.3; appendix table 1.11). The gap became especially pronounced in Orissa, Bihar, and Uttar Pradesh between 1982 and 1992. The reasons the gap between mor- tality rates for young boys and those for girls did not continue to narrow after the early 1980s are not clear. The ratio of male-to-female infant mortality rates is virtually unchanged from the ratio in the early 1980s (appendix table 1.9). in spite of declines in overall neonatal and post-neonatal mortality rates (appendix table 1.12). Despite declines in young child mortality in recent years, over 30 percent of all deaths in India occur among children under 5. Studies show that further reductions in child mortality are key to improving life expectancy for both sexes. For example, between 1941 and 1970. reductions in infant and young child mortality in India accounted for 40 percent of the increase in life expect- ancy (Ruczicka 1984). If the national goal for reducing under-5 mortality by 2000 is achieved. this alone will add about three years to current life expect- THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 21 FIGURE 1.3 MALE/FEMALE RATIOS FOR AGE 0-4 MORTALITY RATES, INDIA AND SELECTED STATES, 1982-84 AND 1992 India Andhra Pradesh Orissa Madhya Pradesh Bihar Rajasthan 1 1982-84 Uttar Pradesh E ] 1992 ;I;I I 0.7 0.8 0.9 1.0 1.1 Male/female ratio Source. RGI (varoIs Veal). ancy. Expected reductions in mortality at other ages would add another year to life expectancy. Mortality in the Childbearing Years During the childbearing years, wonen's risk of dying is double that between the ages of 10 and 14 (see figure 1.2; appendix table 1.1). Furthermore, the differential between male and female mortality rates in India is higher for women ages 15-24 than for any other age group. In 1989-91, mortality rates for women between the ages of 20 and 24--the years of highest fertility- exceeded those for men by one-fourth. For those women who survive the prime childbearing years and thus are at far less risk of dying in childbirth, the bio- logical advantage becomes evident. By 1989-91 mortality rates had "crossed 22 IMPROVING WOMEN'S HEALTH IN INDIA FIGURE 1.4 FEMALE DEATH RATES, AGES 20-24, INDIA AND MAJOR STATES, 1990-92 India Madhya Pradesh Orissa Bihar Uttar Pradesh Rajasthan Andhra Pradesh Gujarat Haryana Tamil Nadu West Bengal Maharashtra Karnataka Punjab Kerala 0 1 2 3 4 5 Deaths per 1,000 Soun, t. R(1 Iivatimi, yeart over" after age 29, with male death rates remaining higher than female rates for the rest of the life span. Regional variations in female mortality during the childbearing years are substantial. Among women age 20-24, when childbearing is most common. death rates for 1990-92 varied from 0.9 per 1,000 women in Kerala to 4.3 in Madhya Pradesh (figure 1.4; appendix table 1. 13). With the exception of Kerala and Punjab. the ratios of male and female death rates at these ages show that female mortality is higher in all the states, with the northern states having the least favorable ratios. The pattern is more favorable for females in urban areas. where relatively high female mortality in the childbearing years persists only through ages 20-24 (appendix table 1.1). THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 23 Trends in Women's Mortality Demographic experience in parts of India and elsewhere suggests that as over- all mortality levels decline and women's status improves, excess female mor- tality begins to disappear. Recent research suggests that economic growth and modernization do not automatically improve the survival chances of girls rela- tive to boys because these variables reduce young male mortality more than young female mortality. Variables related to women's empowennent are the most significant in reducing both child mortality and gender bias (Dr6ze and Sen 1995: Murthi, Guio. and Dr6ze 1995). This trend has been most clearly documented for Sri Lanka, where the pattern of female mortality in the early 1950s was similar to the pattern in India today. With increased female educa- tion and reduced fertility and maternal mortality in Sri Lanka. excess female mortality declined, along with overall mortality levels. As might be expected. excess female mortality disappeared first among girls ages 10-14 and women at the end of their reproductive years and only then among the very young and women at prime childbearing ages (Langford 1984). In India, trends in the ratios of death rates for specific groups defined by age, sex. and place of residence over the past two decades suggest that a similar transition is under way in some states. Overall. male/female mortality differentials are unmistak- ably declining during the childbearing years (figure 1.5). In the large northern states, however, current levels of female mortality are so high that dramatic improvements will be needed before male/female mortality ratios can even begin to reach expected levels. When the ratios begin to even out. they are likely to follow the same pattern as Sri Lanka's: relatively high female mortality rates will decline gradually, persisting longest in the young child and prime childbearing ages. To speed up the transition, health, nutrition, and other social service programs need to specifically target those groups and regions where the prob- lems are greatest and place greater emphasis on overcoming gender bias where it persists. Overview of Causes of Morbidity and Mortality Communicable diseases, maternal and perinatal conditions, and malnutrition account for 68 percent of the burden of disease (premature death and disability) among girls and women in India (see box 1.1 and appendix table 1.14). Most of this burden can be prevented by readily available, low-cost technologies. As a basis for comparison, in China these health problems account for only 27 percent of the female disease burden (Murray and Lopez forthcoming). Among young girls, the main causes of disability and death are respiratory infections, diarrheal diseases, injuries, malnutrition, measles, and tetanus. 24 IMPROVING WOMEN'S HEALTH IN INDIA FIGURE 1.5 MALE/FEMALE MORTALITY RATIOS, AGES 15-39, INDIA, 1979-81 AND 1989-91 Male/female ratio 1.2 - 1979-81 I 1989-91 1.0 0.8 - 0.6 - 0.4 0.2 15-19 20-24 25-29 30-34 35-39 Age group Source: RGI (various years). Perinatal conditions, such as low birthweight, also contribute greatly to the burden of disease for this age group-reflecting the poor health of the mother and the low quality of care during pregnancy and childbirth. Among women ages 15-44, the disease burden is primarily attributable to maternal conditions, neuropsychiatric disorders (especially depression), injuries, sexually transmit- ted diseases (STDS), and tuberculosis. After age 45. cardiovascular diseases become the major cause of death. Other major causes of death and disability among women beyond reproductive age include respiratory infections. malig- nant neoplasms (one-fifth of cancer deaths are from cervical cancer). and cata- racts (Murray and Lopez forthcoming). Rough data on the causes of death by rural and urban residence are avail- able from a survey carried out by the government's Sample Registration Sys- tem in rural areas and from lay reports and incomplete records of medically certified deaths in urban areas. The RGI rural data for 1989 are summarized in appendix table 1.15, and urban data for 1984 in appendix table 1.16. The data from rural areas indicate that the two leading causes of death-other than those associated with infancy, pregnancy, and old age-are respiratory disorders, THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 25 BOX 1.1 THE COST-EFFECTIVENESS reducing the disease burden. The OF REDUCING THE DISEASE BURDEN study concluded that interventions to control childhood communicable dis- Murray and Lopez (forthcoming) car- eases and improve reproductive health ried out a comprehensive analysis of were among the most cost-effective the loss of healthy life caused by about measures available. In India, about 100 diseases and injuries (burden of two-thirds of women's disease burden disease). The burden of disease was is amenable to prevention or treatment expressed as disability-adjusted life with cost-effective interventions. The years (DALYs), a measurement that table below shows the burden of dis- combines losses from premature death ease among Indian females for dis- and disability. eases with highly and moderately cost- In World Development Report 1993 effective interventions. Appendix table the World Bank assessed a wide range 1.14 provides a complete listing of the of health interventions to determine disease burden faced by Indian men which were the most cost-effective in and women, for all conditions. Diseases and Injuries with Cost-Effective Interventions, for Indian Women, 1990 DAL Ys Cost-effectiveness Disease or injury (1,000s) of interventions' Maternal and perinatal conditions 20,903 High Respiratory infections 18,192 High Diarrheal diseases 15,420 High Childhood clusterb 9,178 High Tuberculosis 5,016 High Micronutrient deficiency 3,994 High STDs and HIV 3,778 High Cataracts 1,281 High Cervical cancer 761 High Depressive disorders 5,102 Moderate Ischemic heart disease 4,528 Moderate Motor vehicle accidents 1,745 Moderate Diabetes mellitus 1,154 Moderate Congestive obstructive pulmonary disease 1,103 Moderate Total, diseases and injuries with cost-effective interventions 94,221 a. Interventions with high cost-effectiveness can be implemented for less than $100 per DALY saved, those with moderate cost-effectiveness for $100-$999 per DALY saved. b. Vaccine-preventable diseases of childhood. Sources: For DALYs, Murray and Lopez (forthcoming); for cost-effectiveness. World Bank (1993). 26 IMPROVING WOMEN'S HEALTH IN INDIA which account for around 30 percent of all female deaths, and circulatory problems, which account for another 16 percent. Accidents and other causes account for around 10 percent of deaths each. Within each age group, the pattern does not differ markedly between males and females, except. of course, for maternal deaths in the childbearing years. Data on the proportion of total deaths attributable to pregnancy and childbirth indicate that the percentages in the northern states are much higher than those in the southern states (appendix table 1.17). More specific causes of death are available from data drawn from the medical certificates of death issued in urban areas (appendix table 1.16). The pattern that emerges from these data does not differ markedly from that indi- cated by the rural data. A notable difference in the causes of death among rural and urban dwellers is that a higher proportion of urban females ages 5-24 are likely to die from injuries and accidents than their male counterparts. Maternal Mortality Current understanding of maternal mortality in India-levels, causes, and pat- terns-is at best incomplete and unsatisfactory.5 In contrast to infant mortality, for which RGi estimates are available, there is no adequate system for collecting maternal mortality data on a routine basis." Yet it is clear even from the existing inadequate data that maternal mortality in India is quite high. It is estimated that India, which has only about 15 percent of the world's population, accounts for over 20 percent of the world's maternal deaths. The recent National Family Health Survey (NFHS) estimated a maternal mortality ratio (maternal deaths per 100,000 live births) in India of 437 for 1990-91. This figure is lower than earlier, community-based estimates, which were derived from quite small numbers of maternal deaths in limited areas. Although the data are not adequate to support firm conclusions, the maternal mortality rate and ratio should decline, given the falling birth rates among high- risk very young women and women at the end of their childbearing years. Given current fertility and mortality levels in India. a maternal mortality ratio of 437 per 100,000 live births results in a maternal mortality rate of about 55 maternal deaths per 100.000 women of reproductive age. This level of maternal mortality also means that about 15 percent of all deaths among women of childbearing age are maternal deaths. By comparison, maternal mortality ratios in Europe are on the order of 10 per 100,000 live births. Due to the greater likelihood that she will become pregnant, combined with the greater likelihood that she will die once she becomes pregnant, the average Indian woman is almost 100 times more likely to die of a maternity-related cause than her counterpart in the industrial world. THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 27 Causes of Maternal Mortality Information from the national surveys, hospital records, and community-based data show that over 80 percent of maternal deaths result from one of six major causes: anemia, hemorrhage. eclampsia, obstructed labor. infection, or abor- tion (appendix table 1.18). The most recent national survey (RGI 1993b) indi- cates that hemorrhage is the leading cause of maternal mortality, accounting for 23 percent of these deaths. followed by anemia (20 percent), eclampsia and infection (13 percent each), abortion (12 percent). and obstructed labor (6 percent). Thus, maternal mortality in India follows a pattern similar to that in other parts of the developing world (Tinker and Koblinsky 1993). Hospital- based studies report hemorrhage, infection, abortion, eclampsia, and anemia as the most important causes of maternal deaths, claiming up to three-quarters of the lives lost (Jinda! and others 1990; Damania, Salvi, and Walvekar 1988; Rao 1988; Devi and Singh 1987; Sengupta and Gode 1987). The findings of Bhatia (1988) merit particular attention because of the study's comprehensive design and careful execution. This retrospective field study of deaths among females of reproductive age, sponsored by the World Health Organization (WHO), was carried out in Anantapur District, Andhra Pradesh, in 1984-85. The study estimated that about 36 percent of all deaths among females ages 15-49 in the reference period were caused by complications of childbirth and that these maternal deaths represented a mortality ratio of 800 per 100,000 live births and a mortality rate of 120 per 100,000 women between the ages of 15 and 49. This ratio is the highest of the available estimates for India and provides evidence of the persistently elevated levels of maternal mortality in parts of India during the past decade, even in the south. Of the maternal deaths for which detailed information was available, about two-thirds were due to direct obstetric causes (appendix table 1.18). Infection and hemorrhage accounted for larger and smaller proportions of deaths, respec- tively, than they did in the other studies cited. Abortion is implicated in over 10 percent of deaths in the Bhatia study; about two-thirds of these were induced in order to terminate unwanted pregnancies. This study also found that in almost one-fourth of the deaths, family members were not aware of the serious- ness of the woman's condition and took no action to obtain assistance. In another 4 percent of cases, family members reported that they had been aware that something was wrong but had not attempted to call a health worker or doctor. For each maternal death, the study randomly identified a "control case"-a woman in the same urban area or village who gave birth during the reference period and survived. A comparison of the two types of cases sheds additional light on the characteristics of those women who died and the causes of their 28 IMPROVING WOMEN'S HEALTH IN INDIA deaths. The overall socioeconomic status of the two groups was similar. There were no major differences in antenatal care; in both groups, 40-50 percent of the women registered for antenatal care, and the mean number of antenatal visits was actually slightly higher for those who died. The differences between the two groups in age, number of pregnancies, predisposing conditions, and family composition, however, were striking. As might be expected, significantly greater percentages of those who died had poor obstetric histories or predisposing health conditions or had serious prob- lems during the pregnancy. Although the mean number of pregnancies was slightly higher among the women who died, the mean number of living chil- dren was lower, indicating that more of the children born to these women had died. The women who survived had both more living children (2.9) and more living sons (1.4) than did those who died (2.4 living children and 0.9 sons, respectively). In fact. 55 percent of the women who died did not have a living male child. compared with 25 percent of the control group. That women with poor obstetric histories but without sons persisted in their attempts to bear children despite the risks reflects the intense pressure on Indian women to bear sons. After examining the available information, experts determined that ap- proximately 72 percent of the total maternal deaths could have been prevented (exclusive of those that could have been prevented by safe abortion). Of these, 32 percent could have been averted with proper antenatal care and 69 percent with referrals to appropriate facilities. Other studies have indicated that most maternal deaths in India and in developing countries are preventable (Krishna 1989: Rajaram 1989: Rao 1980). A summary of the measures identified in the community-based study in Anantapur as those most likely to prevent such deaths is given in appendix table 1.19. Of particular significance are the findings concerning the location of the women at the time of their deaths (figure 1.6). Half the women who died from maternal causes were transported to a primary health center (PHC) or hospital and died there. There is no way to estimate accurately the number of women who die at home because transportation is unavailable or unaffordable. These findings emphasize the importance of prompt and appropriate referrals and efficient transportation in reducing maternal mortality. Abortion Induced abortion was legalized in India in 1971 with the enactment of the Medical Termination of Pregnancy Act. The number of legal abortions in India has risen rapidly since 1972. but in recent years it has leveled off at about 600,000 annually (MOHFW 1992). The fact that many legal abortions performed THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 29 FIGURE 1.6 LOCATION OF WOMEN AT TIME OF DEATH, ANDHRA PRADESH, 1988 At health facility At home or hospital 41% 50% In transit 9% Source: Bhaia (1988) in private facilities are probably not reported may affect the data. In addition, a number of illegal abortion procedures are in use, from modern surgical tech- niques carried out by private practitioners without the requisite licenses to a variety of folk methods. The actual numbers of illegal, unsafe abortions per- formed and the extent of associated morbidity and mortality are unknown. In one hospital study (Rao 1988), infection resulting from abortion was the single highest cause of death (26 percent of direct obstetric deaths and 18 percent of deaths from all causes). In community-based studies of Andhra Pradesh and Karnataka. illegal induced abortions were estimated to be responsible for about 6 and 3 percent of total maternal deaths, respectively (Reddy 1992: Bhatia 1988). The studies indicated that about two-thirds of all abortion deaths in- volved induced abortions and the other one-third miscarriages. According to the Andhra Pradesh study. roughly one-half of the abortion deaths were caused by hemorrhage and the other half by infection.7 The Indian Council of Medical Research carried out a study of induced abortion in the states of Haryana. Orissa, Rajasthan, Tamil Nadu, and Uttar Pradesh in 1983-84 (ICMR 1988b). It found that for the five states combined. 6 of each 1,000 pregnancies ended in legal abortions and 13 per 1,000 in illegal abortions. Assuming this relationship holds for subsequent years and for the rest of India, the approximately 600,000 legal abortions reported in 1990 indi- cate that a total of about 1.3 million illegal abortions are performed annually in the country. For the five states combined, only about 55 percent of the abor- 30 IMPROVING WOMEN'S HEALTH IN INDIA tions were carried out in the first trimester, and of these only about one-quarter were provided by doctors (government or private) or other health staff. A recent report funded by the Ford Foundation argues that previous re- search seriously underestimates the magnitude of illegal abortion and suggests that nearly 7 million induced abortions occur annually. These figures imply that for every legal abortion in India, 10 more are performed illegally. The study also estimates that the number of abortion-related deaths is significantly higher than was previously reported, accounting for at least 15 percent of all maternal deaths (Chhabra and Nuna 1994). Maternal Morbidity During pregnancy, a woman may suffer from conditions that are not life threat- ening but that hamper her ability to function or that have long-term implica- tions for her health and well-being after the pregnancy. She may suffer from diseases common among adults in India (such as tuberculosis) or develop long- term complications from prolonged or obstructed labor, such as uterine prolapse or obstetric fistulae. Severe chronic illnesses can be exacerbated by pregnancy and the mother's weakened immune system. Malaria and viral hepatitis are more prevalent in pregnant women and can develop into obstetric emergencies (Mukherjee 1994: Tinker and Koblinsky 1993). Based on estimates of maternal morbidity for developing countries, at least 40 percent of pregnant women in India have a serious illness and 15 percent develop life-threatening complica- tions during their pregnancies. The proportion is even higher if the number of women who miscarry or suffer stillbirths is included. Unfortunately. there are no recent community-based studies of maternal morbidity in India. Most stud- ies focus on the nutritional status of pregnant women, especially on anemia, and a few have investigated specific conditions such as syphilis (Upe. Sathe, and Sathe 1979). Because so little information is available on maternal morbidity in India. the findings of a prospective study of 349 pregnancies in 281 women in Rajasthan in the late 1970s are worth presenting in some detail. The incidence of illness correlates strongly with the number of pregnancies (parity). increasing from 14 percent among those pregnant for the first time (primiparas) to 30 percent among those pregnant for the second time, and rising to as much as 58 percent among women in their fifth or later pregnancy. The incidence and severity of anemia were also found to increase with parity (ICMR 1974). Maternal morbid- ity in this study includes complications arising from pregnancy, childbirth, and puerperium, most prominently postabortion complications (29 percent). fever of unknown origin (26 percent), infectious and parasitic diseases (ll percent), respiratory diseases (8 percent). and skin diseases (8 percent). THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 31 Women's Nutritional Status During PregnancY The generally poor nutritional status of Indian girls and women is part of a vicious cycle that has particularly devastating consequences for pregnant and lactating women and their infants. Malnourished women are more likely to give birth to low-birthweight babies, and if the underweight baby is a female who survives, she in turn is likely to continue to be undernourished throughout her childhood, adolescence, and adult life. This lack of nourishment has detrimen- tal effects on her reproductive and lactating capacities, not to mention her overall development. Pregnant and lactating Indian women, particularly those of low socioeco- nomic status, are likely to take in a very inadequate amount of calories and protein. Nutritional requirements increase substantially during pregnancy and lactation, and even when women are more than adequately nourished in normal times, the fact that their caloric intake does not increase significantly during these events means that the women are nutritionally stressed. For women who are chronically undernourished, the stress is much greater (Das Gupta 1995). The direct consequences are inadequate weight gain during pregnancy and underweight babies. In a study of pregnant women in Uttar Pradesh, the aver- age weight gain over the entire pregnancy averaged 6.9 kg (about 15.2 lbs), with the poorest group gaining 6.3 kg (13.6 lbs) and the wealthiest 7.7 kg (Bhardwaj and others 1990). Other studies have reported similar figures (Tripathy and others 1987). For purposes of comparison, the average weight gain in Thailand and the Philippines is close to 9 kg (Krasovec and Anderson 1991) and in industrial countries about 12 kg (26.4 lbs). Iron-deficiency anemia in pregnancy is an important cause of maternal morbidity and, when severe, mortality in India (box 1.2). Maternal anemia contributes to maternal deaths from hemorrhage. infection, and eclampsia. (For example, international data indicate that some 40 percent of severely anemic women are at a heightened risk of heart failure and fatal hemorrhage during childbirth.) Anemia during pregnancy can also result in intrauterine growth retardation, low-birthweight babies, and poor lactation. Fertility Any discussion of maternal mortality and morbidity is incomplete unless the underlying cause-fertility-is taken into consideration, since no woman is at risk of dying in childbirth or of developing a pregnancy-related problem or illness until she conceives. While the major contributing factor to death among pregnant women is lack of access to adequate health services, some women face additional risks, including poor nutritional and health status and unwanted or unplanned pregnancy. In addition, childbearing poses particular risks for 32 IMPROVING WOMEN'S HEALTH IN INDIA BOX 1.2 THE INSIDIOUS RISKS OF ANEMIA of Gujarat and Maharashtra found that about 90 percent of pregnant women Anemia is a major health problem suffered from anemia. Other studies among indian women. Studies carried have found rates of anemia between out by the Indian Council of Medical 50 and 90 percent among pregnant Research found that over 65 percent women (Sheshadari and Gopaldas of girls ages 1-14 surveyed in the cit- 1989; Raman 1988, 1980; Agarwal, ies of Hyderabad, New Delhi, and Agarwal, and Tripathi 1987; Agarwal Calcutta were anemic (ICMR 1982; 1984). A recent population-based sur- appendix table 1.20). Anemia is par- vey in Punjab indicated that 86 per- ticularly widespread among women cent of pregnant women showed some during pregnancy, when iron require- degree of anemia and that 56 percent ments increase nearly fivefold had severe anemia. An analysis of data (Hallberg 1988). A variety of studies from the referral hospital for the area have shown that a high percentage of revealed that severe anemia contrib- pregnant women in India are anemic, uted, directly or indirectly, to 35 per- particularly in the last trimester. One cent of all in-hospital maternal deaths study conducted in the rural districts (Sarin 1995). women and their offspring when the women are very young or at the end of their childbearing years. become pregnant frequently, or space their pregnan- cies too close together. In most developing countries, fertility begins to decline first and most rapidly among women who have had multiple pregnancies and older women who choose to terminate childbearing after a certain number of children. India is a case in point. Births among young women ages 15-29 account for three- fourths of total fertility (lIPS 1995). Marital fertility at ages 35-49 has fallen by more than half over the past two decades; in both rural and urban areas, women age 35 and above now account for barely 10 percent of total fertility. A reduc- tion in high-parity births in India is also indicated by the decline in the average number of children born to married women. The estimated total fertility rate (TFR) has dropped from around 6 children per woman in 1970 to 3.4 children in 1992-93. Fertility levels vary widely among the states, with Uttar Pradesh having the highest TFR. 4.8 (figure 1.7). The risk of a pregnancy occurring too early in a woman's reproductive years is also declining because the age at which women marry is rising. Rela- tively speaking, however, women in India still begin childbearing at young ages, which carries higher health risks than pregnancy during ages 20-34 and can interfere with schooling and other socioeconomic opportunities. Some 10-17 percent of total fertility in India is accounted for by births to women in THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 33 the 15-18 age group. Pregnancies are almost entirely limited to married women, so the risk of adolescent girls conceiving is governed by the age at which girls are married, and women in India marry relatively young. In 1972,41 percent of women between the ages of 15 and 19 were married; since then, the mean age at which women marry has been rising steadily, increasing from 17.2 to 19.5 years between 1971 and 1981.8 The proportion of women ages 15-19 who were married in 1992 is shown by state in figure 1.8. As expected, the northern states had higher percentages of young married women. In Madhya Pradesh, Andhra Pradesh, Bihar, and Haryana, the proportion of girls 15-19 who were married was still over 40 percent. Fertility below the age of 20 is higher in urban areas than in rural areas, while fertility at later ages is higher in rural than in urban areas (Ips 1995; RGI 1994). FIGURE 1.7 TOTAL FERTILITY RATES, INDIA AND MAJOR STATES, 1992-93 India Uttar Pradesh Bihar Haryana Madhya Pradesh Rajasthan Gujarat Orissa West Bengal Punjab Maharashtra Karnataka Andhra Pradesh Tamil Nadu Kerala 0 1 2 3 4 5 Total fertility rate (per woman) Source: JIPS 11995) 34 IMPROVING WOMEN'S HEALTH IN INDIA The spacing of births is determined by a combination of factors related to breastfeeding, nutrition, and exposure to the risk of conception, but data on these factors are limited. According to RGI (1994), about 37 percent of live births in 1992 occurred within two years of the previous live birth. Many researchers have hypothesized an association between maternal mortality and the length of time between births (Govindasamy and others 1993). Short inter- vals between births have a clearly demonstrated association with increased rates of infant mortality and low birthweights. Infant mortality is more than twice as high for children born within 24 months of the preceding birth as for infants born after 48 months (uPs 1995). Births should be spaced at least two years apart, since shorter intervals may pose a danger to the health of the mother and the survival of both the infant and older siblings. The importance of spacing births appropriately underscores the need for more widespread avail- ability of temporary contraceptive methods. Although maternal mortality data are not comparable to the overall fertility and mortality data available for India, in general both maternal mortality rates and ratios across regions reflect the differentials in the fertility data. Maternal mortality rates are high in states where fertility is high simply because women there are having more births. Maternal mortality is also high in those states where more children are born to very young women, older women, and women who have experienced multiple pregnancies-although the most important fac- tor is the lack of adequate obstetric care. The continuing decline in overall fertility rates is reflected in lower maternal mortality rates and ratios; the impact on mortality rates, however, is substantially greater than it is on ratios (Fortney 1987). The proportion of women in demographically high-risk categories who become pregnant is dropping and will continue to taper off as fertility falls and the age at which women marry rises. However, in some states very young women, high-parity women, and women near the end of their childbearing years continue to become pregnant, posing significant and avoidable risks to both themselves and their infants. In this regard, accelerated policy and pro- gran efforts are needed to increase the age at which women marry. lessen the health risks of pregnancy, and reduce the incidence of unwanted pregnancy. Those women who do become pregnant need access to improved obstetric services. Other Female Morbidity If data on mortality and morbidity in pregnancy are inadequate and incomplete, for female morbidity generally they are almost nonexistent. Most data on female morbidity that is not directly related to pregnancy are from hospitals, clinics. THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 35 FIGURE 1.8 PERCENTAGE OF CURRENTLY MARRIED WOMEN, AGES 15-19, INDIA AND MAJOR STATES, 1992 India Madhya Pradesh Andhra Pradesh Bihar Haryana West Bengal Uttar Pradesh Rajasthan Karnataka Maharashtra Orissa Tamil Nadu Gujarat Punjab Kerala 0 10 20 30 40 50 60 70 Percent sourc(: lips I 19951. and selective or focused studies and thus do not provide information on mor- bidity rates in the general population. The sections that follow deal first with diseases and conditions that are not gender specific. and then with those prob- lems that are entirely or primarily confined to women. Infectious and Other Diseases The limited studies available generally paint a picture of high morbidity and malnutrition among Indian girls and women (Bhatia and others 1995; Chatterjee 1991: Chidanbaram, Soorasangaran. and Anbuganapathi 1986; Rao and others 1973). Among children, a higher proportion of female morbidity is likely to be 36 IMPROVING WOMEN'S HEALTH IN INDIA caused by diseases that are also major causes of death for both sexes. such as respiratory infections (Devadas and Kanalanathan 1985) and diarrheal dis- eases (Cohen 1987: Pettigrew 1987). Several disorders emerge as widely preva- lent among women who are not pregnant: iron-deficiency anemia; parasitic infestations; respiratory infections (including pulmonary tuberculosis); and re- productive and urinary tract infections. In addition, some diseases. such as malaria, leprosy, and filaria, are endemic in certain areas. The few studies that compare the health of women and men in the same household report a higher prevalence of illness among women (Duggal and Amin 1989; Jesudason and Chatterjee 1979). However, a gender difference in the incidence of disease has not been found, leading some researchers to sug- gest that higher female morbidity comes about because women receive less medical attention than men during periods of illness. An examination of data on malaria in India clearly demonstrates both the gaps in the data and the greater incidence of disease among females (Chatterjee 1991). These data cover primarily the numbers of cases detected through blood smear examinations and the deaths reported by PHCs. Although such data are gathered for the purposes of malaria surveillance, they are not random. For passive case detection, blood smears are usually collected from patients visit- ing PHCs, among whom women are underrepresented. For active case detec- tion, outreach workers (usually male multipurpose workers) contact women in their homes, so that women are possibly, but not necessarily. overrepresented. Some studies of the PHC data that give breakdowns by age and gender are available (Tewari and others 1984). Blood-smear slide positivity rates are higher for females than for males (Ohlin 1984). Two interpretations of these findings are possible: either malaria is more prevalent among females than among males, or women who actually have malaria are more likely than men to visit PHCs. presumably because women often do not receive treatment until their illness is well advanced and they or their family members become convinced of the need for treatment. In either case, the need for public health services to give increased attention to women's illnesses-in terms of data collection as well as patient identification and treatment-is clear. Nutritional Deficiencies That protein-energy malnutrition is widespread among Indian girls, boys, and women is documented in a variety of studies covering both rural and urban populations in all areas of the country (Harriss 1990: Basu 1989b: Srikantia 1989a; Ghosh 1985: Gopalan 1985; NNMB 1980a. 1980b). Poor nutrition be- comes evident among females during infancy, persists through childhood. and THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 37 tends to increase with age. In a study of two Delhi slum populations, Basu (1989b) found that only 50-65 percent of female infants below the age of 1 year received adequate nourishment or were only mildly malnourished. For female children ages 5-9, the percentage fell to about 30-55 percent. It is probable that the results of this anthropometric study reflect not only differen- tial nutrition but also differential morbidity. Anthropometric data also show that many women do not achieve full physi- cal development (NNMB 1980a, 1980b). A large proportion of those surveyed in the 20-24 age group were below the height (145 cm, or about 56 in) and weight (38 kg. or 86 lbs) at which women are more likely to deliver low-birthweight babies. Since a smaller pelvis can prolong labor and obstruct delivery, incom- plete skeletal growth or stunting also poses serious risks during childbirth. Some 12-33 percent were shorter than the norm, and 15-29 percent weighed less than the average. The percentages of young women under 20 who are under the weight and height levels required to deliver children safely are likely to be higher because these females may not have completed their adolescent growth spurt. Most women in northern India become pregnant before reaching full maturity, posing considerable risk to mother and child. The data on the relative nutritional levels of males and females provided by various anthropometric measures are ambiguous. A number of studies have found that malnutrition is more frequent and often more serious in female children (Chen, Huq. and D'Souza 1981; Kielmann and others 1978; Levinson 1974). However, it should be noted that the data available from the National Nutrition Monitoring Bureau (NNMB 1980a, 1980b) did not, by and large, indi- cate that the nutritional status of female children was significantly worse than that of males. Other recent studies also have not reported an overall difference in nutrition (Basu 1990; Srikantia 1989b; Das Gupta 1987). The NNMB surveys (1980a, 1980b) documented low intakes of vitamin A and iron among girl children and adolescents. Vitamin A deficiency. which has been firmly linked to high mortality and morbidity in children, is likely to be an underlying cause of high levels of respiratory and genitourinary tract infections in women. Other studies have also documented iron and calcium deficiencies among female children, adolescent girls, and adult women (WHO 1992; Harriss 1986). With the onset of menarche, women's needs for iron increase. In adult- hood, the daily iron requirements of women are twice those of men. Anemia can have several causes. The diet may not contain enough iron, or the iron may not be effectively absorbed. For example. iron in meat is absorbed well, but only a low proportion of iron in cereals and vegetables, which are more con- mon in the Indian diet, is absorbed. Malaria, infestation by intestinal parasites such as hookworm, and reproductive loss of blood-for example, through menstruation-contribute to the loss of iron. Iron-deficiency anemia is a major 38 IMPROVING WOMEN'S HEALTH IN INDIA health problem for Indian women from an early age (India. Department of Family Welfare 1994: Gillespie, Kevany, and Mason 1991). A multicenter study found anemia in over 95 percent of girls ages 6-14 in the east (Calcutta), around 67 percent in the south central areas (Hyderabad), 73 percent in the northern areas (New Delhi). and about 18 percent in the south (Madras) (appendix table 1.20). The prevalence of anemia among women ages 15-24 and 25-44 years follows similar patterns and levels. Besides posing risks during pregnancy, anemia increases women's susceptibility to diseases such as tuberculosis and reduces the energy women have available for daily activities such as household chores, child care, and agricultural labor. Any severely anemic individual is taxed by most physical activities. including walking at an ordinary pace. Gynecological Problems Nationwide estimates of the prevalence of gynecological disorders in India are not available. Murray and Lopez (forthcoming) report that women suffer more than double the disease burden that men do from STDs and that cervical cancer causes a greater disease burden than any other single cancer. Women's repro- ductive health problems have been studied at the community level even less frequently than other aspects of women's morbidity, in part because of the difficulties of diagnosing gynecological problems in the field. A few popula- tion-based studies influenced by clinical experience have focused on specific disorders such as cervical and uterine cancer (Garud and others 1983; Wahi and others 1972: Mali, Wahi, and Luthra 1968) and vaginal discharges and genital infections (Bali and Bhujwala 1969). A study of women in two villages in Maharashtra (Bang and others 1989) provides data on the prevalence of gyne- cological diseases, although the study was carried out in a tribal area and therefore is not typical of rural Maharashtra, let alone of India generally. Some 55 percent of the women studied had gynecological complaints, mostly related to menstruation. vaginal discharge, or burning on urination. In addition, many complained of two nonspecific but related symptoms, low back pain and lower abdominal pain. On clinical examination, astonishingly high levels of disease were identi- fied: 92 percent of the women were found to have at least one gynecological or sexually transmitted disease, with an average of 3.6 diseases per woman. Nota- bly, almost all of the women who reported symptoms were found to have a gynecological disorder, but so were 85 percent of those who had no complaints. Half of this morbidity resulted from infections of the genital tract, for example. bacterial vaginitis (62 percent) and cervicitis (49 percent). In addition, over 57 THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 39 percent had dysmenorrhea. Some 7 percent of the women had primary or secondary infertility. and nearly 1 1 percent were infected with syphilis. Of the women studied, only 8 percent had ever had a gynecological exami- nation or received treatment for a gynecological disorder-an indication not only of the women's failure to recognize their need for treatment and inability to obtain it but also of an apparent lack of awareness of the magnitude of the problem. India does not have many female doctors able to detect and treat gynecological problems among rural women, who are particularly reluctant to approach male doctors about gynecological or sexual disorders. Female nurses and paramedical field staff are not trained to deal with these problems, contrib- uting to the almost total absence of care. Properly equipped laboratories are even more scarce. A burden of disease of the extent indicated by Bang and others (1989) inevitably results in a host of complications for women: difficulties in occupa- tional and domestic work (chronic backache was reported by over 30 percent). fetal wastage (miscarriages and stillbirths), infections that are transmitted to newborns in the birth canal, sterility, sexual disorders, anxiety, and stress. In addition, the study indicated a significant association between the use of con- traception and subsequent gynecological problems such as menstrual and cer- vical disorders and pelvic inflammatory disease. probably because the contra- ceptive device or method aggravated preexisting conditions. The fact that preexisting gynecological disorders can jeopardize a woman's ability to use contraception safely or effectively links women's general health problems to the high rates of maternal morbidity and mortality and underlines the impor- tance of improving the ability of the health services to meet all women's repro- ductive health needs, not just those associated with pregnancy and childbirth. A new problem that is spreading rapidly is HIV/AIDS, which will significantly affect the health of Indian women in coming years, requiring the health system to pay much greater attention to women's reproductive and sexual health needs (see box 1.3). Occupational Health Problems Little information is available on the occupational health problems of women because the great majority are employed in the informal sector. The majority of poor rural women work as agricultural laborers. an occupation that predisposes them to specific health difficulties. Long hours spent standing in water while weeding and transplanting rice (essentially a female occupation) increases women's susceptibility to vaginal infections, infectious and parasitic diseases, insect bites, arthritis, and rheumatism. 40 IMPROVING WOMEN'S HEALTH IN INDIA BOX 1.3 THE MANY FORMS OF crease women's susceptibility to HIV REPRODUCTIVE TRACT INFECTION infection. There is increasing evidence that There are three types of reproductive Indian women suffer a significant toll tract infections (RTIs): sexually trans- as the result of RTIS. In addition to the mitted diseases (sTDs); infections such study carried out in two villages in as candidiasis and bacterial vaginosis Maharashtra (Bang and others 1989), that are caused by abnormal growth results of research on gynecological of organisms normally present in the problems in other areas of India are vagina; and infections associated with becoming available. A recent study of unhygienic delivery and other unsani- married women in a subdistrict of tary practices. Women are not only Karnataka with a child under the age more susceptible than men to these of six months found that 70 percent of infections but are also more prone to the mothers in the sample had clinical develop complications, in part because or laboratory evidence of nrIs. The most infections in women are difficult to common conditions were cervicitis, diagnose and are therefore more bacterial vaginosis, and PID. The con- likely to go untreated. RTIS can cause tribution of STDsto the high prevalence pelvic inflammatory disease (PID), prob- of RTIs among these women appeared lems with pregnancy and childbirth, in- to be relatively low: evidence of STD fertility, and chronic pain. STDS specifi- infection was found in only 10 percent cally can lead to chronic abdominal (Bhatia and Cleland 1995; Bhatia and pain, infertility, and life-threatening others 1995). Four additional studies complications such as ectopic preg- in other rural and urban areas of India nancy and cervical cancer; HIV/AlDs and confirm earlier findings of relatively syphilis may directly cause death. Re- high levels of gynecological morbidity cent research reveals that STDS in- (Latha and others 1995). Back pain and osteoarthritic complaints are also common among women who must work during harvests and perform other tasks that require stooping. Back problems, a symptom regarded as nonspecific by the medical profession. have been called "the feminine affliction" and can be traced to a variety of underlying conditions (Shatrugna and others 1990). The authors based their analysis on a study of women hospitalized for fractures. Most of the fractures among women over 40 were the result of minor trauma that occurred in the course of ordinary activities, and among younger women (ages 18-39) most were a result of work-related accidents. The authors concluded that several factors contributed to these problems: (a) the work done by young girls, which requires them to adopt postures that are detrimental to bone integrity, such as stooping or carrying heavy loads; (b) early and continuous nutritional depriva- THE DIMENSIONS OF FEMALE MORTALITY AND MORBIDITY 41 tion among women, which contributes to osteoporosis; (c) early and repeated pregnancies and years of lactation: and (d) work carried out by adult women that requires sitting, standing, or stooping for long periods of time and that is dangerous, or pays so poorly that women cannot improve their diets, or both. Cooking, an almost exclusively female occupation that takes up a substan- tial portion of most women's time. is particularly hazardous to Indian women. Kitchens are rarely adequately vented, so women are commonly exposed to dangerous levels of smoke particles and pollutants. One study of rural kitchens measured concentrations of pollutants that averaged a hundred times the level deemed acceptable by WHO (Smith, Agarwal. and Dave 1983). Another study found that women's exposure to cooking fumes was equivalent to smoking twenty packs of cigarettes a day (Smyke 1991). Wood smoke, one of the most common pollutants. causes lung problems, which in turn place a strain on the heart. Although one hospital-based survey spanning fifteen years found a simi- lar incidence of lung problems among men and women, the cause was traced to tobacco smoking among men but to kitchen smoke among women (Smith, Agarwal, and Dave 1983). The age of onset of lung diseases was lower among women than among men, and nearly all the women affected were from low- income groups. Respiratory diseases are a leading cause of death among women and girls over 5 years of age, and evidence links impaired fetal development, low-birthweight babies, and perinatal death to maternal exposure to pollutants, particularly in the presence of anemia, an almost universal condition among Indian women. Indian women encounter health hazards in virtually all their occupations. For example, women working in the carpet industry suffer from ankyloses and chronic postural defects that may result in difficult pregnancies or even steril- ity. Workers who roll bidis (indigenous cigarettes) are exposed to tobacco dust and are susceptible to problems such as tuberculosis, asthma, allergies, back- aches, and rheumatic complaints. In industries that process coir.jute, and cashew nuts or that involve cotton, tea, or rubber, and in the textile industry, workers are routinely exposed to toxic chemicals and physical stress. Workers in the garment and embroidery industries complain of chronic back pain and eye problems due to poor physical conditions and lighting in the workplace (Chatterjee 1987: Ghosal and Chakraborti 1987). All these problems can be further aggravated by malnutrition, anemia, frequent childbearing, and long workin2 hours. Social Health Issues Indian women are exposed to physical assaults such as rape, burning, and beating at unusually high rates. A study of women of childbearing age in three 42 IMPROVING WOMEN'S HEALTH IN INDIA rural villages in Karnataka found that 22 percent reported being physically assaulted by their husbands. Twelve percent reported being beaten an average of three times within the previous month (Rao and Bloch 1993). Although these problems almost certainly contribute to the injuries that are a leading cause of death (appendix table 1.14), specific data on the incidence of physical assault against women and on the resultant morbidity and mortality are conspicuously absent. Whether accidental or intentional. burns are a major cause of hospital admissions in urban hospitals (Karkal 1985). Women's deaths from burns appear to have been increasing since 1979: this development appears to be related to commercialization of dowry demands (Pawar 1990). High rates of alcoholism among men, common among poor populations in tribal. rural, and urban India, are also a woman's health problem because of the well-docu- mented link between alcohol consumption and domestic violence. The next chapter discusses the socioeconomic environment that gives rise to these and other factors that profoundly affect Indian women's health. , . � ��; -, , � � �,� /',� ' � ��` �� � �`j ' f w � „ �° ., � ��'`-�_��° � .�+`� i r � sis� ���.кtn���. �.лг . '! £- ' � � ,.� . . . � д . .. _. й ` �' � �� � { д � - • " _ �� ' � � . �.а � '9�� ....__._a.�,.,.w,i77 .�� , , г -.�г+-N �--.вп^" 1 � ,� . . . _ - � �� а'� R . +r � �_.�+r�' _` `у. К ,�F ' ' а �• i ; - + у f ' ,s '�__ - - . . ,�.�, а - - -� _ - -- �..: .,� , °'г . � �,: , CHAPTER TWO The Sociocultural Context in India. where many people live in poverty and the health infrastruc- ture is poor. males as well as females suffer. However, women face unique risks because of their reproductive biology, and in a country with one of the world's highest maternal mortality ratios, the dangers are particularly pronounced. Moreover, age- and gender-specific mortality rates indicate that girls and women under 30 are further disadvantaged because of sociocultural factors. Although impressive progress has been made in improving education and health for the population in general, in some states-particularly in the north-the mortality rates show that the 'female disadvantage- relative to males niot only persists but is worsening. For this reason, and because the northern states are home to a major portion of India's population. the discussion that follows focuses on northern India. Status of Women In traditional societies, the circumstances of both individuals and households, as well as access to key social resources, are to a large extent structured by family, marriage, and kinship relationships. These relationships can vary greatly-in fact, the kinship systems of Hindu northern India, Hindu southern India. and Muslim India are all different. What is common to them is that they define gender in social terms-that is, the proper roles, functions. and behavior of women within the larger social system. 45 46 IMPROVING WOMEN'S HEALTH IN INDIA Two related sets of criteria can be used to assess the status of women within these systems (Basu 1989a: Dyson and Moore 1983). First. exposure to and interactions with the outside world are instrumental in determining the possi- bilities available to women in their daily lives. Second, the situation of women is affected by the degree of their autonomy, or capacity to make decisions both inside and outside their households. Autonomy includes the ability to control their own physical movements: to acquire, retain, and dispose of earnings and property: to have some say in their reproductive careers-for instance. in choos- ing a husband and using contraception and to associate with their natal kin. By these criteria, the position of women in northern India is notably poor. Traditional Hindu society in northern rural areas is hierarchical and dominated by men, and its patrilineal. patrilocal structures have important implications for women. Marriage provides a good example. North Indian Hindus are expected to marry within socially acceptable boundaries-that is. according to their caste. The marriaues are alliances in which young women and men have no say. The bride and groon Must not be related, and the man must live outside the woman's natal village. "Wife-givers"' are socially and ritually inferior to "wife- takers." necessitating the provision of a dowry. After tle marriage, the bride moves in with her husband's relatives. This arrangement influences the lives of fenale children, who are generally considered more of a burden to their parents than soiis because of the costs of losing a productive worker and providing a dowry. North Indian Hindu brides entering their husbands' households are strant- ers in a strange place.' They are controlled by the older feniales in the house- hold. and their behavior reflects on the honor of their husbands and of the larger patrilineal group. Restrictions on their personal movements and interactions with men often amount topurdah (literal seclusion or veiling the head and face from public observation). Because emotional ties between spouses are consid- ered a potential threat to the solidarity of the patrilineal group, the northern system tends to segregate the sexes and limit commuiLInication between spouses-- a circumstance that has direct consequences for family planning and similar "modern" behaviors that affect health. It is typical of societies with such cul- tural traditions that the norms are internalized by those who are disadvantaged by them, and India is no exception. A young Indian bride is brought up to believe that her own wishes and interests are subordinate to those of tier hIs- band and his family. The primary duty of a newly married young woman, and virtually her only means of improving her position in the hierarchy of her husband's household. is to bear sons. A comparison with the situation in southern India brings the circuminstances of women in northern India into clearer focus. In the south, a daughter is THE SOCIOCULTURAL CONTEXT 47 traditionally married to her mother's brother (her maternal uncle) or, failing that, to her mother's brother's son (her first cousin). If these marriages are not possible, other nominal uncles and cousins are given preference. Such mar- riages are unthinkable in northern India. These contrasting marriage systems have substantially different implica- tions for women. In southern India, men are likely to marry women to whom they are related. either actually or nominally, so that the strict distinction found in the north between patrilineal and marital relatives is absent. Men are likely to have social, economic, and political ties with relatives by marriage, and women are likely to be married into familiar households near their natal homes. Since no premium is put on controlling their physical movements, women in the south are much more likely to retain close relationships with their natal kin, and affective ties between spouses are culturally accepted. The social distinction that prevails in the north between the families of the bride and bridegroom is also absent. Southern marriages have typically involved a bride price (a sum of money agreed to as part of the marriage settlement) rather than the dowry traditional in the north, but any exchange of large sums of money or goods among close relatives is considered inappropriate in southern India. The north- ern dowry is a more open-ended arrangement that demands a higher proportion of a family's money and goods. Over the past several decades, however, marriage patterns in southern India have changed markedly. Social. economic, and demographic developments have made marriages between close relatives less common, and the bride price has given way to a dowry system akin to that in the north (Caldwell, Reddy, and Caldwell 1983).' There is no doubt that the rise of a dowry system has made daughters in southern India a more expensive and less desirable proposition than they were a generation ago. A study in rural southern India found that a dowry frequently consumes over one-half of a household's assets (Rao and Bloch 1993). Nevertheless, as long as the underlying ethic of marriage in the south remains the reinforcement of existing kinship ties, the relatively favor- able situation of southern Indian women is unlikely to be threatened. The reasons for the cultural differences between northern and southern India and the consequences of these differences for Indian women have been the subject of much speculation. Both cultures predate the Muslim presence in India and are in fact often seen as a reflection of the older distinction be- tween the Dravidian south and the Aryan north. Schultz (1982), Miller(1981), and Bardhan (1974) have all stressed the economic basis of these cultural differences, noting that the north-south contrast in the status of women corre- sponds to a greater dependence on female agricultural labor in the rice-growing south relative to the wheat-growing north. But while it is possible to construct 48 IMPROVING WOMEN'S HEALTH IN INDIA analytically useful models by disaggregating various economic components and incorporating a historical basis, in practice the cultural contrasts between these two regions exist independently of regional socioeconomic differentials. Basu (1990, 1989a. 1989b) studied two groups of rural migrants from the north (Uttar Pradesh) and the south (Tamil Nadu) of India, living in similar circumstances in a resettlement area in Delhi. The researchers were able to examine the position of the two groups of women in the same setting and to observe the health of each group. In terms of the criteria set out above. the contrasts between the two groups follow fairly predictable lines. The Tamil women exhibited far more autonomy than those from Uttar Pradesh. Some 64 percent of the Tamil women. but only 6 percent of those from Uttar Pradesh, were employed outside the home. The author attributed this difference to cul- tural rather than socioeconomic factors. (Household incomes in the two groups were similar.) The Tamil women's ability to seek employment outside the home is an indication of the relative control they had over their own lives. Their greater degree of autonomy was reflected in the much higher level of interaction with the outside world that all of them, not just those who were employed, enjoyed in their day-to-day lives compared with the women from Uttar Pradesh. In terms of health care, this exposure to the world beyond their households not only increased their knowledge of available health care services but also gave the women the confidence to seek medical care. The demographic variables for the two populations mirror these distinctions: both fertility and mortality levels were higher in the population from Uttar Pradesh, and female mortality was higher than male mortality for the 0-4 age group. Among the Tamil Nadu 0-4 age group, however, the male mortality rate exceeded that for females. Consequences of the Female Disadvantage The unfavorable status of women in India affects the health status of women and their female children both directly and indirectly. The effects include a strong preference for sons: arranged marriages for very young girls- inequitable allocation of resources such as food, health care. education, and income: and discrimination against widows. Preference for Sons In a situation where female children are regarded as a net cost to the family and male children are considered assets because of their potential contribution to family productivity and the wealth their brides will bring, a strong preference for sons is inevitable. In its most extreme form, this preference results in female infanticide and sex-selective abortion, the latter a fairly recent phenomenon. Accurate data measuring the full extent of these practices are lacking. but THE SOCIOCULTURAL CONTEXT 49 female infanticide has been documented in both northern and southern India. George. Abel, and Miller (1992) studied twelve villages in the South Arcot district of Tamil Nadu and found that female infanticide was practiced in six. Why some villages did not practice infanticide while others did is not clear, but the findings suggest that infanticide was related to social status (caste), the number of living daughters. educational levels, and geographic location.3 In those villages where infanticide did occur, 10 percent of newborn girls were not allowed to survive. The use of medical techniques such as amniocentesis and ultrasound to determine the sex of a fetus prior to sex-selective abortion appears to be in- creasing. A study of amniocentesis in a large Bombay hospital found that 96 percent of female fetuses were aborted. compared with only a small percentage of male fetuses (Ramanamma 1990). Statistics on births from Haryana suggest that the sex ratio at birth in that state, especially in rural areas, has become more masculine since the early 1980s (UNFPA 1991). A review of 1981-91 data indicates that sex-selective female abortions amounted to almost 1 percent of actual female births in India. In the Republic of Korea. the share was estimated at 5 percent for the same period: a troubling prospect is that India might expe- rience a similar trend. Where a preference for sons persists, gender bias through higher rates of sex regulation befire birth may come to replace excess female child deaths after birth (Das Gupta and Bhat 1995). The Indian government has indicated its strong opposition to antenatal sex determination, and the 1994 Antenatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act makes providling such tests a legal offense. How- ever. implementing the act has proved difficult. Female infanticide and sex-selective abortion are the most extreme reflec- tions of the low status of women and girls in Indian society. The preference for sons is more readily apparent in differential treatment that leads to higher mortality rates for girls-particularly those born into families that already have a daughter. In a study of the Ludhiana district of Pun jab, Das Gupta (1987) found that among firstborn children ages 0-4. the death rate was higher for males than for females (as would be expected). However, this ratio was dra- iatically reversed for younger siblings. For second children. the female death rate was higher. and with each successive birth the male/female ratio declined further. When parents already had a living girl, a second female was more likely not to survive than a female born to a family whose firstborn child was male. Food Intake ((mong Females Gender differences in food intake are apparent in lata co,,ering breastfeeding. A female child is likely to be breastfed less often and for shorter periods than her male siblings and to be weaned sooner (tis 1995: Khan and others 1989: 50 IMPROVING WOMEN'S HEALTH IN INDIA Ghosh 1987: McNeill 1984: Kumar 1983; Das. Dhanoa. and Cowan 1982: Levinson 1974). Population-based surveys suggest that male and female chil- dren are breas(fed for 25.3 and 23.6 months. respectively (lIPs 1995). One direct result of weaning females earlier than males is that women tend to be- come pregnant sooner after giving birth to a daughter than after delivering a son. This differential has been reported for all states (RGI 1988b). At least to some extent, the practice of breastfeeding female children for shorter periods of time reflects the strong desire for sons. If women are particularly anxioUs to have a male child, they may deliberately tr-y to become pregnant again as soon as possible after a female is horn. Conversely, women may consciously seek to avoid another pregnancy after the birth of a male child in order to give maxi- mum attention to the new son (Khan and others 1989). In recent years, increasing attention has been given to differentials in the allocation of food within households. Although overall rates of malnutrition among children and women are high and weaning practices poor, ethnographic literature suggests that females are not fed as well as males in northern India (Harriss 1986; Miller 1981). Studies in Uttar Pradesh (Khan and others 1989). Andhra Pradesh (Bidinger. Nag, and Babu 1986), and Tamil Nadu (Devadas and Kamalanathan 1985) all indicate that female children are discriminated against when it comes to the allocation of food within households. However, a study in Punjab found that caloric intake was virtually identical for girls and bovs. Girls were not more malnourished than boys, although males were given more high-quality foods such as items containing fat. while females were given more cereals (Das Gupta 1987). The recent national health survey found no evidence that female children are nutritionally disadvantaged (iPs 1995). The malnutrition prevalent in a significant proportion of adult Indian women can be attributed primarily to inadequate food intake. Even in households that theoretically have enough food, the way it is distributed may leave women inadequately nourished. Typically. adult men and male children are fed first. Women eat only after the men have finished, and a young wife must allow her mother-in-law to eat first. Whatever is left is divided among the young mother and her female children (Caldwell, Reddy, and Caldwell 1989: Jeffery. Jeffery and Lyon 1989). This disparity in the distribution of food may be as much a matter of poor communication as of deliberate practice, since men are normally unaware of how much women eat. Whatever the reason, and given the nutri- tional demands of childbearing and lactation, the lack of nourishment puts women at particular risk dUring their childbearing years. Even when they have enough food. Indian women may be malnourished because of the poor nutritive quality of what is available or because their systems are unable to absorb iron effectively owing to intestinal parasites or malaria. THE SOCIOCULTURAL CONTEXT 51 Health Care for Girls and Women It is increasingly being recognized that differences in health care may be more significant than differences in nutritional status in determining the gender dis- parity in young child mortality (ups 1995; Basu 1989b). There is considerable evidence that male children receive more and better health care at an earlier age than female children do. One study in the Ludhiana district of Punjab found that low-caste female children under age 3 received less medical care than other children and that the medical care provided tended to be of poorer quality. Two decades later. Das Gupta (1987) found that the situation had not changed. A hospital study in Ludhiana concluded that gender bias prevented three out of four girls who were ill enough to require hospitalization from receiving the care they needed (Booth and Verma 1992). Caldwell. Reddy, and Caldwell (1983) found that in rural Karnataka, twice as many boys as girls were brought to the primary health center. And in a study of one rural area in western ULttar Pradesh, Khai and others (1989) reported that over a one-week period roughly three times as many boys as -irls were brought to the primary health center. Recent state-level reports for Uttar Pradesh (PRC and IIPs 1994) confirm these earlier findings. More male than female children were fully vaccinate(d (23 and 17 percent, respectively). Severity-three percent of male children, compared with 62 percent of female children, were taken to a health provider or health facility inl the event of an acute respiratory infection. For India overall, in 1992-93 more boys than girls were vaccinated and treated for acute respiratory infec- tions and fever (mlps 1995). Like female children, adult women are at a disadvantage with respect to health care. lousehold surveys typically report more incidence of illness for females than for males (Khan and others 1989). This finding is especially striking because female morbidity is likely to be underreported, for several reasons: women respondents may be reluctant to reveal details of their illnesses to interviewers; they may purposely downplay any health problems to avoid disrupting domestic duties- or, consistent with their socialization. they may not wish to imply that they are asking for medical care. Community-based studies make it clear, however, that one reason for the relatively high morbidity rates among women is that women receive less medical treatment than men (Kielmann and Taylor 1983: Dandekar 1975). Hospital and health center records provide supporting evidence: fewer women than men are hospitalized or visit clinics (Kahn and others 1989: Murthy 1982). Comiimuiity-based studies also reveal that a high proportion of women receive no treatment at all for their illnesses and that among those who do, self-care, home remedies. and the traditional medical care deNcribed at the end of this chapter are the most common methods 52 IMPROVING WOMEN'S HEALTH IN INDIA used. In contrast, men are more likely to receive modern medical treatment, including high-quality institutional care (Das. Dhanoa, and Cowan 1982: Miller 1981). Compared with men. women also tend to receive care at later stages of an illness, even in the case of life-threatening conditions (Kielmann and Taylor 1983). That women seek medical help only when an illness is well advanced, greatly reducing their chances of survival. is corroborated by hospital data showing that fatalities are higher among female than among male patients (Kynch and Sen 1983). Even the major diseases common to both men and women result in higher female mortality because. while these diseases may be recognized easily, they are treated less frequently and less effectively-and, again, later in the illness-in women than in men. Additionally, households tend to spend less on women's health than on men's (Das Gupta 1987). Education and Women Females are clearly at a disadvantage in India with regard to education. Lit- eracy levels give a clear picture of the educational situation of Indian girls and women. Most Indian women are illiterate, and most Indian illiterates are fe- male. Data from the 1991 census indicate that only 39 percent of females above age 7 are literate, as opposed to 64 percent of males. Of the 324 million illiter- ates enumerated in India in 1991, 197 million (61 percent) were girls and women. Although substantial progress has been achieved since India won its independence in 1947, when less than 8 percent of females were literate, the gains have not been rapid enough to keep pace with population growth: there were 16 million more illiterate females in 1991 than in 1981. Across the states, female literacy ranges from only 21-26 percent in Uttar Pradesh, Bihar, and Rajasthan to slightly over 50 percent in Maharashtra and Tamil Nadu Kerala. with almost 90 percent female literacy in 1991, stands apart (figure 2.1). By contrast, more than 50 percent of Indian males in all states are literate (appendix table 2.1). The central and state governments have recently initiated efforts to bridge the gap between the educational levels of men and women and to in- crease literacy overall. The National Literacy Mission has been successful in a number of districts, in areas where the organization has implemented pro- grains, literacy levels have increased dramatically, especially among women. Underpinning the high levels of female illiteracy in India are low rates of female school enrollment and retention. However, these rates now show a promising upward trend. Gross enrollment ratios in primary education increased from 82 percent for boys and 33 percent for girls in 1981 to 116 for boys and 88 percent for girls in 1991. Statistics suggest that from 1981 to 1991. female enrollment in primary schools grew at 3.7 percent annually and male enroll- THE SOCIOCULTURAL CONTEXT 53 FIGURE 2.1 FEMALE LITERACY RATES, INDIA AND MAJOR STATES, 1991 India Kerala Tamil Nadu Maharashtra Punjab Gujarat West Bengal Karnataka Haryana Orissa Andhra Pradesh Madhya Pradesh Uttar Pradesh Bihar Rajasthan 0 20 40 60 80 100 Percent Source: RCI (1992). ment, at 2.5 percent. Still, high dropout rates and the fact that some children never enroll at all mean that only about 60 percent of all boys and 40 percent of all girls complete the first five years of primary school. In the nine northern states, where 63 percent of the population lives, only about 28 percent of girls finish the first five years of school. In India as a whole, about 46 percent of boys and 28 percent of girls in the appropriate age group progress to upper primary school (World Bank 1994b). Whether a girl will be enrolled in school-and, once she is enrolled, how long she will be allowed to continue-is linked to socioeconomic status. In rural India, girls from families with little or no land and with limited resources (such as agricultural laborers) are less likely to be enrolled in school and more 54 IMPROVING WOMEN'S HEALTH IN INDIA likely to be withdrawn early than girls from landed families. In urban areas, the girls most at risk of not attending school are from slum families whose adult members work in a variety of poorly paid, low-status occupations or in the unorganized or informal sectors. In both urban and rural India, elementary school enrollment rates for girls from scheduled castes and tribes also tend to be comparatively low (Kurrien 1990). According to the 1991 census, these groups, which are particularly socially and economically disadvantaged, made up 17 and 8 percent of the population, respectively. Primary school enrollment levels aside, however, girls from all but the highest socioeconomic levels of Indian society are likely to be withdrawn from school before they have completed their secondary education. Studies indicate that the importance of educating young girls is commonly recognized in India (Kurrien 1990). Most Indian primary schools are seriously deficient in many respects (particularly in rural areas), and it is generally agreed that the wide discrepancy between attitudes and actual practice can be attrib- uted to several key socioeconomic factors. These factors include the high direct costs of education, especially for poor households: the need for female labor at home (that is, the high opportunity cost of educating girls): the low expected returns to households from investments in the education of daughters, given that girls are lost to the household after marriage; and social concerns about exposing older girls to males with whom they have no kinship ties. Such con- cerns are responsible for the abrupt withdrawal of many girls from school at menarche. even though these girls may be only weeks or days from completing a school year or course (Caldwell, Reddy, and Caldwell 1989). The importance of the link between a woman's educational level and her health (and that of her female children) cannot be overemphasized. Studies in developing countries in general, and in India in particular, have consistently documented a strong relationship between a mother's education and her children's survival-that is, the more educated the mother, the more likely it is that her child will survive (see, for example. RGI 1988a). The mechanisms responsible for this link are reasonably clear. The more educated a woman is, the more likely it is that her husband and in-laws will allow her to decide whether and when to seek health care for her children (or. for that matter, herself). Educated women are also more likely to seek care earlier in an episode of illness and to choose modern over traditional medicine. Furthermore, the evidence indicates that educated mothers are more likely to continue with recommended treatments and to return to the nurse or doctor if the problem persists, rather than try an alternative method. Caldwell. Reddy. and Caldwell (1989) argue that these changes are not the direct result of health education acquired in school (although the potential for such education as a source of change is obviously great). but rather of the sense THE SOCIOCULTURAL CONTEXT 55 of empowerment schooling can convey. For most Indian girls, attending school is the first step in a process of familiarization with the modern outside world. Women who have had such exposure are better prepared to move beyond the traditional confines of household and village and to see themselves as able and entitled to cope with the world. The more educated a woman is. the more likely she is to want and to be able to obtain contraceptive services, modern preven- tive and curative health care, immunizations, and schooling for both her male and fenale children, and the less likely she is to want her daughters to marry early.' Women and Earli Miarriage Traditional marriages concern families rather than individuals and are arranged when the principals are still children. The beginning of cohabitation ("effective marriage") is marked by a ceremony held at a later date. The individual wishes of males and females are rarely considered in arranged marriages. However, the traditional marriage has particular implications for girls, who are under great pressure to marry by the time they reach puberty. or very soon thereafter. A recent study showed that despite the government's efforts to increase the age of marriage. over one-half of all women ages 20-24 were married before reaching 18, the legal minimum age of marriage (tlPS 1995). The age at which Indian girls marry has been steadily rising, but particularly in the north. girls are married so young that their education is cut short. In fact, there is a high correlation between the age at which women marry and their educational level (Chatterjee 1991). Among women ages 25-29, the median age at marriage is 15 for illiterate women and 22 years for women who have completed high school (itPs 1995). Early marriage is likely to have adverse physical consequences for adoles- cent girls by prematurely exposing them to the risks of pregnancy. If teenage girls whose nutritional status is poor become pregnant before they have at- tained full stature and their pelvises are fully developed. the resulting cephalopelvic disproportion makes obstructed labor-a major cause of mater- nal death-far more likely (Chatteijee 1991 ). The incidence of other complica- tions of pregnancy. including obstetric fistulae and eclaipsia. are also more common in adolescent girls (Mathai 1991). PhYsical Constraints and Limited Access to Resources The physical restrictions on women's movements. combined with limited ac- cess to financial resources within the household, severely constrain women's ability to seek health care for themselves and their children. Social mores 56 IMPROVING WOMEN'S HEALTH IN INDIA regarding the seclusion of women in northern India result in a reluctance to have women and girls examined by an outsider such as a doctor, particularly if he is a male, as most doctors are (Basu 1990; Jeffery. Jeffery, and Lyon 1989). Furthermore, a woman who wishes to obtain health care, whether from a local traditional practitioner. the district hospital, or some intermediate provider, is not free to do so on her own. She must obtain permission from her husband or in-laws. be escorted by a male family member if she travels outside the village, and find the money to pay for services and drugs. These physical and financial constraints underscore the need for government outreach activities such as those the government's Family Welfare Program provides. They also highlight the need to address the socioeconomic constraints that inhibit women's de- mand for services. Women and Work In addition to their reproductive roles, almost all rural women fulfill important productive functions throughout their adult lives, and in many cases, so do female children. These functions are so closely linked that they cannot be considered independently of each other (Chatterjee 1990: Jeffery, Jeffery, and Lyon 1989). India's reported female labor force participation is low by both developing and industrial country standards. Women's share of the adult labor force is 24 percent, compared with 35 percent for all developing countries (United Nations 1995). Labor force participation varies by region, however. Traditionally, northern Indian women are expected to keep to their homes and courtyards and the household activities that are carried out there. Men, by contrast. work and earn livelihoods in the outside world of fields and bazaars (what is termed the "inside-outside" dichotomy (World Bank 1991a). The ability to withdraw women from outside work is one of the most important symbols of economic and social status in rural northern Indian society. In practice. however. only the richest landowning families can afford to do with- out the money their women earn outside the home. In more modest landowning households, women typically work on family lands during peak agricultural seasons and do other outside work. including caring for animals and gathering fodder and fuel. In landless families, the income provided by women who perform agricultural or domestic labor is often the household's chief support. Ironically. the agricultural innovations of recent decades (the "Green Revo- lution") have not necessarily reduced the burden of labor (particularly unpaid labor) that falls on women. Although modern technology such as handpumps. fodder choppers. and mechanized mills have made some tasks easier, the workload of women in most landowning agricultural households has probably increased, for several reasons. Scrub land previously used for grazing is now being cultivated, and processing crops such as wheat and rice requires more THE SOCIOCULTURAL CONTEXT 57 labor and time. In addition, more acreage is being devoted to field than fodder crops, so that obtaining fodder for household animals, which is women's work, has become a more pressing and time-consuming task. The decreasing avail- ability of firewood means that women must spend more time gathering it or making dung cakes as a substitute. Furthermore, few innovations have taken place in household tasks, which are performed exclusively by women. Finally, when field labor is mechanized. it becomes men's rather than women's work, depriving laboring women of a potential source of income (Chatterjee 1991; World Bank 1991a; Jeffery. Jeffery, and Lyon 1989). The extensive and often strenuous physical labor that women must per- form, combined with men being given preference in the household allocation of food, accounts in good measure for malnutrition among Indian women. One study estimated that when women's physical activity, including field and do- mestic labor, was taken into account, women had a higher daily expenditure of calories than men in the same households (Batliwala 1982). Productive responsibilities are hardest on young women in their childbearing years. Typically, women work until late in their pregnancies; no special provi- sions are made for rest or additional food, and most women resume work before they have fully recovered from childbirth. The result is often a cycle of "mater- nal depletion" that can have devastating consequences for a woman's health and undermine her ability to carry out her responsibilities, both productive and reproductive. A woman whose physical reserves are already exhausted by childbearing, lactation, anemia, and heavy agricultural labor has no reserves to ensure that another pregnancy will be safe and healthy. Continued physical activity until late in pregnancy and a lack of adequate rest not only negatively affect women's health but also contribute to excessive rates of stillbirths, pre- mature births, and intrauterine growth retardation (Khan, Ghosh Dastidar, and Singh 1982; ICMR 1977). Women and Poverty Examining the contrasts among regional cultural norms in India is one ap- proach to analyzing the status of women and the consequences for women's health. However, within and (to some extent) across regions, socioeconomic differentials are the clearest determinants of the status of women's health. Poor health is the basis of a cycle from which women are never entirely able to escape, especially poor women who depend on the wages they earn as laborers. A woman's health determines how productive she is able to be, and how much she earns by her productive activity is a major determinant of how much she and her family will have to eat. If she is in poor health, her productivity will decrease and she will be unable to buy food and medicine, without which she cannot get well. The state of women's health is therefore of the utmost impor- 58 IMPROVING WOMEN'S HEALTH IN INDIA tance not only to the women themselves but also to their households and the survival of young children. In poor households. pressure on young girls to earn begins at an early age. Girls may work alongside their parents in agricultural occupations or, in certain localities, may participate in home-based industries such as carpet weaving and bidi (cigarette) rolling. By the time they are adolescents, these girls are often working the same long hours as adults. In such situations, the typical female diet is unlikely to provide the nutrition the girls need to keep up their energy. Persistent nutritional deprivation often keeps such girls from growing properly, resulting in small. malnourished women who often give birth to low-birthweight babies (Ghosh, Bhargava, and Moriyama 1982). Since women's agricultural work tends to be seasonal. poor households dependent on women's earnings from this kind of labor are particularly vulner- able to seasonal fluctuations in the availability of food and are therefore more likely to suffer from poor nutrition at certain times of the year. Pregnant and lactating women are particularly affected, often losing weight during seasons of the most severe deprivation. Infants may be weaned suddenly at such times. with detrimental effects on their health, although weaning may relieve the strain on malnourished and overworked mothers to some extent. The dependence of poor households on women's labor appears to have some positive health consequences for females and raises questions about the conventional criteria used to assess the status of women. There is considerable evidence that female children at the lowest socioeconomic levels receive more equitable treatment than female children from better-off, upper-caste families. Basu ( 1989b) found that in the Uttar Pradesh population she studied, the groups defined as low income or low caste were much more even-handed in providing medical treatment for male and female children than wealthier, higher-caste groups. A widening of gender differentials at higher socioeconomic levels has also been noted in mortality rates (Miller 1981) and, in some cases, indicators of nutritional status (Sen and Sengupta 1983). The more equitable treatment female children at lower socioeconomic levels receive appears to reflect their potential as income earners, even at fairly young ages. One measure of the status of women in India has been their ability to obtain paid employment outside the home. a freedom that is usually regarded as an important improvement over the traditional restrictions that have kept women at home, at most allowing them to perform unpaid family labor. However, in rural northern India the situation of women who work outside the home is perceived differently. Women engage in agricultural and other casual labor because their economic circumstances are often dire, and any improvement in their situation that allows them to give up such employment altogether is con- sidered a major achievement by all concerned. Status is not the only issue THE SOCIOCULTURAL CONTEXT 59 involved here; in the hierarchic. male-dominated society of northern India. poor women may be vulnerable to sexual victinization by their high-caste male employers (Sharma 1985). In most of India, gender inequality in the household places a greater burden of poverty on women than on men. The tribal populations that are concentrated in remote or hilly areas of India present a somewhat different picture. In terms of their physical freedom and their ability to control resources, the position of women in tribal societies is typically better than in the rest of India. However, because they are geographically remote, tribal areas are the most impoverished in India and the least likely to be served by modern health care services. Women and Widow-rhood Indian women generally marrv men older than themselves, have a survival advantage over men after age 30 (more similar to worldwide male/female mortality ratios than in early years). and are less likely than men to remarry. As a result, almost 65 percent of women age 60 and above are widows, and the proportion rises to 80 percent among women age 70 and above. The loss of a husband usually leads to a significant decline in household income. to social marginalization, and to significantly higher mortality rates than among married women of the same age (Dreze and Sen 1995). The legal system and society discriminate against women. preventing them from inheriting property from their husbands and fathers. In the large northern states, a widow is expected to remain in her husband's village. receiving little support from her in-laws and community. Without access to their own resources, widows are particularly dependent on sons. thus reinforcing the general preference for sons over daugh- ters (Desai 1994). Traditional Health Systems and Their Significance for Women's Health The pluralism characteristic of so many aspects of Indian society and culture is evident in beliefs about health, illness. and healing and extends to the ways in which the various types of medical systems are used. Several traditional, text- based medical systems are currently in use in India, as is the more recently introduced allopathic (modern Western) medicine. In addition. Indians pa- tronize a wide variety of other traditional health practitioners. Some traditional practices-for example, breastfeeding and the appropriate use of certain herbs and plants-can be beneficial; other practices. such as applying substances to the umbilical cord. can be harmful. 60 IMPROVING WOMEN'S HEALTH IN INDIA Traditional Text-Based Systems of Medicine Avurveda, the classical Hindu system. is concerned with maintaining and im- proving an individual's total health. The system is based on formal medical treatises that describe the etiology, classification, pathology, diagnosis, prog- nosis. and treatment of various diseases. The texts also describe the logic and philosophy behind the ayurvedic system. providing details of human anatomy, fetal development, the female reproductive organs, normal and abnormal deliv- eries, and the diseases of children. Ayurvedic medicine has its own categories of medical specialists and provides guidelines for nursing care and personal hygiene. The ayurvedic arsenal of medicines includes plant products, mineral substances, and animal products in the form of distillates, products of fermen- tation, powders, tablets. and pills. Siddha, a variant of ayurvedic medicine practiced in Tamil Nadu, places greater emphasis on the use of minerals and metals than Ayurveda, and particularly on mercury-based preparations, which are believed to contain special healing properties (Basham 1981). Ayurvedic medicine has changed a great deal during this century, and some established training colleges now concentrate on medicines and aspects of treatment simi- lar to those used in allopathic medicine. The other major indigenous system of medicine. Unani, was brought to India by the Muslims, who are its chief practitioners. The system is built on the ancient Greek humoral doctrines and the medical concepts of Hippocrates and Galen. It eschews all surgical interventions, and its methods are passed down through generations of practitioners known as hakims. Diagnoses are made on the basis of perceived alterations in the state of a person's humors. or bodily fluids, and imbalances in these fluids are believed to be the cause of most diseases. Another form of nonallopathic healing that has taken root in India (particularly Bengal) is homeopathy, which is actually Western in origin. On the theory that like can be cured by like, homeopathy seeks to create resistance to disease through small doses of disease-producing agents. Beliefs Concerning the Causes of Illness Underlying the systems of medical care in use in India. particularly in rural areas, is a set of widespread traditional beliefs concerning the nature of health itself and the causes of different types of diseases. These beliefs, grounded as they often are in the supernatural, are sometimes at odds with modern Western medicine. Foods are divided into two categories. hot and cold. Although the category to which a food belongs and the degree of its potency vary somewhat across regions. the fundamental dichotomy is the same throughout India. Milk, THE SOCIOCULTURAL CONTEXT 61 cheese curd, and most greens and fruits are considered cooling, while meat, chilis, other spices. and alcohol are considered heating. Although cold foods are seen as more beneficial, a balance of the two sorts of food is considered important. Overuse of spices is thought to lead to fever, for example, and an excess of cold foods, to give rise to influenza. Improper behavior is also be- lieved to be a root cause of illness. Headaches are ascribed to immoderate behavior, while excessive sexual indulgence is thought to weaken a man and to lead to a range of diseases, including tuberculosis. Indian dietary practices and the associated beliefs about their physiological implications have a significant impact on attitudes toward pregnancy in general and the care and diet of pregnant women and new mothers in particular. Pro- grams aimed at improving the health of women need to take traditional beliefs into account. Traditional Indian views about diet and behavior are in many ways not inconsistent with modern medicine and can be accommodated by flexible practitioners concerned with the ultimate success of treatment rather than with the correctness of one or another belief or system. However, another set of traditional beliefs involving the influence of divine or supernatural forces remains very much at odds with allopathic medicine. Local female deities who are believed to capriciously or accidentally "invade" individuals are held responsible for a group of diseases that includes smallpox, chicken pox, measles, typhoid fever, and plague.' Epidemics are understood as a sign of displeasure with the whole community for immoral behavior or ne- glect of regular worship. The appropriate response involves propitiating the deities to persuade them to leave the afflicted individuals: medical treatment is specifically avoided, as a displeased goddess could react by killing those af- flicted. It is not widely understood that smallpox has been eradicated because the disease is confused with chicken pox. and in any event goddesses may be quiescent for long periods but do not die. Basu (1990) reported that when a minor epidemic of chicken pox occurred in the resettlement area of Delhi she was studying, the outbreak was regarded as a divine visitation, and by and large no one sought outside help. not even to ward off secondary infections. The possibility of committing transgressions against the supernatural world is considered much greater during pregnancy, at the time of childbirth, and in the first year of life than at any other time in the life cycle. The belief that infants are particularly susceptible to invasion by spirits explains much about what appear to be low levels of care infants are accorded. In fact, the seeming casualness about the conditions in which women give birth and the apparent lack of intensive care for newborns denote a high degree of concern. Fear of stirring up evil influences that may harm a child can be a major reason for not seeking antenatal or postnatal care and for making few preparations for a birth. 62 IMPROVING WOMEN'S HEALTH IN INDIA Beliefs and Practices Related to Pregnancy and Childbirth Within the general context of beliefs related to health and illness, those con- cerning pregnancy and childbirth are of particular relevance to women's health. The information given below concerns primarily northern India: customs in the southern part of the country are somewhat different (Wadley 1980).7 PREGNANCY. The primary role of every Indian wife is to bear her husband's children. In some communities in southern India, the advent of a pregnancy (especially if it is the first) is celebrated. In the north. however, custom dictates that a pregnant woman observe rules of modesty, particularly with regard to her natal family, since her pregnant condition is tangible evidence of her sexuality. A woman does not announce a pregnancy before it becomes obvious. nor is it publicly noted or celebrated. One result of these attitudes is that in parts of Uttar Pradesh and Bihar it is considered improper for a woman to visit her natal home once she is unmistakably pregnant or to give birth in any place other than her husband's household.' For these women, a first pregnancy marks a defini- tive break between a young wife and her natal family at a time of particular stress. Women are not considered the "proprietors" of the products of conception, their role being to nourish their husbands' offspring. Just as women have little control over the ability to engage in productive work, so they have limited control over their own pregnancies. Nevertheless, it is generally recognized that a woman's health can affect the outcome of her pregnancy and that some changes in her diet and work schedule may be beneficial. The nausea. vomit- ing, and indigestion characteristic of early pregnancy are believed to be the result of a "heated" condition. Women are advised to eat cold rather than hot foods during pregnancy. especially certain fruits, rice, and milk products, which are considered strengthening. However, a pregnant woman in rural northern India usually has no way of obtaining food that is not normally available in the household. Her diet is conditional on what her mother-in-law and husband permit, and she normally hesitates to ask for anything extra or special for fear of being thought shameless. Moreover, the idea of making special dietary ar- rangements for a pregnant women is unheard of, so that even if a husband brought his wife something special, it would have to be shared with the rest of the household. A study in Punjab found that while women understood the need for a more nutritious diet during pregnancy and lactation, little effort was made to provide more or better food, and the women themselves felt unable to demand it (Das Gupta 1995). Some studies suggest that a pregnant woman's diet is further constrained by the belief that overeating during pregnancy will result in either a large baby, and consequently a difficult labor, or a small, weak baby that has THE SOCIOCULTURAL CONTEXT 63 not had enough space to develop because of overconsumption of food (Jeffery. Jeffery, and Lyon 1989: Nichter 1989). In any event, the idea of providing a special or more substantial diet for pregnant women is by and large an abstraction, since most rural households survive near the margin and cannot afford to buy anything extra. Pregnant women are fortunate if they are able to eat their fill of the grain and milk products that are typically available. The reality is that few women eat any differently when they are pregnant than they ordinarily do. Consequently. preg- nant women tend to suffer from an average caloric deficit of around 25-35 percent of their nutritional requirements (Bhardwaj and others 1990). Because many of the women are already undernourished, the lack of proper nutrition during pregnancy results in a high incidence of maternal depletion and low- birthweight babies and endangers both mothers and children. Although it is generally recognized that rest is desirable durring pregnancy, this consideration is outweighed by economic necessity. A pregnant woman is expected to fulfill her responsibilities without disrupting the work of other women in the household. Pregnant women norrnally go about their usual tasks throughout their pregnancies. often until the onset of labor. Depending on the status and situation of the household. these tasks typically include household work such as cooking and childcare: physical labor such as carrying water, wood, and fodder (often onr the head); and agricultural work. An indication of the extent and strenuousness of the activities of a sariple of pregnant women in a village in western Uttar Pradesh is given in appendix table 2.2. Rest is a luxury, and only women who becorIme seriously ill can give up their normal work routine. For the most part, pregnancy is not considered a condition that requires medical care. This attitude directly influences a woman's ability to obtain antenatal care and medical intervention even when there is a clear need. Even a woman who has had difficulties with previous pregnancies or shows signs of an incipient miscarriage is usually treated only with home remedies. In general, she will not receive additional medical treatment for specific problems-let alone routine antenatal or postnatal care-for a number of reasons similar to those discussed earlier. First. [ie decision that a pregnant woman seek help rests with the mother-in-law and husband. Second. practical and financial con- siderations limit her ability to obtain medical care. Third, there is considerable fear that the treatment may be more harmful than the malady. Such fears commonly result in resistance and delay in seeking medical intervention when a pregnant woman becomes ill. CHILDBIRTH. About 55 percent of deliveries in urban areas now take place in hospitals, and in imajor cities, such as Bombay and Madras. that have well- established health systems the figure rises to over 90 percent. However, in rural 64 IMPROVING WOMEN'S HEALTH IN INDIA areas only about 16 percent of deliveries are institutional (IPs 1995). The majority of women still give birth at home, attended only by the older women of the household or a traditional birth attendant known as a dai. While the specific role and practices of the dai differ across regions, in much of northern India she is not seen as someone with specialized or expert knowledge. Her standing is affected by the traditional belief that birth is a "polluting" process. The occupation is sometimes handed down from mother to daughter, although in general a woman becomes an active dai only when forced to do so by eco- nomic necessity, which explains why many widows take up this occupation. Because childbirth is considered polluting, old clothes, rags, bed linen, and cots are used during the delivery, with serious implications for hygiene. After delivery, the umbilical cord is cut with a sharp instrument that may not be sterile. The unsanitary circumstances of such deliveries, including the internal examination and the cutting of the cord, result in high rates of puerperal infec- tion and neonatal tetanus. The dai performs an essential role for the household by cleaning up during and after the delivery. She is responsible for delivering the placenta, for removing the waste and dirty linen from the place of delivery, and for helping to bathe the postpartum woman. Experienced older women are often knowledgeable about the birth process and can time labor pains and contractions, judge the progress of labor, and check fetal movements and presentation. However. only a dai will examine the parturient woman internally to assess the degree of cervical dilation and the baby's transit. Although a dai can recognize many life-threatening conditions. she is not equipped to deal with them. In fact, a dai often refuses to attend at deliveries she suspects may involve difficulties. advising the family to take the woman to the nearest medical facility. The government is currently implement- ing a training initiative for these women (known as the Intensified Training of Dais Program) in all rural districts. THE PUERPERIUM. The birth of an infant is followed by forty days of con- finement, during which time mother and child are secluded. The vulnerability of the infant and the polluted state of the mother are the prevailing themes during the postpartum period. While postpartum isolation is understood as a means of protection from evil spirits, it also provides a period of relative rest for the postpartum woman. Few women receive any form of postpartum health care, other than abdominal massages by the dai. Because a woman is consid- ered polluted after childbirth, she rarely seeks medical help for other illnesses that may develop in the postpartum period. Local practitioners may be con- sulted if a mother fails to lactate or bleeds excessively, but few other conditions are likely to be given much notice. THE SOCIOCULTURAL CONTEXT 65 After the delivery (depending on how the household is organized), the puerperal woman may be excused from her normal chores. In particular, she does not cook for the household during the period of postpartum "pollution." The new mother eats separately and must avoid certain "cold" foods. In con- trast to attitudes toward nutrition during pregnancy, it is generally held that a new mother must have sufficient nourishing food to establish and maintain lactation. However, lactation makes demands on a woman's energy that are extremely difficult to meet for someone who is already undernourished. There- fore, while the traditional long period of breastfeeding is beneficial to infants and toddlers, it can exacerbate the mother's poor nutritional condition. ABORTION. A variety of factors explain Indian women's reasons for seek- ing abortion. Contraceptive failure was reported by 42 percent of clients in government-approved institutions in 1990-91 (Chhabra and Nuna 1994). Hos- pital-based and urban studies indicate that most of these clients are married, between the ages of 20 and 35, and have one or more children. Data on the percentage of unmarried women seeking public sector abortions suggest that the figure is low. However, although proportionally small. this group of women is at a higher risk for complications stemming from abortion because unmarried women are more likely to wait until the second trimester or to seek a clandes- tine abortion outside the government system (Kerrigan. Gaffikin, and Magarick 1995). Studies suggest that women who seek noninstitutional abortions do so for socioeconomic reasons-for instance, most illiterate women seek abortions outside the government system. Most already have many children or have reached their desired family size (Kerrigan, Gaffikin, and Magarick 1995). The 1983-85 tCMR study of induced abortion (1989a) and the review by Chhabra and Nuna sought to discover why the incidence of illegal abortion remains so high when the procedure is readily available at government facili- ties. Several interrelated factors appear to be involved. First, the number and location of approved facilities and registered practitioners vary widely among and within states, and there is an acute shortage of primary health centers. For example, Maharashtra has one approved institution for every 8,000 couples. but Bihar has only one for every 132,000 couples. Second, although the per- centage of those who are not aware that government clinics provide termina- tions appears to be declining, some outreach may still be necessary to make women aware of this nominally free service. In addition, women may prefer a private termination because they believe it will be better than the government- sponsored service. To a large extent, the decision by many women to use private rather than public practitioners is another instance of the general prefer- ence for private services, as well as of women's reluctance to be examined and 66 IMPROVING WOMEN'S HEALTH IN INDIA treated by male doctors, who predominate at government clinics. Women are also reluctant to use a public facility for an abortion because of the lack of privacy. The studies shed some light on the reasons women choose a traditional rather than a modern abortion. The first consideration is cost: a "modern" abortion, whether public or private, is expensive. As chapter 3 notes, inpatient procedures carried out at public facilities, although nominally free, are rarely so in practice, and abortion is no exception. Second, women may not have the time or the means to travel to a distant public facility, so that a traditional procedure carried out locally is the only feasible alternative (and, again, the cheapest). Third, modern procedures are held to be inherently dangerous and are often considered more hazardous and a greater violation than a nonclinical procedure (Jeffery, Jeffery, and Lyon 1989). Many Muslims express strong religious objections to induced abortion. Ironically, however, because relatively few Muslim women use contraception, they may be more likely to have to contend with unwanted pregnancies and may be forced to consider abortion as an option (Jeffery, Jeffery, and Lyon 1989). INFERTILITY. Infertility in women can result from reproductive tract infec- tions (particularly STDs), unsafe abortions, and complications of childbirth (often relating to hygiene). Since a woman's status rests primarily on her suc- cess in bearing children, infertility-which is always held to be the wife's problem. since the possibility that her husband may be infertile is not consid- ered-is a major disaster for a woman. She is often abandoned or sent back to her parents' home for failure to conceive or to produce sons. Not surprisingly, a wide variety of home remedies, traditional medicines, and rituals are avail- able to treat infertility. г - :r.� � �_ ...`� ;�,� '�>'� ::;�,г а '�; �_ ; �" . _ � 1; ��1ы . �� . ��. I �э �� ч: � � '"иа.Р,�. ,у,.. • - �>• к�; л, �А� 4 j � - � 1 \ л �i� , _, rу,у i f ���.�, 14 l � • � J� Fa �': �� � � �. , .,. 1\� 'z ,� ! . ' f k л � �;,, � � ..vн1W �� ' ���'''''',,,'''���цццIII I� �I --� •� ,�,� �"� у � ���` Е - +��`ц^д�1 ;.:�,� • � �.'�,'��ч'°"� _� � .� � k_�'= а ,9 '' ,�;' ,�'� �`.':� ы<" �г� �.°wf�',�, ��,г.'' . . C H A P T E R T H R E E Health Services and How They Are Used India's health care delivery systerns can be grOLIped according to four sectors. The public sector includes government-l-Lin hospitals, dispensa- ries, and health centers. The notfi)t--j)r(?fitsectot- comprises nongovernmental oruanizations (NGOs) that are private Voluntary organizations and charitable institutions. General practitioners. private hospitals and dispensaries, and other re-istered and licensed practitioners make up the ot-Ouni-ed jwivate seclol-. Finally, ail encompasses practitioners without allopathic medical qUal ificat ions. including faith healers and herbalists (Bhat 1995). Stud- ies suggest that the private sectors provide about 80 pet-cent of health care. niost1v for Curative services. The government is the source of illost preventive care (box 3.1 ). Aside front the informal private sector, health care is concen- trated in urban areas. For example, in 199 1 the ratio of hospital beds to POpLila- tion was 20 per 100,000 Population in rural areas, compared with 238 beds pet- 100.000 population in urban areas (Duggal. Nandrqj. and Vadair 1995). Government Services Public sector services in India that are intended to rneet the health and nutfi- tional needs of wornen and children are provided through the Health and Farn- ily Welfare Programs of the Ministry of Health and Family Welfare (NIOHFW). The National Family Welfare Prograrn. established in 1951, has helped to 69 70 IMPROVING WOMEN'S HEALTH IN INDIA BOX 3.1 PROVISION AND FINANCING ban areas. Private providers are domi- OF HEALTH SERVICES: PUBLIC AND nant when it comes to the provision of PRIVATE ROLES ambulatory curative care, even among the poor. For inpatient treatment, the Public health spending is relatively low, government supports the greatest pro- representing only about 1.3 percent of portion of care; on average, about 60 the gross domestic product. Of the to- percent of all hospitalized cases are tal health spending in India, about 75 admitted to public facilities. This un- percent is out-of-pocket spending by derscores the important role that pub- private households, 3 percent is by cor- lic hospitals play in providing care at porate or third-party insurance, and 22 the first-referral level, such as for treat- percent by the government. State and ment of obstetric complications. local governments account for about Surveys undertaken in five states 75 percent and the central government show that the burden of household for about 25 percent of total public ex- health expenditure falls disproportion- penditures on health. Public spending ately on the poor and on rural popula- for health is significantly lower in the tions. Household health spending av- poorer states, where the health status eraged 5 percent of total consumption of the population is lower. expenditures in rural areas but 2 per- The government is by far the domi- cent in urban areas. Contacts with pri- nant source of preventive health care, vate providers for treatment of illnesses such as immunizations, antenatal care, generally cost one and a half to two family planning services, and infectious times more than contacts with govern- disease control in both rural and ur- ment providers. (World Bank 1995) achieve the notable reductions in fertility and infant mortality rates of the past forty years. The Family Welfare Program launched the Child Survival and Safe Motherhood (CSSM) Program in 1992 to accelerate improvements in the health status of women and children. In addition, it administers the Intensified Train- ing of Dais Program (ITDP). The Integrated Child Development Services (ICDS) Program of the Department of Women and Child Development in the Ministry of Human Resources Development also provides services for women and chil- dren, primarily in child nutrition. This section summarizes the features of those programs that are most relevant to the health of women and female children. Specific issues related to the programs and recommendations are discussed in chapter 4. The Family Welfare Program India's Family Welfare Program has developed gradually since the National Family Planning Program-the first such program in the developing world- was launched in 1952. Progress during the 1950s was limited: some research HEALTH SERVICES AND HOW THEY ARE USED 71 was carried out, institutes to train population analysts and family planning workers were set up, and a small number of rural and urban clinics was estab- lished. The 1960s saw an increase in facilities for sterilization, the opening of the first sterilization camps in rural areas, and the first groups of auxiliary nurse-midwives (ANMS), who were attached to rural health facilities with the goal of expanding family planning methods through outreach. A full-fledged Department of Family Planning was set up in 1966 in the Ministry of Health, and annual targets for fieldworkers were initiated. In the second half of the decade, the ministry introduced a major campaign to pro- mote intrauterine devices (IUDs) and a social marketing program that provided condoms through commercial outlets at subsidized prices. (In 1987 the pro- gram was expanded to include oral contraceptives.) The hospital-based Post- partum Program was launched in 1969 to deliver antenatal and postnatal ser- vices to expectant mothers and to provide family planning services as well. In the early 1970s, the program's focus shifted to sterilization. The several types of local family planning and health workers, both male and female, became "multipurpose" workers responsible for providing a set of basic family planning, maternal and child health, and public health services. Also at this time, a community-oriented service network was developed that aimed to ex- pand family planning and maternal and child health services. During 1975-77, family planning became a priority, with one very clear consequence: a dramatic increase in the number of sterilizations, in part because of pressure by overzeal- ous workers. The issue came to the fore in the elections of March 1977. result- ing in a change of government. However, the new government did not dis- mantle the family planning program. Instead, it placed all the voluntary family planning programs, along with other primary health care services, under the umbrella of "family welfare" and changed the name of the Ministry of Health to the Ministry of Health and Family Welfare. The early 1980s saw the introduc- tion of improved technologies for female sterilization, including laparoscopy and minilaparoscopy. The new emphasis and technologies led to a shift from vasectomies to tubal ligations. About 80 percent of all sterilizations were va- sectomies in the early 1970s; ten years later, 80 percent were tubal ligations. Under India's Seventh Five-Year Plan (1985-90). a three-tiered rural health infrastructure became the norm. Family welfare subcenters, staffed by one male and one female multipurpose (ANM) worker, were established to serve populations of 5,000 (3,000 in particularly undeveloped, tribal, or hilly areas). Priman health centers (PHCs) serve a population of 30,000 and are staffed by a medical officer, associated facility staff, and field supervisors, at a ratio of approximately I supervisor to 5 multipurpose workers. Community health cen- ters (CHCS). which cover a population of about 100,000 (the area of a commu- nity development block), are staffed by specialists in pediatrics, surgery, and obstetrics and gynecology. CHCs are expected to serve as "first-referral units" 72 IMPROVING WOMEN'S HEALTH IN INDIA that provide essential obstetric care, including cesarean sections and blood transfusions. In urban areas. postpartum centers, urban family welfare centers, health posts, dispensaries, and hospitals are designed to provide family plan- ning and maternal and child health services. Under the Eighth Five-Year Plan (1992-97), the government's aim has been to strengthen child health services by expanding the universal immuniza- tion program (UIP). increasing the use of oral rehydration therapy for treating diarrhea, improving treatment for acute respiratory infections, providing vita- min A prophylaxis against blindness, and strengthening newborn care. Mater- nal services are also being strengthened and expanded under the Safe Mother- hood Program to include improved antenatal and postpartum care, anemia prophylaxis, referrals for high-risk pregnancies, improved training for dais. increased availability of essential obstetrical care, and timely emergency care. Most observers agree that the program does not yet reach many who need its services and that the quality of care needs to be improved. In January 19921 the MOHFW issued the Action Plan for Revamping the Family Welfare Program in India. a comprehensive blueprint that touched on many concerns observers had recognized for at least a decade. But the ministry has found it difficult to modify the way the program is implemented at state and local levels. Steps have been taken recently, in part through the CssM Program, to upgrade facilities, improve staff training, strengthen links with communities and NGOs, and ex- pand information, education, and communication (IEC). The government took another important step in 1995 when it began to implement measures to eliminate family planning targets that required provid- ers to meet method-specific contraceptive "quotas" (see chapter 4). Removing these numerical targets, shifting to a broader approach to population planning and health service delivery, and increasing the emphasis on providing access to quality services should help improve women's health status. reduce unwanted fertility, and increase client satisfaction. THE CHILD SURVIVAL AND SAFE MOTHERHOOD PROGRAM. Launched in Au- gust 1992, the CSSM Program is designed to improve the health status of women and children and reduce maternal, infant, and child mortality rates. The pro- gram aims to achieve by 2000 the nine goals of the National Health Policy approved by Parliament in 1983, all of which relate to maternal and child health. The maternal health goals include reducing the maternal mortality ratio to 200 maternal deaths per 100,000 live births. supplying 100 percent of preg- nant women with tetanus toxoid immunization and antenatal care. and ensuring that trained personnel attend 100 percent of deliveries. The progran is designed to address the major causes of morbidity and mortality in women and children, all of which can be prevented with readily HEALTH SERVICES AND HOW THEY ARE USED 73 available and cost-effective interventions. While many of these interventions are provided within the framework of the Family Welfare Program. under the CssM they are being integrated, expanded. and improved. The improvements include providing additional and more modern equipment, ensuring the reli- ability of supplies of essential drugs. and retraining medical and paramedical personnel. Additional areas of emphasis that are beginning to receive needed attention include improved care for newborns and strengthened referral ser- vices for pregnancy-related complications. The program aims to improve maternal health by identifying women early in their pregnancies and providing a minimum of three antenatal checkups, achieving universal coverage with tetanus toxoid vaccine and iron and folic acid tablets, providing advice to pregnant women on adequate food and rest. detecting complications of pregnancy early and making appropriate referrals. ensuring that trained personnel are present at all deliveries, encouraging institu- tional births for women with poor obstetric histories and significant risk fac- tors, improving the management of obstetric emergencies. and encouraging birth spacing. The government has prepared guidelines and training materials for the program. It provides essential supplies, equipment, and cash assistance and coordinates and supervises program activities. State governments are re- sponsible for implementing the program and supervising delivery of the ser- vices. The program is to be operational in all districts by 1997. In the states of Assam. Bihar, Madhya Pradesh, Orissa, Rajasthan. and Uttar Pradesh. where maternal mortality rates are particularly high, the government is providing additional inputs to establish first-referral units in rural areas for managing obstetric complications. The states have been requested to place gynecologists, pediatricians, and female paramedical staff in vacant posts on a priority basis, and to include on the approved drug list those drugs essential for managing obstetric complications. If no specialists are available, the states have been asked to organize skill-based training for medical officers in order to strengthen the units. The Safe Motherhood component has progressed at a slower pace than the Child Survival component. Coverage of antenatal and postpartum care services is very low in the large northern states and needs to be expanded in order to reduce maternal mortality and morbidity and improve infant outcomes in these regions. The referral system linkina households to the medical community also needs to be strengthened. A particularly difficult challenge, and one that must be met if maternal mortality is to be reduced, is providing prompt and effective treatment for obstetric complications. many of which occur without warning during labor and delivery. Many facilities do not have qualified specialists. adequate operat- in theaters, or facilities for providing blood transfusions. It has also proved 74 IMPROVING WOMEN'S HEALTH IN INDIA difficult to deploy female medical officers to some of the most underserved rural districts because of the living conditions. THE INTENSIFIED TRAINING OF DAIS PROGRAM. A program to educate dais in hygienic delivery practices was introduced in the 1950s and continued through the 1960s. After a ten-year hiatus, the MOHFW initiated the Intensified Training of Dais Program (ITDP) with the objective of training at least one dai (also known as a traditional birth attendant. orTBA) in each village. The prograrn was implemented on a pilot basis in eleven districts by an experienced NGO. Under the CSSM Program, the training initiative is being phased in to cover all rural districts. The program gives priority to womnen who are already functioning as dais and aims to provide them with essential maternal care and birthing skills. Many earlier programs have failed to provide ongoing contact after the initial train- ing, a shortcoming the tTDP seeks to correct. Dais are taught to identify preg- nant women in the early stages, ensure that they receive tetanus toxoid immu- nization, provide anemnia prophylaxis. and maintain hygiene during delivery. They are also trained to recognize and refer women with problem pregnancies and to seek treatment for women who develop complications during or after childbirth. Following six days of institutional training with hands-on instruc- tion, the trainees are supplied with safe delivery kits and weighing scales. The program has encountered several difficulties. Many dais who have been trained are not practicing in their villages, and the supply and use of safe delivery kits have been variable. Moreover, the training of traditional birth attendants is only an intermediate and, even then, only partially effective solu- tion. Training may improve basic care practices, including hygienic deliveries, but TBAs are not capable of managing the obstetric complications that are the major cause of maternal death and disability. The Integrated Child Development Services Program ICDS was developed by the Ministry of Social Welfare with UNICEF assistance in the mid-I1970s. The government of India finances over half of the cost, and the food costs are borne by the states. The program's objectives are to: 0 Improve the nutritional and health status of children under 6 years of age and of pregnant and lactating women, thereby reducing the incidence of mortality. morbidity. and malnutrition 0 Lay the foundation for the proper psychological, physical, and social devel- opment of children HEALTH SERVICES AND HOW THEY ARE USED 75 0 Through nutrition and health education, enhance the capability of mothers to look after the normal health and nutritional needs of their children 0 Achieve effective cooperation among government departments concerned with promoting child development. ICoS programs are administered for community development blocks (about 100,000 people), tribal development blocks (about 50.000 people), and slum populations (about 100,000 people). Services are delivered through centers staffed by female workers (anganwadis), each of whom serves a population of 1,000. The anganwadi workers, who are recruited locally, are the key to the success of the ICDS. They are part-time volunteers and receive an honorarium rather than a salary. They are responsible for organizing preschool activities and supplementary meals for children at the centers, providing health and nutrition education for mothers. making home visits, building community sup- port, and assisting health workers with immunization and other services. The ICDS currently covers over 50 percent of the development blocks in India, although not all villages in a given block are included in the program. Under the government's Eighth Five-Year Plan (1992-97), the program is being expanded to all development blocks in the country and has taken addi- tional steps to improve linkages with the health system. Coordinating commit- tees were established at block, district, and state levels; health staff were ap- pointed as technical advisers to the ICDS at all these levels: and joint supervision has been undertaken. Coordinated government orders were issued in February 1991 by the relevant ministries, formalizing areas of coordination. Private Services Most of the care delivered in the private sectors is allopathic, whether provided by allopathic doctors or by traditional practitioners. Drug sellers and pharma- cists also commonly diagnose and prescribe drugs. as well as dispense drugs (World Bank 1995). Practitioners may work within the not-for-profit, orga- nized. or informal sector. This section reviews the various types of private sector services available: the section on health care utilization and coverage offers further insights. drawn mostly from investigative data, into the private sector's role in health care delivery in India. The Not-for-Profit Sector There are more than 5.000 registered health-related NGOs in India. They tend to vary widely in size and in orientation and are concentrated in the southern 76 IMPROVING WOMEN'S HEALTH IN INDIA states, Maharashtra. and Gujarat. Most large NGos have their operational base in urban areas. In general, the NGOs involved in providing family planning. health care, and related services for women have been effective. largely be- cause of the flexibility of their programs, their skills in interpersonal communi- cation, and their involvement with the community and its overall problems. For example, NGOs might be more likely than organizations dealing exclusively with health to take into account the practical situation of urban slum women, for whom immediate needs such as food. housing. water, and employment often take precedence over preventive health or family planning measures. Accordingly. NGOs' strategies for slum areas might include a range of activi- ties, particularly projects aimed at helping women and children generate in- come and obtain more and better food. Some NGO efforts to organize women and tackle problems of women's status directly have been remarkably success- ful (Bhatia and others 1995: Murthy 1991). For example, NGos have helped form grassroots women's organizations onahila niandals) and groups in rural areas that are dedicated to the development of women and children (Bennett 1992). Because NGOs have had considerable success in working with women, the Family Welfare Program is involving some of these groups in efforts to promote the use of contraceptives and improve health. In 1994-95, the pro- gram provided grants-in-aid to six NGOs. Since 1991, World Bank assistance has included funds aimed at increasing the involvement of NGOS in family welfare. To date. the services NGOs provide are relatively small in scale and are available to only a small proportion of the rural population. The Orgaized Private Sector Little systematic data has been collected on the organized private sector in either urban or rural India. although such care is certainly widely available. Efforts to interpret the available information is complicated by the problem of determining whether a physician is actually "in practice." Studies of the num- ber of qualified physicians. hospital beds, and dispensaries (outpatient facili- ties) over the past several decades have found significant growth (Duggal, Nandraj, and Vadair 1995: Jesani and Anantharam 1989; see also appendix table 3.1). Clearly, the private sector would not have grown if private health care had not been in demand. Jesani and Anantharam estimate that in all sys- tems of medicine. fewer than 15 percent of qualified doctors and about 40 percent of health care providers with paramedical qualifications work for the government. suggesting the probable extent of the private sector. Another study found that private sector facilities, although more Urban than rural overall, are not concentrated in urban areas to the same degree as government facilities. For instance. 30 percent of private sector hospital beds were in rural areas. com- pared with only 10 percent of government hospital beds (Bhat 1995). HEALTH SERVICES AND HOW THEY ARE USED 77 The Informal Private Sector in addition to government and private practitioners of the formal systems of medicine (see chapter 2 for a discussion of the medical systems in use in India), a range of other persons play healing roles throughout the country. particularly in rural areas. Typically. Indians needing health care resort to them at one time or another, depending on the nature and seriousness of the condition and the age and gender of the sufferer. Because of the general reluctance to consult strangers about health prob- lens. local traditional practitioners have an advantage over allopathic doctors. since they are likely to be part of local society and known to the family mem- bers who make decisions about a household's health care. People are also well aware that allopathic doctors tend to concentrate on the illness itself, while traditional practitioners also deal with the etiology of a condition and the social consequences. Moreover, traditional practitioners are likely to devote more time and attention to their patients than their allopathic counterparts. Kakar (1988) reported that traditional healers may spend three or four times as much time with their patients as allopathic practitioners spend with theirs. In addition, modern medical procedures often fail to conform to traditional expectations. Patients (1o not expect to have to provide a history of their coin- plaints because they assume that, as healers, practitioners will know what the problems are. Similarly, traditional healers always specify how long a recovery will take and are usually willing to accept deferred payment. They do not use the clinical approach favored by many modern health care providers, which tends to alienate poor, usually illiterate, villagers. The burden of illness in rural India that results from the high incidence of infant and child death and pervasive morbidity is enormous (see chapter I). Kakar (1988) found that over 80 percent of interviewees or their family mern- hers in rural Haryana had experienced one or more symptoms of illness in the two-week period prior to the interview. It is not surprising, therefore, that locally available traditional practitioners are called on to treat many cases. Kakar studied the rural Haryana block. which had a population of approxi- mately 135,000 in 1985, and found that in addition to government doctors, private allopathic physicians, and other un!iceI-sed allopathic practitioners such as pharmacists, some sixty-four registered tiaditional medical practitioners main- tained full-time practices there. Of these, only nine were fully institutionally qualified, and forty-five had no institutional qualifications whatsoever. Eleven of them restricted themselves solely to the practice of traditional systems: the others combined traditional approaches and, to some extent, allopathy. Some preferred to be known as specialists in certain types of diseases, particularly those affectin2 children and women. In addition, there were as many as 600 folk practitioners and local healers of various descriptions within the block. 78 IMPROVING WOMEN'S HEALTH IN INDIA Another survey of "rural doctors" found that 27 percent practiced allopathy exclusively, while another 61 percent reported using more than one system of medicine (Viswanathan and Rohde 1990). Among these practitioners, only 38 percent had some type of medical qualifications or were registered, and only 49 percent had attended college. Studies from other parts of India confirm the number and variety of private health practitioners and modes of practice cur- rently available (Nichter 1989 for southern Karnataka: ICMR I 988a for Bihar, Gujarat. and Kerala). Utilization and Coverage of Health Services Patients are eclectic in their choice of health care practitioners and services. Over 75 percent of those interviewed by Kakar (1988) reported that they rou- tinely sought treatment from various kinds of traditional and local practitioners for at least some kinds of ailments. Duggal and Amin (1989) report similar findings for rural Maharashtra. In general, the more serious and incapacitating an illness is considered, the more likely it is that allopathic treatment will be sought. The data also indicate a correlation between patients' socioeconomic status and their use of allopathic medicine. a fact that probably reflects the effects of education. A larger proportion of those from wealthier, high-caste families recognize the symptoms of common diseases and are likely to seek allopathic attention for them. Education is probably also responsible for the finding that the relatively young are more likely than their elders to utilize modern health care (Kakar 1988). Data showing the frequency of use for various kinds of practitioners and systems are limited and may be misleading. The results of many small surveys (see, for instance, CDRT 1989 for Bihar) probably overstate utilization rates for allopathic practitioners because of bias in the way the questions are framed and asked. The ICNRstudY (1988a) in Bihar, Gujarat, and Kerala asked about public and private allopathic. traditional, and home treatment options but made no attempt to record respondents' use of local practitioners. But community-based studies show that local practitioners are used extensively. The heavy use of traditional and local practitioners suggests that they are more accessible to women and children-especially poor women and chil- dren-and that they are culturally more acceptable than allopathic providers. However, studies of the services these practitioners provide indicate that the quality is in many cases questionable and all too often ineffective and possibly harmful. A study in Maharashtra found that these practitioners treated some 70 percent of all the episodes of illness they saw with injections (Duggal and Amin 1989). Viswanathan and Rohde (1990) reported that "rural doctors" treated 40 percent of diarrhea episodes with injections, using oral rehydration in only 6 HEALTH SERVICES AND HOW THEY ARE USED 79 percent of cases. And in Haryana. 65 percent of those treated by "traditional practitioners" received only allopathic drugs, many of which were inappropri- ate and even potentially harmful (Kakar 1988). Virtually every field study on the use of medical care in India has concluded that private allopathic practitioners are considered superior to government doc- tors (Basu 1990). The extent of the preference for private sector practitioners is shown in appendix table 3.2, which provides data from studies in Andhra Pradesh, Bihar, Gujarat, and Uttar Pradesh. These data indicate that in Andhra Pradesh, Bihar, and Uttar Pradesh. 63-81 percent of those needing health care in the preceding three months sought treatment from private practitioners. People prefer private doctors for several reasons. First, it is generally as- sumed in India that anything worthwhile or valuable will cost money, thus, medical services that must be paid for are seen as better than government services. In addition, practitioners who charge for their services are expected to be more polite and attentive and to devote more care and concern to patients. People are also dissatisfied with government services. Studies are consistent in reporting that the major reasons for this dissatisfaction include the costs of payments to staff and for drugs, although services and supplies are nominally free; costs of travel and difficulties in reaching distant facilities: rude and improper behavior on the part of health staff: staff shortages; lack of supplies and drugs; and long waits to see a doctor. Results for Andhra Pradesh, Bihar. Gujarat, and Uttar Pradesh are summarized in appendix table 3.3. (The average waiting time in the study was 97 minutes in Bihar. 39 minutes in Gujarat, and 10 minutes in Kerala.) It is noteworthy that more people use the government system in Gujarat than in the other states studied, perhaps because the costs of obtaining services (although not of travel) have evidently been kept within bounds. The high cost of services was least frequently mentioned as a source of dissatisfaction with government programs. Maternity Care ANTENATAL CARE. Although one of the major responsibilities of the Family Welfare Program is to provide antenatal care to pregnant women, the number of women who receive this care is still relatively low. Data for 1992-93 (see appendix table 3.4) indicate that 77 percent of women in urban areas and 41 percent of women in rural areas received an antenatal checkup from a doctor or other health professional (tIPS 1995). The percentages varied widely across states, ranging from 23 percent in Rajasthan to 97 percent in Kerala. Only 21 percent of Indian women received a home visit from a health worker during pregnancy. Although the percentage was greater in rural areas (24 percent) than in urban areas (10 percent), the frequency of home visits and the number of 80 IMPROVING WOMEN'S HEALTH IN INDIA women served need to be increased for rural women who do not have easy access to primary health centers. A related and important issue in the delivery of antenatal care in India is the timeliness of the initial contact. Women fre- quently are not seen until a pregnancy is fairly advanced, often far into the third trimester. This delay substantially reduces the usefulness of prenatal care. which is not being provided soon enough to incorporate preventive measures or to identify problem pregnancies that need special treatment. Tetanus toxoid vaccine provides immunization against tetanus for both women and their newborns. Overall. 54 percent of pregnant women received tetanus toxoid vaccinations in 1992-93 (appendix table 3.5). Coverage is low- est in Rajasthan (28 percent) and Bihar (31 percent). The question of why levels of antenatal care are so low in rural India needs to be considered from both the supply and the demand sides. On the program (supply) side, surveys show that significant numbers of women are unaware of the location of the nearest subcenter or other facility or do not know that female health workers based at such facilities provide antenatal care. These surveys also indicate that the pro- portion of pregnant women contacted by fieldworkers is low, which helps explain the general lack of awareness. On the demand side. when women who had recently given birth but had not received any antenatal care were asked why they had not sought care, they overwhelmingly gave answers such as "did not feel the need" and "not customary" (MODE 1990). These results reinforce the findings of community-based studies, which suggest that antenatal care is often not considered necessary because pregnancy is not normally viewed as a condition requiring medical attention. ANEMIA PROPHYLAXIS. Appendix table 3.6 shows that only 51 percent of pregnant Indian women received iron and folic acid supplements in 1992-93. Although coverage was above 50 percent in most states, it was substantially lower in Uttar Pradesh (30 percent). Rajasthan (29 percent). and Bibar (21 percent). An evaluation by the Indian Council of Medical Research of the anemia prophylaxis program carried out in eleven states (MOHFw and UNICEF 1989) found that only 12 percent of the woren targeted reported that they were actually offered iron and folic acid supplements. which were distributed in tablet form. Of the women who were offered tablets. 4 percent refused them. Of those who accepted the tablets, 60 percent dropped out of the program, most of them (almost 80 percent) because further supplies were not available. Clearly, problems with supply and distribution have been severe, and given that two- thirds of the women appeared willing to take the supplement when it was offered, solving these problems would undoubtedly increase coverage. It is also safe to assume that fieldworkers would be more willing to distribute the tablets if a sufficient supply were available. HEALTH SERVICES AND HOW THEY ARE USED 81 It cannot be concluded from the study that the program's difficulties are limited to logistics, however. First, because many Indians believe that such tablets are strong and potentially dangerous, particularly for pregnant women, fieldworkers may be reluctant to distribute the supplement. Second, even if fieldworkers distribute the tablets. women may not actually take them. Third. the report compared the hemoglobin levels (an indicator of iron-deficiency anemia) of pregnant women who were receiving supplementation with the hemoglobin levels of those who were not and found that 88 percent of both groups were below acceptable levels. The mean hemoglobin level in women who took the supplement increased significantly over time: however, after 30 to 60 tablets. the level stabilized. Even after consumption of the complete course of therapy. the hemoglobin concentration, which started from very low initial levels. remained around 9.2 g/dl. well below the minimal acceptable level of II g/dl. The study found that the quality of the tablets was very poor. The content of folic acid in the supplements was well below the recommended level, while that of iron was below the recommended level in about 30 percent of the samples. DELIVERY. The number of deliveries that take place in institutions or are attended by trained providers remains low (figure 3.1). About one-quarter of deliveries in India occur in a public or private institution (appendix table 3.7). The majority of deliveries (74 percent) take place outside health facilities: around 35 percent are attended by dais and some 30 percent by other persons such as female relatives or neighbors. The proportion of deliveries attended by doctors is particularly low in states like Rajasthan (Il percent). Deliveries that take place in institutions are most likely to be attended by trained personnel. In public medical facilities. 67 percent of deliveries are attended by a doctor and 37 percent by a nurse-Iidwife. and in private institutions the proportions are even higher: 86 and 13 percent. respectively (lPS 1995). A significant proportion of obstetric emergency procedures require blood transfusions, which are not available on a timely basis in rural areas because of a scarcity of blood bank, and mandatory HIV testing requirements. Overall. most facilities that should provide referral services are insufficiently staffed and equipped to handle emergencies resulting from the complications of preg- nancy. Such services need to be in place on t 24-hour basis, since the most life- threatening situations, such as hemorrhage and obstructed labor, cannot be anticipated. Limited transport and poor roads contribute to the difficulty of accessing even inadequate facilities. Even where trained health staff and good health facilities exist, many women believe in traditional systems of health care delivery and feel no need to seek outside assistance (ORG 1990). Furthermore, many families do not want to 82 IMPROVING WOMEN'S HEALTH IN INDIA FIGURE 3.1 PROPORTION OF DELIVERIES ASSISTED BY HEALTH PROFESSIONAL, 1992-93 India Kerala Tamil Nadu Maharashtra Karnataka Andhra Pradesh Punjab Gujarat West Bengal Haryana Madhya Pradesh Rajasthan Orissa Bihar Uttar Pradesh 0 20 40 60 80 100 Percent Source. H1PS H995). incur the extra costs of a delivery in an institution when the birth can be conducted at home at minimal expense. This finding demonstrates the need for IEC and for services that are more readily accessible and affordable. POSTPARTUM COVERAGE. While few women receive adequate prenatal care, even fewer receive care after giving birth (IPs 1995: Mathai 1989). The same factors that constrain the delivery of antenatal care and institutional births also affect the delivery of postpartum care. Providing such care is made all the more difficult by the traditional practice of seclusion following a birth. Even among ANMs. the idea of postpartum care is not well understood, and postpartum visits are more likely to focus on family planning or immunizing the child than on the mother's health. HEALTH SERVICES AND HOW THEY ARE USED 83 Prevention and Management of Unwanted Pregnancy FAMILY PLANNING. Contraception is increasingly widely used in India. The percentage of married couples using modern methods of contraception rose from about 10 percent in 1970 to almost 40 percent in 1992-93. According to the National Family Health Survey carried out in 1992-93 (lips 1995). steriliza- tion is the predominant contraceptive method in use (figure 3.2). Variations across states in the use of modern contraceptive methods are substantial: utili- zation rates range from over 50 percent in Maharashtra and Punjab to only about 20 percent in Uttar Pradesh and Bihar (figure 3.3). The prevalence of female sterilization is the most striking aspect of contra- ceptive use in India. Few couples use reversible contraceptive methods.' Fe- male sterilization accounts for 27 percent of the 31 percent prevalence of sterilization. or almost nine-tenths. Program issues affecting this imbalance are discussed in chapter 4, but issues affecting demand are equally important. While virtually all married Indian women seem to know about female steriliza- tion. only 61 percent of married women of childbearing age know about IUDS and only 66 percent about oral contraceptives (IlPS 1995: see also appendix table 3.8). This lower level of awareness-and the gap between women's knowl- edge about and use of reversible methods-reflects the government's emphasis on sterilization. FIGURE 3.2 DISTRIBUTION OF USERS BY MODERN CONTRACEPTIVE METHOD, 1992-93 IUD (5%) Condoms (7%) Orals (3%) Sterilization (85%) . [IS ...u " 19) 84 IMPROVING WOMEN'S HEALTH IN INDIA FIGURE 3.3 CURRENT CONTRACEPTIVE PREVALENCE RATES, MODERN METHODS, INDIA AND MAJOR STATES, 1992-93 India Kerala Maharashtra Punjab Karnataka Gujarat Andhra Pradesh Tamil Nadu Haryana West Bengal Madhya Pradesh Orissa Rajasthan Bihar Uttar Pradesh 15 25 35 45 55 Percent Smme. [IPS (1995) Successive SUIVeYS undertaken since 1970 indicate a decline in unmet need, defined as the percentage of respondents at risk of pregnancy who report that they do not want additional children but who are not practicing contraception. The 1988 survey reported that unmet need stood at about 19 percent of all eligible couples (compared with 40 percent in 1970); half of these couples indicated that they had agreed to be sterilized soon (ORG 1990). Of the remain- der, the largest numbers indicated that they did not want to be sterilized because they feared the operation. State estimates of unmet need range from about 10 percent in Punjab and Maharashtra to about 26 percent in Uttar Pradesh. The National Family Health Survey estimated Unmet need in India at 20 percent in HEALTH SERVICES AND HOW THEY ARE USED 85 1992-93 (appendix table 3.9). The data also indicated that the unmet need for spacing births was slightly higher than that for limiting family size. While the data sources ma\ not be entirely comparable. both show significant levels of unmet need. MEDICAL TERMINATION OF PREGNANCY. After the legalization of induced abortion in India in 1971, the MOHFW made a systematic effort to train doctors. provide equipment, and approve facilities where procedures could be carried out. The number ot approved institutions increased steadily, and by 1990 there were more than 6.000. However, the number of procedures (fewer than 600.000 annually) carried out in approved facilities has remained almost constant since 1985 (MOHf;w 1992). The incidence of illegal procedures, by contrast, appears to be increasing. At least twice as many illegal as legal abortions occur through- out India. and the incidence of illegal procedures may be as much as ten times that of legal abortions. Indigenous practitioners, particularly dais, perform more abortions than qualified personnel in the public and private sectors combined (Kerrigan. Gaffikin, and Magarick 1995: Chhabra and Nuna 1994). The worldwide shift from sharp curettage to vacuum aspiration for treat- ment of incomplete abortion and termination of pregnancy during the first trimester has improved the cost-effectiveness, safety. and accessibility of the procedure (Kerrigan. Gaffikin, and Magarick 1995). This shift has been under way since the 1980s, although there have been lags in the provision of equip- ment, and many doctors still use curettage. Furthermore, in many countries. vacuum aspiration is safely practiced by trained paramedics, particularly in areas where physicians are in short supply. In India, however, the legislation regulating abortion restricts the procedure to registered medical practitioners. � �. � � � т � �� � ' , � � �� ��'. _ . ._ ,,,,,... ��,.� .�; �"�`� � ,.�,� � �� йf � �� � ` , ,й � ���s • � С� � �� � д�. � . '.+ .,х+вi.у4 ` '" FFF� . "-°�+т ' � ыv.. �� ��� • .. :�� � Г� �� * _ :�.�r ' ц� �� ��, �� � �-�,.i..511�ыTO� �м., �����. s � � . }' г ? � {э . . .л.вУ."' ,.. , �.л� w. �п, ���.. ,. ....,. ...г .. , , •- , C H A P T E R F 0 U R Strategies for Change improvin g wornen's lives-and improving their lives means irnprov- ing their health-requires a strong and sustained government commitment, a favorable policy environment, and well-targeted resources. As part of its strat- egy, the government must seek to balance the roles ofthe public and private sectors. The public sector plays a crucial role in financing and providing essen- tial services for wornen, since some of these services have characteristics of public goods and, in particular, provide positive externalities. I In the absence of public financing, many of these essential services would not be adequately provided or might not be provided at all. Furthermore, subsidized services for poor wornen are necessary if health care resources are to be equitably distrib- uted. However, not all health services-even those that are publicly funded- need to be provided by the state. The challenge for the government is to rnaxi- mize the reach and breadth of private sector reproductive health services and to improve their quality, using appropriate incentives and regulatory arrange- ments. Mechanisms need to be explored that will encourage a shift from the private sector's current focus on curative care to a broader approach that in- cludes promoting preventive care. This concluding chapter identifies a set of issues that are both directly and indirectly related to improving the health of Indian women and girls. The discussion and recommendations that follow are intended to provide a basis for further consideration of the issues and to help in setting priorities for future 87 88 IMPROVING WOMEN'S HEALTH IN INDIA World Bank assistance. As indicated in the Preface. this report focuses on improving the health of Indian women and girls through public and private health care and related services. Long-term improvements in education and employment opportunities for women will have a positive impact on the health of Indian women and their children. In the short term, significant improve- ments can be expected as existing health care services for women are strength- ened and expanded to meet specific needs. These incremental investments are justifiable because they will reduce the burden of disease and the associated costs, including productivity losses. The most cost-effective interventions in the health sector are those that improve the health of children and of women of reproductive age. Both demand- and supply-side factors discourage and sometimes prevent women from utilizing health services, and both must be taken into account in planning health care initiatives for women. Demand-side factors include not knowing which organizations offer services or where treatment can be ob- tained, a lack of knowledge of the benefits services can provide (caused in part by women's low educational level and in part by the way modern health care is viewed), inability to pay, and the need to obtain permission to receive care. Supply-side issues involve the quality of health care services and the accessibil- ity of health centers and hospitals. For analytical and planning purposes, the distinction between supply and demand factors is useful. However, it is important to recognize that in the final analysis, the division between the "supply" of services and the "demand" for them is artificial. Successful family welfare, health, and nutrition projects, whether undertaken by the government or the private sectors, have proved many times over that high-quality services provided by workers who have the confidence of the communities in which they work generate their own demand (Bhatia and others 1995: Griffiths, Lynn, and Breins 1991, Murthy 1991). This finding has been demonstrated for small-scale projects and much larger initia- tives such as the Tamil Nadu nutrition and West Bengal family welfare projects supported by the World Bank, which returned highly positive results. The following sections recommend program strategies for providing ser- vices, increasing demand for public and private modern services, and establish- ing priorities for research, including "action research" in areas essential to women's health. Program Strategies for Providing Services Since 1974. when the government of India's Report on the Status of Wonen first drew public attention to the adverse circumstances of Indian women, the 2overnment has taken a number of significant positive steps. These include STRATEGIES FOR CHANGE 89 establishing the Department of Women and Child Development, in 1986. and, in 1992, initiating the Safe Motherhood Program to expand and strengthen maternal health services. The government has also expressed its strong support for the Program of Action developed at the 1994 United Nations Conference on Population and Development in Cairo, which calls for a client-centered ap- proach to reproductive health and family planning. To further its support for women and improve reproductive health and women's access to adequate health care, the Indian government needs to put in place a number of policy and implementation measures to strengthen the existing Family Welfare and Inte- grated Child Development Services (ICDS) programs. These measures are iden- tified in the following sections. Family Welar Program The Family Welfare Program is specifically responsible for providing family planning and health services to women and children. This section covers three general areas that should be the focus of efforts to improve girls' and women's health: policy, the strengthening of existing services. and the provision of additional services. It identifies two areas of particular importance in planning new services: non-pregnancy-related female morbidity such as reproductive tract infections-a serious problem that is largely unrecognized-and maternal mortality, which is very high in India. PoucY. The following policy areas need special consideration; many of them involve programs that are already in operation. M Regionil emphasis. For reasons of equity and administrative convenience, central government support for state Family Welfare Programs is calculated in terms of population norms. However, the demographic and epidemiological evidence (chapter I ). the underlying sociocultural constraints (chapter 2). and the experience with program implementation (chapter 3) all make it apparent that additional resources must be channeled to the states on the additional criteria of financial need and performance in implementing the new reproductive health approach. This is necessary in order to accelerate progress and reduce the north-south differentials in fertility, mortality, and services. as well as to pro- mote and build on effective performance. Special efforts to meet requirements for facilities and staff, increase the number of women facilities reach, and make sustainable improvements in the quality of services are all indicated. Similarly. communications efforts aimed at increasing the demand for services should be concentrated primarily in tie north, while the current favorable trends in de- mand in some of the southern states should be maintained and expanded. 90 IMPROVING WOMEN'S HEALTH IN INDIA E Program targets and monitoring. Since the early 1980s, the family planning program has helped the country move toward the government's demographic objective of lowering fertility. Progress has been achieved predominantly by reducing family size through female sterilization. Little effort has been made to encourage and enable couples to delay and space births. The MOHFW is aware of this problem and for some years has issued policy statements emphasizing the importance of temporary contraceptive methods as well as of maternal and child health services. Until recently, the program's target and monitoring sys- tems, which together have driven the sterilization component, have proved difficult to modify. However, in 1995 some states began to phase out the targets, and in April 1996 the government announced that all districts are released from the contraceptive target system. This positive development cre- ates the basis for developing and agreeing on new indicators of program perfor- mance and for shifting the emphasis of the program to a client-centered ap- proach to meeting couples' reproductive health needs. States are engaging in a "bottom-up" planning exercise, starting with plans developed by each block, and followed by district and state plans, to be ready by mid- 1996. IMPROVING EXISTING SERVICES. India's rural health infrastructure, includ- ing the subcenter outreach system, is largely in place, but implementation problems have been well documented (Measham and Heaver 1996: World Bank 1994c: Satia and Jejeebhoy 1991). The range of services is limited, the services offered do not necessarily meet standards of quality, and worker productivity and thus coverage levels for key services are low. It is unrealistic to expect that additional health programs for women will have any substantial impact unless the health system on which the new services will be based is strengthened and the quality of existing services improved. Issues concerning program manage- ment and the delivery of key services are described below and are linked to a series of options and recommendations for strengthening existing services. 0 Integrating family planning and maternal and child health services. Inte- gration of the family planning and maternal and child health programs was mandated in the mid-I 970s but has not been completed. A division of labor has evolved: sterilizations have been concentrated in the winter months (Decem- ber-March). leaving the rest of the year relatively free for other activities, principally immunization of children. This division is now being eliminated, and family planning services are being developed and implemented as part of an integrated cycle of maternal and associated child health services that begins when a pregnancy is identified and continues with child health care and family planning counseling after the delivery (appendix table 4.1). Because of women's limited financial resources and time and their varying needs, it is important that STRATEGIES FOR CHANGE 91 health care delivery sites be conveniently located and provide as much choice as possible in both integrated and specialized services. U Prioritization and work routines. The introduction of the Safe Motherhood Program and the expansion of child survival interventions under the Eighth Five-Year Plan place additional responsibilities on fieldworkers and highlight the importance of developing work routines that significantly increase worker productivity. For example, work rules that direct ANMS to visit every house- hold, offering a wide range of services, should be replaced with rationalized work routines based on prioritized activities and clients. 0 Training. Assessments of training needs for Family Welfare Program staff have consistently documented gaps in workers' technical knowledge and skills. This finding underscores the importance of practical, hands-on, pre-service and in-service training by competent trainers using high-quality materials. A major reason that temporary family planning methods are not widely used at present is that ANMs lack the requisite motivation, technical skills, and knowledge. For example, if ANMs are to insert intrauterine devices (lUDs), they require careful clinical training, including hands-on experience, as well as knowledge and communications skills to inform women of potential side effects. In addition, expansion of reproductive services will require staff that is specially trained in maternal care, particularly in handling obstetric complications, and in diagno- sis and treatment of reproductive tract infections. There is a particularly acute shortage of female obstetricians and gynecologists, anesthesiologists, and labo- ratory technicians. Training is also the key to conveying to all staff techniques or technologies that can improve the quality of care and to teaching the commu- nication skills essential for effective worker-client interaction. The technical competence of staff needs to be periodically assessed to ensure that the training is achieving its goals and that workers are in fact able to carry out the tasks assigned to them. 0 Traditional birth attendants. In rural areas where women do not yet have access to appropriate facilities and health personnel, well-trained and super- vised TBAs, or dais, can help improve pregnancy and childbirth outcomes as an immediate measure, although with limited effectiveness. Because such a large percentage of deliveries in rural India takes place at home-a situation chang- ing, but slowly-the government has been providing intensive training to dais. Assessments have shown that the results have not been very encouraging. Because of insufficient training, poor supervision, and pressure from older female household members, the dais did not always utilize the procedures they had been taught: many who received training did not practice at all. There was 92 IMPROVING WOMEN'S HEALTH IN INDIA no follow-up training, the kits provided at the conclusion of the training were not replaced regularly, and difficulties often arose in paying the women the small amount they were to receive for each delivery. Significantly, it appears that the broader community did not understand that certain dais had received training and could therefore be called on for help during deliveries (Jeffery, Jeffer\', and Lyon 1988). This lack of awareness stemmed in part from the dais' unwillingness to be identified with the family planning program-another indi- cation of the importance of changing the program's image. Until recently the program was also burdened by the unrealistic expectation that dais would be able to provide a broader range of services- In fact, even the best dais are unable to manage serious complications of pregnancy, which require medical skills and equipment beyond their capacity. Maternal and child health projects sponsored by the Indian Council of Medical Research (Murthy 1991) and the results of the pilot phase of the Intensified Training of Dais Program (ITDP) in eleven districts (Mathai 1991) indicate that properly selected, trained, motivated, and supervised dais are effective in providing and promoting antenatal care, attending routine deliver- ies, and providing counseling in family planning after the birth. The essential aspects of successful training for dais are selecting motivated participants. offering consistent follow-ups to the initial training, and providing adequate supervision. (Details of the ITDP are given in chapter 3.) The ITDP needs to focus its efforts on the northern states, where the fewest women receive antenatal care and deliveries more often proceed without trained attendants. Greater emphasis should be placed on training dais to identify women with problem pregnancies and obstetric complications and to refer these women to higher levels of the system, where they can be effectively managed. 0 Protecting at-riskfemale children. The data on female mortality, morbidity. nutritional status, and health service coverage presented in chapters 2 and 3 indicate that young Indian females are particularly at risk of receiving inad- equate health care and nutrition. Moreover, data indicate that the gap between male and female child mortality has widened in recent years (see figure 1.3). Family Welfare and (CDS fieldworkers are in a unique position to identify at- risk female children and to intervene directly (by providing health care and supplenentarV nutrition) and indirectly (by serving as advocates and counse- lors of mothers and other household members). Improvements in female edui- cation will be necessary to reduce gender bias over the long run. Nevertheless, fieldworkers can be trained and encouraged to take an active role in identifying and targeting these at-risk females in order to reverse the current disturbing trends in male/female mortality ratios. ANMs and anganwadi workers need to be alerted to the dimensions and implications of gender bias and mortality trends STRATEGIES FOR CHANGE 93 for young females and to receive support in their efforts to provide effective interventions. 0 Anfenamal care and attendel deliverY. As earlier chapters have made clear, existing antenatal coverage levels are low, and in many areas the quality of services is poor. The first step in improving antenatal coverage is the early identification of pregnant women. However, even if local antenatal services are available and workers have identified pregnant women, the prevalent belief that pregnancy and childbirth do not normally require medical attention may keep women from using the services (see chapter 2). If women do not use the services, workers cannot identify problem pregnancies and potential obstetric complications in time to prevent emergencies. Part of the problem is that the idea of "pregnancy entitlement"-meaning that for the sake of her own and her baby's health a pregnant woman needs rest, extra food. and medical attention for any illness or complication even if it does not appear to be related to her pregnancy-is virtually unknown in India. Even if the pregnant woman accepts this idea. other members of the household may not, reducing the chances that the woman will obtain antenatal care and that a trained attendant will be present at the birth. Conveying the "safe motherhood" message to pregnant women and their families is essential if maternal mortality and morbidity are to be reduced. Women need to be convinced of the benefits of antenatal care and of pregnancy entitlement. It is also important to emphasize the necessity of having a trained attendant at the birth and access to reliable emergency services. The pregnant woman herself and her household. particularly her mother-in-law, other older women, and men, are the principal target audiences for these messages. As many health care providers and community audiences as possible should be included in these outreach efforts. The attitudes of male field workers (male multi- purpose workers. community health volunteers, and traditional and local medical practitioners) are also influential and should be taken into account in communi- cations skills trainin . 0 Anemia p-evcntiotn and contra. Iron-deficiency anemia, which is wide- spread anmong women in India. ranks among the top direct and indirect causes of maternal mortality and morbidity (see chapter I ). However, the present program. launched in 1970, which seeks to prevent anemia in pregnant and lactating women through the distribution of iron and folic acid (IFA) tablets. needs to be strengthened. According to the National Family Health Survey (NFHS), only 51 percent of mothers received IFA tablets through the program (lPS 1995). The primary reason for this poor outcome is a weak logistics and distribution system. Other problems that need to be addressed include compli- 94 IMPROVING WOMEN'S HEALTH IN INDIA ance in taking the tablets, the quality of the tablets offered, and the program's overall focus, which has been on prevention rather than on both prevention and treatment. The government has initiated a more comprehensive approach to anemia control that includes providing simultaneous deworming treatment in areas where worm infestation is severe enough to negate the effects of supplementa- tion; addressing othercauses, such as malaria. that could hinder the supplement's effectiveness: increasing the dosage of IFA; and, in extreme cases, giving iron intravenously to women diagnosed with severe anemia. The practicality and effectiveness of these approaches under current circumstances in India need to be evaluated. Given the importance of anemia prevention and control to Indian women, this area should be a priority of operational research in women's health. Anemia in adolescent girls should also be recognized and given appro- priate attention. Additional approaches to providing iron supplements could include community-based distribution, distribution through traditional practi- tioners, and the promotion of fortified foods, green leafy vegetables, and other iron-rich foods. 0 Temporary conttraceptive methods. India cannot fully achieve its population and health objectives until the full range of contraceptive choices is available and Indian women are permitted to control the spacing and timing of pregnan- cies. Currently. female sterilization is the most readily available method. Only about 3 percent of women in their reproductive years use either 1UDs or oral contraceptives (liPs 1995). Three major difficulties have constrained the use of temporary contraception in India. First, there is ample evidence that ANMs have not encouraged couples to use temporary methods, not only because workers are under pressure to meet preset sterilization targets but also because they are not confident about their ability to clearly explain and deal with technical issues such as potential side effects. Second. public education has focused on motivat- ing women to seek sterilization. Third. it has proved difficult to ensure suffi- cient supplies at health facility and community levels. Achieving sustained increases in the acceptance and the continued use of temporary contraceptive methods will require a variety of new approaches: modifying program targets; expanding the variety of contraceptive methods available; improving the clinical and interpersonal skills of program staff: pro- moting wider availability of oral contraceptives and condoms through public programs, social marketing, and commercial channels; and ensuring that couples who choose temporary methods receive appropriate follow-up services. In ad- dition, the suspicion that oral contraceptives are not safe, which is widespread in the Indian medical community, needs to be addressed. Expanding the number of contraceptive methods available in India would attract new users and increase contraceptive prevalence rates. For example, STRATEGIES FOR CHANGE 95 progestin-only oral contraceptives, which do not interfere with breastfeeding, could be an appropriate choice for new mothers. Injections are culturally well accepted in India, and it is generally agreed that an injectable contraceptive would find ready acceptance. However, proposals to make injectable contra- ceptives and, more recently, Norplant available through the government Fam- ily Welfare Program have aroused the opposition of India's feminist movement because of concerns that these contraceptives could be provided under false pretenses. A special effort by the MOHFW to engage women's advocacy groups in a dialogue concerning these methods is important to this issue. M Medical termination of pregnancv. The number of legal medical procedures to terminate pregnancy has leveled off in recent years, while the proportion of illegal and unsafe locally performed procedures appears to have escalated. It is clear that medical terminations performed by qualified personnel, which are often performed at facilities distant from women's homes and may be prohibi- tively expensive, are competing with more convenient, less expensive alterna- tives performed locally, which many believe are less dangerous for women than surgical techniques. The constraints involved in delivering medical termi- nations suggest that increasing the number of procedures performed at public sector facilities will require an increase in the number of approved facilities. improvements in the quality of services provided, and public education. De- volving authority from specialists and training a wider range of health provid- ers to perform terminations in the first trimester can also make these services more available, to spare women the complications and deaths associated with unsafe practices, particularly in rural areas. The complications of unsafe abor- tions should be promptly referred and treated. The high levels of abortion in India underscore the need to make contraceptives more widely available so that women can avoid unwanted pregnancies in the first place. PROVIDING ADDITIONAL SERVICES. Existing health services are inadequate to meet women's needs in the key areas of non-pregnancy-related morbidity and maternal mortality. 0 Non-pregnancy-related morbidity. At present, both the Family Welfare and ICDS programs include services for pregnant and, to some extent, lactating women. Neither program addresses women's special health needs beyond those directly associated with pregnancy and childbearing. Although data on non- pregnancy-related morbidity are limited, the existing evidence is sufficient to indicate that women's needs in this area are extensive. Diarrheal diseases, respiratory infections. malnutrition, intestinal parasites, malaria, tuberculosis, and reproductive tract infections, which make up a large proportion of the disease burden, are amenable to cost-effective prevention and treatment. A 96 IMPROVING WOMEN'S HEALTH IN INDIA more socially aware health system could help create conditions that would make these services more accessible and acceptable to women. The prevalence of reproductive tract infections and other gynecological disorders is very high and results in a greater disease burden for women than for men (see Murray and Lopez forthcoming, and chapter I). However. women tend to ignore such ailments, seeking neither diagnosis or treatment unless the problem becomes disabling. Gynecological morbidity is thus particularly diffi- cult to deal with; it is so common that women do not perceive it as important or urgent. Yet women are vulnerable during most of their life span; for example. reproductive tract infections can be caused by unsanitary practices during men- strUation. and cervical cancer occurs most often after the childbearing years. The emergence of HIV/AIDS makes preventing and treating STDs even more important. Gynecological morbidity is also directly linked to fertility (particu- larly to secondary sterility) and infant health and should therefore be of direct concern to the Family Welfare Program. To incorporate the diagnosis and treatment of non-pregnancy-related fe- male morbidity into Family Welfare services. fieldworkers will have to be trained, laboratory diagnostic capabilities upgraded. and public education ef- forts accelerated. ANMs need to be trained to recognize gynecological problems and to distinguish between those they can treat and those that should be referred to a specialist. At a minimum, they should be trained to identify symptoms and screen women at particular risk for STos before inserting LIDs. Wherever pos- sible, pregnant women should be tested for syphilis. and treatment provided. Primary health center doctors with no background in the field should also be trained to diagnose and treat basic gynecological problems. The greatest chal- lenge, however, will be to develop approaches to communicating information and providing education that ANMs, other program staff, and any community group or spokesperson can use to encourace women to recognize symptoms of gynecological problems and to seek treatment. Men should also be made aware of the seriousness of STos and urged to seek preventive and therapeutic action when they themselves are infected. Given the high incidence of gynecological morbidity. development of approaches to making the diagnosis and treatment of such conditions an integral part of Family Welfare services should become a priority area of operational research in women's health. N Maternal mortalitv. The existing health system is not able to meet the needs of pregnant women. especially when a pregnancy is complicated, or to cope with obstetrical emergencies dlring labor and delivery. Three major gaps in the system hinder the provision of essential obstetric care: absence of links be- tween commIunities. subcenters, and referral facilities; lack of equipment and STRATEGIES FOR CHANGE 97 trained staff at referral facilities; and lack of emergency transport. To signifi- candy reduce maternal mortality, all three of these constraints must be addressed. 1. Absence of links. There are currently no effective linkages among the various levels of the health system to facilitate patient referral and the exchange of information. Developing a fully functioning referral system whereby pa- tients identified by Family Welfare orICDS fieldworkers can be readily referred to an appropriate facility for proper treatment is a long-term. but essential, undertaking. During the current phase of implementing the Safe Motherhood Program. it is important to identify and deal with problems in referring women and providing a "continuum of care" and to draw on this experience as the program is expanded. 2. Shortcomings of referral ficilities. The facilities in the referral chain (primary health centers, community health centers. and subdistrict and district hospitals) in many cases do not have the equipment, facilities, or trained staff to deal with obstetric complications. The gap in facilities is greatest for the com- munity health centers. which should be providing first-referral services for women with obstetric complications. A representative sample of districts and municipalities in four major states found that only 22 percent of required com- munity health centers were in place (World Bank 1995). The Safe Motherhood Program is addressing the need to improve the physi- cal condition of referral facilities and to equip and staff them properly. Experi- ence indicates that, given adequate resources under the Eighth Five-Year Plan to provide services such as major surgery, the facilities are likely to achieve the expected physical improvements. However, a practical and safe approach to making blood available for transfusions is still lacking. Recruiting and retain- ing specialists at community health centers and rural hospitals involves its own set of problems. The government needs to expand training for public sector specialists in order to ensure that the referral facilities have the staff they need to provide essential obstetric care at referral facilities. Training existing staff to perform some of the functions of specialists and contracting with private pro- viders for some services are additional options that should be considered. 3. A lack of emergency transport. There are no systematic arrangements for transporting emergency cases from rural areas to referral facilities. No single solution will resolve this problem. since conditions vary across regions and localities and strategies need to be adapted to such variables as available resources, distances between sites, and terrain. One proposed approach in- volves drawing on the increasing number of motorized vehicles in rural India, including three-wheeled vehicles and tractors. While borrowing vehicles, even for emergency purposes. is not feasible, it may be possible to persuade local 98 IMPROVING WOMEN'S HEALTH IN INDIA residents to offer their vehicles in an obstetrical emergency by providing reim- bursement for fuel and mileage. Similarly, it may be possible to involve the locally elected panchavats in planning community- based transport. Opera- tional research projects to assess the practicality, effectiveness, and cost of such measures, as well as the available financing options (such as establishing emergency transport funds at referral facilities), should be undertaken. If the emergency transport funds or other approaches are judged to be effective and replicable, they should be implemented and expanded as rapidly as possible. The Integrated Child Development Services Program The ICDS Program, described in chapter 3. has many of the same kinds of difficulties as the Family Welfare Program and other social sector initiatives in India. These programs lack effective and supportive supervision, and pre- service and in-service training is of mixed quality. ICDS program evaluation studies have indicated that the components of the program relating to women tend to be neglected in comparison with services for children. Furthermore, the program would benefit from a more client-centered monitoring and evaluation system. Thus far, the program has tended to focus on process (such as the number of feeding days) rather than on impact (for instance, the proportion of the target population successfully treated). In particular, coverage of pregnant and lactating women under the ICDS supplementary feeding component is gen- erally quite low. IN-SERVICE TRAINING. The relatively poor record of the women's compo- nents of the ICDS Program suggests that anganwadi workers and their supervi- sors need improved training in this area. These workers need a better under- standing of the essential package of antenatal services, even if they themselves do not perform the tests and procedures. They also need to be comfortable with "priority messages" they are asked to deliver on the importance of antenatal care, diet, and rest and of having a trained attendant at the delivery. A special ICDS project carried out in Gujarat and Maharashtra indicated that after com- pleting an in-service training program emphasizing both the technical and communication aspects of their duties, anganwadi workers acknowledged that educating women was part of their job and had enough confidence in their skills to be effective educators (Griffiths, Lynn. and Brems 1991). NUTRITIONAL SUPPLEMENTATION FOR WOMEN. Nutritional supplementa- tion for pregnant and lactating women is one of the most significant contribu- tions the ICDS Program can make to improving women's health in India. How- ever. supplementary feeding for adult women has proved far more difficult STRATEGIES FOR CHANGE 99 than for children, both because it is often considered inappropriate for women to consume food in public and because it has been difficult to identify a food that women will consume readily. There may also be regional variation in the type of supplementary food that is acceptable. Given the high prevalence of malnutrition among Indian women and the serious consequences for mother and child of inadequate weight gain during pregnancy. developing successful ways of providing nutritional supplementation to malnourished pregnant and lactating women and increasing awareness of nutritional needs during preg- nancy are priority areas for operational research in women's health. The type of supplement, its composition, and alternatives for delivering it all need to be explored. NUTRITIONAL SUPPLEMENTATION FOR CHILDREN. Since its inception, the ICDS Program has been expanded gradually and priority given to disadvantaged areas. Within areas covered by the program. malnourished children are, in principle, targeted for supplementary feeding. In practice, however, there are serious gaps in the program. One problem is that the program has not suffi- ciently targeted children under 3 years of age. A much higher percentage of children ages 3-6 receive food than do children in the more vulnerable under- 3 age group, in part because younger children cannot come to the anganwadi centers by themselves. A study in two districts in Gujarat and Maharashtra found that supplementary nutrition failed to reach nearly half of the severely malnourished children 3 years and under (Maharaja Sayajirao University of Baroda 1989). Since a disproportionate share of such children are often female, the ICDS Program's failure to target malnourished children individually has unfavorable consequences for young girls. Targeting individual malnourished children-in particular, females-for supplementary feeding will help com- pensate for the disadvantage these children suffer at home. ADOLESCENT GIRLS. The importance of improving adolescent girls' knowl- edge of health care services and nutrition before the girls marry and begin their childbearing careers is being increasingly recognized. The ICDS Program has begun to implement interventions to reach girls in this age group and to link them with anganwadi activities. A scheme currently under way in some ICDS blocks involves selecting three girls to assist the anganwadi worker for two days a week and to act as a link between the center and village households; the girls also receive a daily food supplement similar to that for pregnant and lactating women. However, because the number of adolescent girls who can be included in the ICDS program is limited, other channels for reaching adolescent girls, including schools, also need to be explored. The effectiveness of these approaches should be evaluated to guide further action. 100 IMPROVING WOMEN'S HEALTH IN INDIA Coordinating Services There is substantial complementarity in both the target beneficiaries of and the services provided under the Family Welfare and ICDS programs. In terms of maternal health, the programs have common objectives, including the identifi- cation of pregnant women and high-risk pregnancies, the provision of tetanus toxoid immunization and antenatal and postpartum care, and the improvement of anemia prophylaxis for pregnant and lactating women. Because of the causal relationship between illness and nutrition, health services are key to achieving the nutritional goals of the ICDS. Coordination between the Family Welfare and ICDS programs at the field level has improved in recent years, in large measure because staff from both programs have been involved in the universal immunization program. The ICDS Program has taken a number of steps to improve linkages with the health system (see chapter 3). In February 1991. the relevant ministries issued orders regarding "areas of coordination" to demonstrate to the staff of both programs that cooperation is a serious concern at the highest levels. However. modifying existing field practices requires more than formal orders. Measures to improve cooperation between these two important programs have been suggested in the following five areas: planning, work routines, supervision, informal training and curricula for formal training (World Bank 199 1b). Increased coordination between ANNis and anganwadi workers at the field level is essential if improvements are to be made in the efficiency, effective- ness, and coverage of health services for Indian women and their children, especially young females. Current standards make an ANM responsible for a population of 5,000 or more-at current fertility levels, from 150 to 180 births a year, or about one birth every other day. Moreover, in most cases the subcenter area includes several villages, only one of which can have a resident ANM. Given her maternal care caseload, her other extensive responsibilities, and the typically difficult logistics, the ANM needs to be able to draw on the help of a local "team" to develop community links and provide adequate services to the largest number of women. This team should include anganwadi workers in the ICDS blocks, trained dais, female community health volunteers or village health guides (if they are available), and the subcenter ANNI. The anganwadi worker has several advantages: she is resident and works in her own community, is responsible for covering only about one-fifth of the population assigned to an ANM. and is in daily contact with village mothers at the anganwadi center or through home visits. Consequently, she is in a better position than the ANM, particularly if the ANM is not resident in the village. to learn about newly pregnant women or to identify young female children whose growth may be faltering or whose illnesses are not being treated. Coordination STRATEGIES FOR CHANGE 101 between the two types of workers has begun to increase, and this development should enhance the chance that cases (such as problem pregnancies) which require attention beyond what the anganwadi worker can provide will receive appropriate treatment by the ANM or referral to a higher level of care. Similarly, an anganwadi worker can carry out certain routine activities that would other- wise fall to the ANM, such as distributing iron tablets and monitoring compli- ance with the program, permitting the ANM to make more profitable use of her time. Meeting Clients' Needs The government can take several steps to meet women's health needs, in addi- tion to strengthening services. Through legislation, legal enforcement, and information, education, and communication (IEC). harmful practices such as domestic violence and discrimination can be curbed. Working closely with civil society, particularly NGOs and women's groups, will make services more responsive to women and improve utilization and impact. Information, Education, and Communication If demand is to be effectively created or enhanced, IEC strategies must be consonant with the perspectives of the community. Therefore, careful qualita- tive research will be needed as a basis for designing messages to convey knowl- edge and modify behavior. Mass and interpersonal media should be used to improve knowledge and practices related to contraception, safe sex, safe moth- erhood, nutrition. HIV/AIDS prevention, and intrahousehold relationships. The importance of promoting demand for services is recognized in both the Family Welfare and ICDS programs, primarily through support of IEC activities. Television (which is spreading rapidly in India) should be used actively to convey information about health services and reinforce the messages provided by health staff. Female fieldworkers who are in daily contact with women are another key source of information about health, particularly in rural areas. Strategies aimed at ensuring that much-needed information reaches women should emphasize interpersonal communication, and both the Family Welfare and ICDS programs should give high priority to communication training for fieldworkers. Specifically. JEC strategies and fieldworker training are needed to: m Develop approaches to working effectively with households where the status of girls is particularly low 102 IMPROVING WOMEN'S HEALTH IN INDIA 0 Communicate the benefits of antenatal care and pregnancy entitlement, as well as the importance of family members and TBAs being able to recognize complications and facilitate referrals 0 Develop a specific identity for "safe motherhood" that emphasizes the trag- edy and preventability of maternal death N Understand the knowledge. attitudes, and practices of target audiences and address systemic and cultural constraints oil the use of services such as tempo- rary contraceptive methods and vasectomies Conduct an ongoing dialogue with women's groups to involve them in plan- ning and to address their concerns 0 Inform women about the health risks associated with traditional methods of abortion and recommend safe, legal practices and postabortion family planning Encourage men to share responsibility for family planning and reproductive and women's health (see box 4.1) 0 Teach women and their families to recognize symptoms of gynecological problems and other conditions that can be prevented or treated cost-effectively and to understand the importance of seeking medical attention. Efforts in these and related areas must be undertaken locally. The discussion of the sociocultural context of health in India in chapter 2 describes the basic beliefs, customs, and social circumstances that communications efforts need to take into account. However, regional and local variations must always be ex- pected-a reality that strongly supports a division of labor between central (national) and state initiatives based on decentralized planning and materials development. Since many Indian states are larger than most of the world's countries, even state-level generalizations can be unreliable, but central minis- tries can provide invaluable support by acting as a clearinghouse to document. store, and make available information on the communication efforts through- out India. Two aspects of effective communication that are particularly important should be given special consideration in planning training for fieldworkers: personal attitudes and beliefs, and the importance of two-way communication. Fieldworkers will be able to function more effectively if they can discuss their own beliefs and keep an open mind about the messages they need to communi- cate. They also need training in how to deal with situations in which the advice STRATEGIES FOR CHANGE 103 BOX 4.1 MALE INVOLVEMENT Reaching boys at a young age through school-based and mass me- Most reproductive health programs dia programs can be particularly ef- administered by the Indian government fective in shaping later attitudes and have neither included men as a target practices. Programs directed to boys audience forlEc activities nor promoted and men are needed to promote con- their involvement in reproductive health traceptive use and safe sex, increase or family planning programs (Pachauri awareness of women's health prob- 1995). However, men's dominance in lems, decrease gender bias, and re- interpersonal and household relation- duce violent behavior. For example, ships makes them key decisionmakers both male and female multipurpose in reproductive health matters. Efforts workers can play a larger role in pro- to improve women's health status must viding IEc to males. therefore include initiatives oriented to men. they wish to give conflicts with the views of their clients or other household members. In such situations, an understanding that communication is a two- way process is crucial. The goal of the training in "communication" that fieldworkers presently receive is to convey their "modern and correct knowl- edge" to the village community-in other words, to "educate" the women who are their clients. Fieldworkers are not expected to interact with local women to elicit their ideas about their situation or needs. The need for training in this type of interchange is clearly demonstrated when fieldworkers are asked why rural households are slow to accept family planning and modern health practices. The workers' answers make repeated references to the "illiteracy" and "super- stitious beliefs" of the villagers. Communication can also be understood as a two-way process in which participants learn from each other. Workers know that the services they provide have the potential to improve the health of women and children in the commu- nity. The women know why services may be unacceptable, dangerous, or unavailable. When both sides can share their knowledge and reach a common ground, the demand for services will increase, and the effectiveness of the care provided will improve. Enabling workers to acquire the requisite orientation and skills is a formidable challenge; it is difficult enough to train workers to be effective communicators in the traditional didactic sense. However, there has been some experience in moving toward two-way communication. This ap- proach, which is discussed in the section on NGOs that follows, should continue to be explored. 104 IMPROVING WOMEN'S HEALTH IN INDIA Private Sector Involvement A challenge for the Indian government is to strengthen the complementarity of the public and private sectors to expand the reach and increase the quality of cost-effective health services for women and their families. The for-profit pro- viders can complement government services by delivering essential services to those who can afford them and offering a broader array of health care options. Several steps can be taken to increase the private sector role in improving women's health. The involvement of both the nonprofit and the for-profit private sectors in preventive and promotional activities can be encouraged through training and subsidies for private practitioners who provide essential women's health services, subsidized commercial marketing (for example, niak- ing condoms and iron tablets available through pharmacies and other retail outlets), and incentives for employment-related insurance policies that include key preventive services. The MOHFW has recently taken steps to expand support for NGO participa- tion in the Family Welfare Program. NGOs bring to the program particular advantages: they can be flexible, responsive to local needs, and innovative. They can also design and implement projects whose objectives and compo- nents cut across sectors and therefore address broader development concerns. A woman's development project, for instance, might include nutritional supple- mentation, adult literacy classes, environmental sanitation projects, and income generation schemes. as well as health and family welfare services. A single government department would find implementing such a project difficult at best. It is therefore recommended that the MOHFW support intersectoral projects that include but are not limited to women's health components, even when these projects are implemented outside the public sector framework. NGOs' input into the training of government staff should be encouraged to the fullest extent possible. NGos have invaluable field experience in success- fully delivering services and, particularly, in communicating with clients. For this reason, every effort should be made to involve NGO staff and to draw on the experience of these organizations in planning training programs for govern- ment workers. A promising example of the type of contribution NGOs can make to the training program for government health services and field staff involves an approach to rural development called participatory rural appraisal (Heaver 1991), which several NGOs are adapting for use in the health and nutrition sectors. The concept, which aims at promoting local participation in initiatives to identify and resolve local problems. has been applied in a wide range of sectors and several dozen countries in recent years. Participatory rural appraisal is an example of an empowering approach to development that can be success- fully implemented by an effective NGO with dedicated workers and good rap- STRATEGIES FOR CHANGE 105 port. Implementing this concept may be more difficult in public sector pro- grams. However, it is possible that the staff of NGOs that have had successful experience using this approach-and, in particular, that have the two-way com- munication skills it emphasizes-could incorporate training in these skills into in-service training for government workers. Such skills would greatly enhance fieldworkers' ability to draw out community members, learn how health and nutrition problems (and health services and practitioners) are viewed from a local perspective, and develop locally appropriate strategies. The MOHFW needs to explore how public sector programs in urban areas can be strengthened through effective links with NGOS. The government's coor- dinating body for NGOs could be asked to take the lead in synthesizing their urban experiences and making this information available to both urban Family Welfare Programs and the organizations themselves. The experience of the Population Project in Madras (supported by the World Bank), where NGOS in selected cities and states are actively participating in program implementation, needs to be assessed and shared with other municipalities in India. Participation by Communities and Women's Groups Both the Family Welfare and Ims programs are often faulted for their failure to elicit community participation. Community support can greatly facilitate some aspects of these programs, such as providing safe residences for female work- ers. identifying target and high-risk clients, mobilizing community resources to provide the greatest possible variety of services, enhancing utilization of ser- vices, developing transport schemes for obstetrical emergencies, and defining and implementing IEC strategies. Formation of women's groups can both improve women's access to ser- vices and increase the sensitivity of programs to women's needs. Several ICDS projects supported by the World Bank in Andhra Pradesh, Bihar. Madhya Pradesh, and Orissa include provisions for utilizing or activating mahila mandals (women's organizations) in villages. Under the project, active mahila mandals are given financial support and assistance in organizing activities such as in- come-generating schemes that benefit their members. If efforts to organize community participation in support of ICDS projects through mahila mandals succeed, these efforts should be continued and replicated in other states. Another recent encouraging community involvement effort is the develop- ment of mahila swasthva sanghs (women's health societies) under the Family Welfare Program. Under this scheme, local health workers form groups of fifteen villaoe women to discuss family welfare issues. These groups can act as valuable channels of communication for women's health and safe motherhood messages and as a means of enlisting community support in efforts to expand the number of women receiving key services. 106 IMPROVING WOMEN'S HEALTH IN INDIA Supporting Women's Health through Action Research In establishing the Family Welfare and ICDS programs. India has taken a major step toward providing full health and nutrition services throughout tile country. The government is currently moving to strengthen the services it provides, particularly those intended for women. through the Safe Motherhood Program and a more client-centered approach to family planning. The discussion in this chapter identifies a number of key constraints that need to be addressed so that tile program can function more effectively and the quality of services can be improved. However, introducing changes in such large, well-established pro- grams, particularly given India's federal system (under which the responsibil- ity for implementing programs lies with the states), is a cumbersome task. In light of these constraints. planners and managers may not have sufficient infor- mation to define needed and desirable changes. Even if these changes are identified, administrators may not know how they can be introduced success- full. Tie following section focuses on the use of action research as a basis for investigatina alternatives. The term action (or operational) research can be used to cover a variety of formal and relatively informal research projects, both large and small. What these kinds of projects have in common is all action component-that is, they can be used to introduce, test, or modify program strategies and activities. Action research is also frequently used to evaluate alternatives or options within existing programs. Despite its value, this approach has generally not been applied in social programs in India. Program alternatives tend to be identified with NGo projects, which are assumed to be impossible for the pullic sector to replicate. Yet only by investigating alternatives on a smaller scale (within public sector constraints) can guidelines for larger initiatives and modifications to existing programs be developed. Particularly ill cases where an existing approach is clearly not working and 110 consensus on a viable alternative has been reached (for example, with anemia control), some form of action research is needed to test and compare options. Action research is particularly important in communication and education, where the institutional framework, technical capacity. and organizational support for initiatives are weak. In most cases, neither the central nor the state governments have the capac- ity to carry out studies of this sort without assistance. There are, however. ample private sector groups and NGOs in India with the required expertise and resources to carry out the kinds of action research listed below. The Safe Motherhood Program should provide opportunities for action research. Experience in the districts where the program has been implemented can be used to identify resource constraints and bottlenecks in the delivery of STRATEGIES FOR CHANGE 107 services and provide a basis for assessing the program's effectiveness. The importance of carefully monitoring both implementation and results cannot be overemphasized. Recommendations for operational research on service delivery and for in- stituting IEC projects can be summarized as follows: 0 Safe motherhood messages. Areas that should be explored include identify- ing approaches and potential audiences for safe motherhood messages that emphasize the benefits of antenatal care and pregnancy entitlement and encour- age expectant mothers to have a trained attendant present at the birth. In addi- tion to the pregnant woman herself and her household members, health care providers and community members should be included as target audiences. Alternative approaches should also be tested to reduce the delays in recogniz- ing and referring pregnancies that contribute to maternal mortality. M Anemia prophYlaxis and treatment. Given the extent and seriousness of anemia among women, particularly pregnant women, as well as the current lack of understanding of how best to implement a prevention and control pro- gram, a number of alternatives need to be evaluated. Aspects such as the supply of IFA tablets, women's willingness and ability to comply with the program's guidelines, the quality of any supplements provided, and the problem of para- sites that can hinder the effectiveness of supplements all need to be taken into account in developing alternatives for testing. Approaches to reducing anemia in adolescents who are not yet pregnant also need to be examined. M Increased contraceptive choice. Several possibilities in this area need to be explored: public and private delivery mechanisms, new monitoring and evalu- ation approaches. and local channels of communication that can help make iw)s, oral contraceptives. and vasectomnies more culturally acceptable. NGOS may have valuable experience that can be used in developing initiatives in this area. * Substitution of .saf practices for traditional or local abortion technique%. Research in this area should focus on effective ways of promoting awareness and improving the qUality of available legal termination services and contra- ception. 0 Diagnosing, treating, and ref0'rring gynecological problems. The cost- effectiveness of managing reproductive tract infections by the syndromic and risk approaches should be tested. Research is needed to determine the extent to 108 IMPROVING WOMEN'S HEALTH IN INDIA which Family Welfare fieldworkers can to be trained to recognize and treat gynecological problems and to define workable referral strategies for women whose conditions dictate further evaluation or treatment. 0 Transportation for obstetric emergencies. Options for providing transport for obstetric complications through referral facilities, communities, or private organizations need to be tested for practicality, effectiveness, and cost. * Nutritional supplementation for malnourished girls and pregnant and lac- tating women. Alternative strategies for achieving this goal through the ICDS Program should be developed and compared. * Quality of care. Research in this area should focus on encouraging providers to listen to and meet clients' needs and to adhere to universally accepted stan- dards for equipment, drugs, staff qualifications, and treatment techniques. Out- comes and patient perspectives should be central to the research. * Public-private collaboration. Research is needed to explore opportunities for more effective collaboration between the public and private sectors in the planning and implementation of services for women. Both public programs and private groups need to identify and support organizations that can serve as a forum where women can voice their need and participate in the planning and delivery of more accessible and higher-quality services. Appendix APPENDIX TABLE 1.1 AGE-SPECIFIC DEATH RATES BY SEX AND RESIDENCE, INDIA, 1989--91 (deaths per 1,000) Age All India Rural Urban group Male Female M/F ratio Male Female A/F ratio Male Female M/F ratio 0-4 26.3 28.9 0.91 28.9 32.1 0.90 15.6 16.4 0.95 5-9 2.4 3.0 0.82 2.7 3.4 0.81 1.4 1.5 0.94 10-14 1.4 1.5 0.94 1.5 1.8 0.87 0.9 0.9 1.01 15-19 1.7 2.5 0.69 1.8 2.8 0.64 1.4 1.5 0.94 20-24 2.4 3.2 0.75 2.6 3.5 0.74 1.8 2.2 0.83 25-29 2.7 3.0 0.89 2.9 3.3 0.86 2.3 2.0 1.16 30-34 3.2 2.8 1.12 3.3 3.2 1.04 2.5 1.7 1.53 35-39 4.0 3.4 1.19 4.3 3.7 1.14 3.4 2.4 1.47 40-44 5.5 4.1 1.34 5.9 4.6 1.28 5.1 3.1 1.67 45-49 9.0 5.9 1.53 9.3 6.2 1.50 8.3 4.9 1.76 50-54 13.3 9.0 1.47 13.4 9.4 1.43 12.6 7.7 1.64 55-59 20.7 14.0 1.48 20.6 14.2 1.45 21.0 13.2 1.62 60-64 31.6 23.2 1.36 31.7 23.8 1.33 31.0 20.9 1.49 65-69 47.1 37.6 1.25 47.4 38.5 1.23 46.0 33.9 1.36 70+ 94.2 81.1 1.16 95.3 82.4 1.16 90.0 76.1 1.19 All 10.0 9.8 1.02 10.8 10.7 1.01 7.5 6.6 1.13 Source: RGI (vanious years). 109 110 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.2 CRUDE DEATH RATES BY SEX. INDIA AND MAJOR STATES, 1992 (deaths per 1,000) State Both sexes Male Female M/F ratio India 10.1 10.0 10.2 0.98 Kerala 6.3 7.5 5.2 1.44 Karnataka 8.5 9.3 7.7 1.21 Punjab 8.2 8.9 7.4 1.20 Tamil NadI 8.4 8.9 7.9 1.13 West Bengal 8.4 8.8 8.0 1.10 Andhra Pradesh 9.2 9.6 8.9 I.07 Gujarat 9.2 9.3 9.0 1.03 Haryana 8.7 8.8 8.6 1.02 Maharashtra 7.9 7.9 8.0 0.98 Orissa 11.7 11.4 11.9 0.95 Rajasthan 10.5 10.2 10.9 0.93 Madhya Pradesh 12.9 12. 3 13.5 0.91 Uttar Pradesh 12.8 11.9 14.0 0.85 Bihar 10.9 10.0 11.9 0.84 Notc States are listed h\ dec0nin12g m1ale/fenule antio. rmirce: R(i 1 (1194) APPENDIX TABLE 1.3 LIFE EXPECTANCY AT BIRTH BY SEX, INDIA, 1901-91 (years) Period Aale (percent Female 1percent M/F ratie 1901-10 22.6 na. 23.3 na. 0.97 1911-20 19.4 2 0.9 -2.4 0.93 1921-30 26.9 7.5 26.6 5.7 1.01 1931-40 32.1 5.2 31.4 4.8 1.02 1941-50 32.4 0.3 31.7 0.3 1.02 1951-60 41.9 9.5 40.6 8.9 1.03 1961-70 46.4 4.5 44.7 4.1 1.04 1971-75 50.5 4.1 49.0 4.3 1.03 1976-80 52.5 2.0 52.1 3.1 0.99 1981-85 55.4 2.9 55.7 3.6 0.98 1986-90 58.1 2.7 59.1 3.4 0.96 na NOt apicable Sour c. Ra l (%,irj)u1 VCar`,) APPENDIX 111 APPENDIX TABLE 1.4 LIFE EXPECTANCY AT BIRTH BY SEX, INDIA AND MAJOR STATES, 1981-85 (years) Stat Mal. Female M/F rauia India 55.4 55.7 0.99 MadhyVa PrUdesh 65.4 51.9 1.26 Uttar Pradesh 51.4 48.5 1.06 Bihar 54.2 51.5 1.05 Horyana 61 .5 59.0 I.04 Orissa 53.1 53.0 1.00 Rajasthan 53.3 53.8 0.99 Punjab 62.6 63.6 0.98 West Benal 56.8 5S.0 0.98 Tamil NadU 56.5 57.4 0.98 Maharashtra 59.6 62.1 0.96 Karnataka 59.7 62.0 0.96 Andhia Pradesh 57.2 50.8 0.96 Gujarat 55.5 59.3 0.94 Kerala 65.4 71.5 0.91 Notw. Stats areV UsteWd byV d e lleding- iaIleileNuile r',1n1 laie R I989) APPENDIX TABLE 1.5 LIFE EXPECTANCY AT BIRTH BY SEX AND BY RESIDENCE, INDIA, 1970-85 (years) Rural or Chan ,'e Chanme urban: penod mall, percent, Female (percent) M/F ratio Rural 1970-75 48.9 na. 47.1 na. 1.04 1976-80 51.0 2.1 50.3 3.2 1.01 1981-85 54.0 3.0 53.6 3.3 1.0 1 U/ban 1970-75 58.8 n.a. 59.2 n.a. 0.99 1976-80 59.6 0.8 60.8 1.6 0.98 1981-85 61.6 2.0 64.1 3.3 0.96 n.a. Not applicable. Source: RG1I ( rious car i). 112 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.6 INFANT MORTALITY RATES BY RESIDENCE, INDIA, 1972-92 (deaths per 1,000 live births) Year All India Rural L!rban 1972 139 150 85 1973 134 143 89 1974 126 136 74 1975 140 151 84 1976 129 139 80 1977 1 30 140 81 1978 126 136 71 1979 120 130 72 1980 114 124 65 1981 110 119 62 1982 105 114 65 1983 105 1 14 66 1984 104 113 66 1985 97 107 59 1986 96 105 62 1987 95 104 61 1988 94 102 62 1989 91 98 58 1990 80 86 50 1991 80 87 53 1992 79 85 53 Solurct R(I variotu vears). APPENDIX 113 APPENDIX TABLE 1.7 YOUNG CHILD DEATH RATES BY RESIDENCE. INDIA, 1972-92 (deaths per 1,000 children ages 0-4) Year All India Rural Urban 1972 57.3 62.7 32.3 1973 52.3 56.8 31.4 1974 50.0 54.8 27.3 1975 55.0 60.3 31.7 1976 51.0 55.2 29.7 1977 50.9 56.1 27.1 1978 48.3 53.2 26.3 1979 45.7 50.6 23.9 1980 41.8 46.1 22.2 1981 41.2 45.5 20.4 1982 39.1 43.9 20.9 1983 37.6 41.8 21.4 1984 41.2 46.2 23.2 1985 38.4 43.3 20.7 1986 36.6 40.8 20.9 1987 35.2 39.7 18.2 1988 33.3 35.7 18.7 1989 29.9 33.2 16.9 1990 26.3 29.1 15.1 1991 26.5 29.1 16.0 1992 26.5 29.1 15.6 St,urcu RGI lvarous, yejT . 114 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.8 INFANT MORTALITY RATES BY SEX, INDIA AND MAJOR STATES, 1992 (deaths per 1,000 live births) Shife Both w.w% M11a/. / male M/F irno India 79 79 80 0.99 Kerala 17 21 12 1.75 Karnataka 73 77 67 1.15 Madhya Prade h 104 109 98 1.11 West Bengal 65 67 62 1.08 Andhra Prade,,h 71 73 68 1.07 MaharashItra 59 61 57 1.07 Himachal Pradesh 67 67 66 I.01 Oris,sa 115 1 14 116 0.98 Tamil NadU 5N 58 59 0.98 Bihar 73 71 74 0.96 GujZrt 67 66 69 0.96 Rajasthan 90 88 92 0.96 Haryana 75 73 78 0.94 Punjah 56 54 60 0.90 Uttar Pradesh 98 92 105 0.88 Nwc. Satetik are hiaed by w1ewcendm m,leiaIe ruli Sm , R() i 104j APPENDIX 115 APPENDIX TABLE 1.9 INFANT MORTALITY RATES BY SEX, INDIA, 1972-92 (deaths per 1,000 live births) State Both sexes Male Female M/F ratio 1972 139 132 148 0.89 1974 126 132 135 0.98 1976 129 124 134 0.93 1979 120 119 121 0.98 1980 114 113 115 0.98 1981 110 110 111 0.99 1982 105 106 104 1.02 1983 105 105 105 1.00 1984 104 104 104 1.00 1985 97 96 98 0.98 1986 96 96 97 0.99 1987 95 95 96 0.99 1988 94 94 93 1.02 198') 91 91 90 1.02 1990 80 78 81 0.96 1991 80 81 80 1.01 1992 79 70 80 0.99 .,,upc,-: RG I ( various wa~rs) 116 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.10 YOUNG CHILD DEATH RATES BY SEX, INDIA, 1972-92 (deaths per 1,000 children ages 0-4) Year Male Female Al/F ratia 1972 58.5 67.2 0.87 1973 53.1 60.8 0.87 1974 51.5 58.5 0.88 1975 57.2 63.5 0.90 1976 49.6 51.9 0.96 1977 47.5 54.5 0.87 1978 44.7 52.1 0.86 1979 43.8 47.7 0.92 1980 40.1 43.5 0.92 1981 39.2 43.3 0.91 1982 37.9 40.5 0.94 1983 36.5 38.7 0.94 1984 39.5 43.0 0.92 1985 36.6 40.4 0.91 1986 34.7 38.6 0.90 1987 33.6 36.8 0.91 1988 31.8 34.9 0.91 1989 28.5 31.4 0.91 1990 24.8 27.9 0.89 1991 25.6 27.5 0.93 1992 24.9 28.2 0.88 Source: RGI (various years). APPENDIX 117 APPENDIX TABLE 1.11 YOUNG CHILD MORTALITY RATES, INDIA AND MAJOR STATES, 1982-84 AND 1992 (deaths per 1,000 children ages 0-4) 1982-84 1992 State Male Female MIF ratio Male Female M/F ratio India 38.0 40.7 0.93 24.9 28.2 0.88 Kerala 11.5 9.6 1.20 5.0 2.7 1.85 Karnataka 26.5 24.0 1.10 22.6 20.7 1.09 Andhra Pradesh 28.6 26.7 1.07 20.2 19.8 1.02 Maharashtra 26.0 26.2 0.99 16.0 15.9 1.01 West Bengal 31.5 32.6 0.97 18.4 18.4 1.00 Tamil Nadu 29.9 31.9 0.94 15.0 15.7 0.96 Gujarat 38.1 40.0 0.95 22.8 24.7 0.92 Madhya Pradesh 26.0 52.4 0.97 36.8 40.3 0.91 Orissa 46.2 44.2 1.05 31.7 35.2 0.90 Punjab 21.7 26.1 0.83 16.5 18.3 0.90 Rajasthan 43.7 48.7 0.90 31.2 36.3 0.86 Haryana 27.4 34.0 0.81 21.0 24.8 0.85 Bihar 42.2 45.7 0.92 24.2 29.6 0.82 Uttar Pradesh 52.8 62.5 0.84 33.1 43.1 0.77 Note: States are listed by descending male/feniale ratio in 1992. Sour e: RGJ ivarious years). 118 IMPROVING WOMEN*S HEALTH IN INDIA APPENDIX TABLE 1.12 NEONATAL AND POST-NEONATAL MORTALITY RATES, INDIA, 1972-92 (deaths per 1,000 live births) Neonatal mortahth Post-neonatal NNMR/IMR Year rate (NNAR) mortalit, rate (percent) 1972 71.6 68.2 51 1973 68.2 66.2 51 1974 70.1 55.8 56 1975 78.3 62.1 56 1976 77.0 52.0 60 1977 80.2 49.8 62 1978 77.4 49.6 61 1979 77.4 52.0 60 1980 75.5 48.3 61 1981 69.9 40.5 63 1982 66.7 38.1 64 1983 67.2 37.7 64 1984 65.8 38.2 63 1985 60.1 37.1 62 1986 59.8 36.6 62 1987 57.7 37.7 60 1988 56.8 37.7 60 1989 56.4 34.5 62 1990 52.5 27.2 66 1991 51.1 29.2 64 1992 50.0 29.0 63 ,Voth I%1R. inflitl nioTrtlit rile. 11an.0 Rk;il %111 1 \Clt l e r APPENDIX 119 APPENDIX TABLE 1.13 DEATH RATES BY SEX, AGES 20-24, INDIA AND MAJOR STATES, 1990-92 (deaths per 1,000 population) State /al Fema1il Wt/F rino India 2.4 3.2 0.75 Punjah 4.0 1.7 2.37 Kerala 1.4 0.9 1.46 Andhra Pnidesh 2.9 2.9 1.00 Tamil Nadu 2.7 2.7 I.00 Karnataka 1. 1 2.4 0.92 Haryana 2.1 2.8 0.76 Orisa 3.0 4.0 0.76 West Benial 2.1 2.7 0.76 Maharashtra 1.7 2.5 0.70 Gujarat 1.9 2.9 0.67 Uttar Prade.h 2.6 3.9 0.66 Bihar 2.5 3.9 0.63 Madhya Pradesh 2.7 4.3 0.62 Rajasthan 2.2 3.7 0.59 Iot': S tal T C I Itd h dece ndgI mI/Ilenull e ratio onr". RIO lIalois NC'I') 120 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.14 BURDEN OF DISEASE, INDIA, 1990 (thousands of DALYS) Case All Male Female All causes 287,901 142,308 145,594 Communicable 117,397 58,542 58,856 Infectious and parasitic 83.146 42.483 40,663 Tuberculosis 13.268 8,748 5.046 STDs, excluding HIV 5,566 1.871 3,695 Syphilis 1,898 903 995 Chlamydia 2,187 311 1,876 Gonorrhea 1,480 657 824 Other sTos O 0 0 Hiv 236 152 83 Diarrhea diseases 29,480 14,060 15.420 Childhood cluster 18.328 9.150 9.178 Pertussis 3.013 1.507 1.506 Polio 1.322 758 564 Diphtheria 151 75 76 Measles 7,066 3.507 3,559 Tetanus 6,777 3,302 3,474 Other childhood diseases 0 0 0 Meningitis 1,506 767 739 Hepatitis 355 195 160 Malaria 1,195 614 581 Tropical cluster 3,145 2,166 980 Trypanosomiasis 0 0 0 Chagas' disease 0 0 0 Schistosomiasis 0 0 0 Leishmaniasis 1.375 826 549 Lymphatic filari 1.770 1,339 431 Onchocerciasis 0 0 0 Other tropical 0 0 ) Leprosy 186 95 90 Dengue 444 200 244 Japanese encephalitis 85 42 43 Trachoma 26 7 19 Intestinal nematodes 788 407 381 Ascaris 200 102 98 Tricharis 126 65 62 Hookworm 462 240 222 Other intestinal 0 0 0 Other infectious 8,044 4.008 4.036 APPENDIX 121 Cause All" male Female Respiratory infection 34,251 16,059 18,192 Acute lower respiratory 32.940 15.592 17.349 Acute upper respiratory 358 171 187 Otitis media 629 296 332 Other respiratory 0 0 0 Maternal conditions 7,409 0 7,409 Hemorrhage 846 0 846 Infection 1.256 0 1.256 Eclampsia 282 0 282 Hypertension 132 0 132 Obstructed labor 1,503 0 1,503 Abortion 1,600 0 1 .600 Other maternal 1.789 0 1,789 Perinatal conditions 25,363 12,463 12,900 Nutritional 12,185 5,530 6,655 Protein-energy malnutrition 5,076 2,414 2.661 Iodine deficiency 378 192 187 Vitamin A deficiency 745 373 372 Anemia 5,985 2,550 3,435 Other nutritional ( 0 0 Noncommunicable 83,437 42,071 41,366 Malignant neoplasm 7.158 3.331 3.827 Mouth and oropharynx 1,100 613 487 Esophagus 593 284 309 Stomach 557 340 217 Colon and rectum 266 140 126 Liver 149 102 47 Pancreas 88 51 37 Trachea, bronchus, and lung 387 318 68 Melanoma and other skin 16 7 8 Breast 562 0 562 Cervix 761 0 761 Corpus uteri 38 0 38 Ovary 183 0 183 Prostate 76 76 0 Bladder 67 52 15 Lymphoma 312 214 98 Leukemia 379 221 158 Other cancers 1.627 915 712 (Table continues on the fiollo ing page. 122 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.14 (continued) Caivea All-, Afie Female Other neoplasms 245 144 101 Diabetes mellitus 2.257 1,103 1,154 Nutritional and endocrine 105 57 48 Neuropsychiatric 20, 161 9,338 10,823 Major affective 8,063 2,961 5.102 Bipolar affective 2,305 1.200 1.105 Psychoses 1.650 892 758 Epilepsy 975 510 465 Alcohol dependence 915 838 77 Alzheimer's and other dementia 1,002 490 512 Parkinson's disease 137 69 68 Multiple sclerosis 215 96 119 Drug dependence 78 70 8 Posttraumatic stress disorder 316 123 193 Obsessive compulsive 1,640 731 908 Panic disorder 738 239 498 Other neuropsychiatric 2.128 1,117 1,012 Sense organ 3.014 1.490 1,525 Glaucoma 573 329 243 Cataracts 2,439 1,158 1,281 Other sense organ 2 2 0 Cardiovascular 23.447 12.251 11.197 Rheumatic heart 1.504 613 890 Ischemnic heart disease 10.131 5.603 4,528 Cerebrovascular 4,235 2,129 2,106 Inflammatory cardiac diseases 1,820 899 921 Other cardiac 5,758 3,007 2.750 Respiratory 7.615 3.874 3.741 Chronic obstructive pulmonary disease 2.494 1.391 1.103 Asthma 1,508 830 678 Other respiratory 3.613 1,654 1,959 Digestive 6,335 3,974 2,361 Peptic ulcer disease 926 585 341 Cirrhosis of the liver 2.867 1,968 900 Appendicitis 381 219 162 Other digestive 2,161 1,202 958 Genitourinary 2,085 1.161 924 Nephritis and nephrosis 1,660 778 882 Benign prostatic hypertrophy 326 326 0 Other genitourinary 99 58 41 APPENDIX 123 Cause A1' Male Female Musculoskeletal 1,434 579 855 Rheumatoid arthritis 182 54 128 Osteoarthritis 1,218 504 714 Other musculoskeletal 34 20 13 Congenital abnormalities 8.400 4,163 4,237 Abdominal wall defect 43 23 19 Anencephaly 1,552 612 940 Anorectal atresia 22 12 10 Cleft lip 80 48 32 Cleft palate 75 37 38 Esophageal atresia 29 16 13 Renal agenesis 82 41 40 Down syndrome 1.108 629 479 Congenital heart disease 3.297 1.715 1,582 Spina bifida 1,367 640 728 Other 747 391 356 Oral health 1,057 534 523 Dental caries 672 347 325 Periodontal disease 71 37 34 Edentulism 289 145 145 Other oral health 25 6 19 Other 124 72 52 Injuries 42,110 23,702 18,408 Unintentional 37.678 21.286 16,393 Motor vehicle 6,155 4.410 1.745 Poisoning 966 469 496 Falls 10.182 6,288 3,894 Fires 5.647 1,595 4.052 Drowning 2,71 1 1,457 1,255 Other unintentional 12.017 7.065 4,951 Intentional 4.432 2,417 2,015 Self-inflicted 2.803 1.406 1,397 Homicide and violence 1.510 893 618 War 119 119 0 Other intentional 0 0 0 a. For some condition, figures foi males and temales may not equal the total for both sexes because of rounding. Source: Murray and LopC7 (forthconingi. 124 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.15 DISTRIBUTION OF DEATHS BY CAUSE, AGE, AND SEX, RURAL INDIA, 1989 (percent) Cause Total 0-1 1-4 5-14 15-24 25-34 35-44 45-54 55+ Accidents and injuries Male 12 3 6 24 39 32 19 10 4 Female 10 3 6 18 34 22 12 8 3 Fevers Male 10 14 21 19 10 8 8 8 7 Female 13 16 21 20 14 11 11 9 10 Digestive disorders Male 9 8 18 17 11 12 10 8 6 Female 11 9 22 15 11 8 12 8 8 Respiratory disoiders Male 32 55 29 15 13 19 28 32 37 Female 29 55 29 21 14 21 29 27 31 Disorders of central nervous system Male 7 4 6 8 6 4 4 5 10 Female 7 4 3 8 4 6 4 7 12 Circulatory di.sorders Male 17 8 9 4 10 15 17 23 23 Female 16 7 10 6 12 16 17 18 23 Other causes Male 12 7 10 12 12 12 14 14 13 Female 13 6 10 12 12 15 15 23 13 Total Male 100 100 100 100 100 100 100 100 100 Female 100 100 100 100 100 100 100 100 100 Soucc: RG[(1991) APPENDIX 125 APPENDIX TABLE 1.16 DISTRIBUTION OF CAUSES OF DEATH BY AGE AND SEX, URBAN INDIA, 1984 (percent) Cau.e 0-1 1-4 5-14 15-24 25-44 45-64 65+ ANS All Infectious and parasili( diseaves Male 19.9 42.4 33.9 30.1 28.3 19.0 12.0 18.5 22.0 Female 20.1 45.1 32.2 22.7 25.2 17.0 9.5 17.2 21.2 Neoplasms Male 0.03 0.4 1.6 2.3 3.1 8.1 7.1 4.1 4.3 Female 0.02 0.3 1.1 1.0 3.3 16.8 6.9 1.3 4.1 Endocrine, nietabolic, nutritional, and innunological disorders Male 4.2 8.0 0.8 0.4 1.1 2.7 3.2 3.3 2.9 Female 4.9 9.6 0.7 0.5 0.8 3.1 3.7 2.9 3.3 Di.sorders of blood and blood-forming organs Male 0.5 2.0 4.1 3.8 2.9 3.2 1.7 2.5 2.3 Female 0.6 2.3 5.4 4.3 4.4 4.5 2.4 4.2 3.1 Mental disorders Male - 0.02 0.1 0.0 0.2 0.1 0. 1 n.a. 0. 1 Female - 0.02 2.3 5.4 4.3 4.4 4.5 2.4 3.1 Disorders of nervous and sensory system Male 3.8 11.9 13.6 5.9 3.3 2.2 1.6 5.2 4.0 Female 4.0 10.0 12.9 4.0 3.4 2.2 1.6 4.4 4.0 Disorders of circulatorv system Male 1.4 2.8 7.1 9.3 15.3 34.5 41.3 25.1 22.0 Female 1.2 2.4 7.0 7.8 15.4 33.5 41.1 21.7 19.0 Disorders of gatrointestinal s,stem Male 1.4 3.8 5.3 6.1 9.9 8.7 4.0 6.3 6.5 Female 1.1 2.9 4.3 4.4 6.1 4.6 2.5 3.9 3.4 Disorders of genitournary system Male 0.3 1.1 1.9 1.7 1.8 2.1 1.6 1.6 1.6 Female 0.2 0.7 1.9 1.5 1.9 1.7 1.3 1.3 1.3 Complications of/pregnancv. childbirth, and pierperium Male n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. Female n.a. n.a. 0.3 10.8 7.7 0.2 0.0 0.1 0.1 Disorders of skin and subcraneous tissue Male 0. 1 0.2 0.2 0.4 0. I 0.3 0. 1 n.a. 0.1 Female 0.1 0.2 0.2 0.4 0.2 0.2 0.1 0.0 0.2 STahh connnue.s eni the following page.) 126 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.16 (continued) Cause 0-1 1-4 5-14 15-24 25-44 45-64 65+ ANS All Disorders of musculoskeletal and connective tissue Male 0.1 0.2 0.2 0.4 0.1 0.3 0. 1 n.a. 0.1 Female n.a. n.a. 0.1 0. 1 0.1 0.1 0.1 0.0 0.1 Congenital anolies Male 4.1 0.9 0.4 0.1 0.0 0.9 0.2 0.4 0.8 Female 3.6 0.6 0.3 0.03 0.9 0.9 0.9 3.2 0.8 Conditions originating in perinatal period Male 44.4 n.a. n.a. n.a. n.a. n.a. n.a. n.a. 7.8 Female 41.5 n.a. n.a. n.a. n.a. n.a. n.a. n.a. - Undefined conditions Male 3.5 6.1 9.0 8.7 7.9 5.5 13.4 14.7 7.9 Female 3.7 5.4 7.7 8.8 8.8 6.3 17.2 20.7 9.3 Injury and poisoning Male 1.3 5.6 13.0 26.0 20.4 6.7 3.2 10.6 8.6 Female 1.2 5.0 14.2 29.5 17.6 6.0 3.3 7.1 9.1 n a Not applicable. - Not available. No,e. 4NS. age not 'tated .Souwc. RGI (1987) APPENDIX TABLE 1.17 PROPORTION OF TOTAL DEATHS FROM MATERNAL CAUSES, IN RURAL AREAS, INDIA AND SELECTED STATES, 1989 State Percent India 0.9 Orissa 1.8 Rajasthan 1.7 Madhya Pradesh 1.4 Uttar Pradesh 1.4 Andhra Pradesh 0.9 Bihar 0.9 Gujarat 0.7 Maharashtra 0.7 Haryana 0.6 Tamil Nadu 0.6 Karnataka 0.5 Punjab 0.3 Note State, are lited in descending order of proporion of death trot maternal causes. West Bengal and Kerala are onitted trom the table because there were no maternal deaths In the sample in either state. Source: RGI (199 1). APPENDIX 127 APPENDIX TABLE 1.18 CAUSES OF MATERNAL DEATHS, SELECTED YEARS (percent) Anmuuapur Dicrdir. Karna- ruril and iaku, India, Selected wrban. rural In1dift. rurl- iirban, hospitals, ICTIR, Cause 1984-85 1989 1991 1993 1985 1978-81 1983-84 Direct obstetric cauves Hemorrhage 7.4 19.7 19.5 22.6 15.2 17.3 12.8 Abortion 11.9 4.5 10.8 11.7 16.9 15.1 - Spontaneous 1.5 Induced 3.0 Infection 25.0 24.3 12.7 12.5 - 17.2 17.3 Obstructed labor 5.3 - 11.6 5.5 3.3 5.0 - Eclampsia 9.2 15.2 8.8 12.8 13.0 10.7 12.0 Other direct causes 9.1 10.6 16.7 14.6 36.3 11.5 8.3 Indirect obstetric causes Anemia 9.2 - 19.9 20.3 - 7.8 - Hepatitis; heart disease 9.8 - - - - 15.4 22.5 Other indirect causes 14.1 - - - 15.1 - - - Not available. Soure,: For Anantapur. Bhana (1988); For Karnataka, Reddy 1992,: for India. rural. 1991, RGI 1 1991): 1993. RGI(1993h): for India, urban, RGI (1988b); for selected hospuals. Rao (988): fr ICMR. fCMR (1988bi. 128 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 1.19 MEASURES IDENTIFIED FOR PREVENTION OF MATERNAL DEATHS, ANANTAPUR DISTRICT, 1984-85 (percent) Share of Share of total preventtble imateral Nwn/er leaths deaths Recoinnndcd mieasuet of cavts (percent) (percent) Antenatal care Treatment of anemia during pregnancy 26 12.8 9.2 Proper early antenatal care 18 8.9 6.3 Treatment of hepatitis during pregnancy 7 3.4 2.5 Avoidance of pregnancy through family planning or treatment of hypertension 7 3.4 2.5 Tetanus toxoid immunization 6 3.0 2.1 Total 64 31.5 22.5 Referral care Control of infection through broad-spectrum antibiotics 44 21.7 15.5 Early hospitalization and proper treatment 42 20.7 14.8 Institutional delivery 18 8.9 6.3 Blood transfusion 18 8.9 6.3 Control of dehydration through fluids 10 4.9 3.5 Early cesarian section 7 3.4 2.5 Total 139 68.5 34.2 Total preventable maternal deaths" 203 100.0 71.5 a Exclude death froT imduced ahornion. b OJ the maternal death' for which deiailed i nformatOn wa' ava[able. 221 (78 percent i were judged to have been cither dehtitely o probably pre. entable. Of theC. 18 deaths from lndUced abortin (6 percent of total maternal deaths) could have been pre% ented tmd the procedure been carried out by a qualified doctor Sour, e: Bhatia, 198s) APPENDIX TABLE 1.20 PREVALENCE OF ANEMIA AMONG CHILDREN, LARGEST CITIES OF INDIA (percent) Ags 1-5. Ag's 6-14, Ciry both seves femaule Hyderabad 65.5 66.7 Calcutta 94.4 95.3 Madras 23.2 18.3 New Delhi 57.1 73.3 Source: ICMR I 1982. APPENDIX 129 APPENDIX TABLE 2.1 LITERACY RATES BY SEX, INDIA AND MAJOR STATES, 1991 (percent) State Females Male's India 39 64 Kerala 87 94 Tamil Nadu 53 75 Maharashtra 51 75 Punjab 50 64 Gujarat 49 73 West Bengal 47 67 Karnataka 44 67 Haryana 41 68 Andhra Pradesh 34 56 Orissa 34 62 Madhya Pradesh 28 57 Uttar Pradesh 26 55 Bihar 23 53 Rajasthan 21 55 Notc: Rales are foi age 7 and above States are listed in desecending order of fettuale literacy. Source: RGI (1992). 130 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 2.2 TIME USE DATA OF FIVE PREGNANT WOMEN ON A NORMAL DAY (hours) Woman A Woman B Woman C Woman D VWoman E (3 months (4 months (7 monihs (8 months (8 monh.% Actwitvre pregnt) pregnant) pregnant) pregnant) pregnant) Work for wage or salary (unskilled) 10.0 - - 5.3 Traveling time to workplace - - - 2.0 Handcrafts - - - 2.0 - Food preparation and serving 2.2 2.3 2.0 3.0 4.2 Fetching water 0.5 3.0 2.0 1.3 1.0 Other household work (washing clothes, cleaning, dusting. and the like) 1.3 2.0 3.0 2.3 2.2 Animal husbandry -- 3.0 2.0 3.0 - Self-care, rest. eating. and the like 2.0 3.0 3.0 2.0 2.2 Making cow dung cakes for fuel - 0.3 - - Childcare - - 1.0 2.3 - Grinding grain - 3.0 2.3 4.0 - Sleeping 7.3 7.0 7.0 5.0 6.5 - Not available. Note: Only primary activjfies are included. Sourc e: Khan and other t 1989). APPENDIX 131 APPENDIX TABLE 3.1 INCREASES IN MEDICAL PERSONNEL AND FACILITIES, INDIA, 1964-88 Qualified physicians Doctors Allopaths Hospital beds Dispensuries Year (all systems) Public Private Public Private Public Private 1964 - 39,687 60.502 - - - - 1974 607.909 - - 211,335 57,550 - - 1979 -- 69.137 166.494 331,233 115,372 - - 1981 665,340 - - 334.049 132,628 13,205 2,115 1986 763,437 88,105 242,650 411.255 144,009 - - 1988 - - -- - 13,916 13.579 - Not available. Source Jesan and Anaritharam (1989) APPENDIX TABLE 3.2 UTILIZATION OF HEALTH SERVICES FOR ILLNESS WITHIN THE PRECEDING THREE MONTHS, FOUR STATES OF INDIA (percent) Andira Utar Service PIrdesh Bihar Gujarat Prudesh Government 20.2 24.4 53.8 6.2 Private 69.5 62.9 27.0 80.8 No treatment or home treatment 10.3 12.7 19.2 13.0 Sources: For Bihai and Gujarat, ICMR I 1988ar: for Andhra Pradesh and Uttar Pradesh. ORG (1990) APPENDIX TABLE 3.3 REASONS FOR DISSATISFACTION WITH GOVERNMENT HEALTH SERVICES, FOUR STATES OF INDIA (percent) Aidhria Uttar Reason Pradesh Bilar Gujarat Pradesh High costs of staff or drugs 23 63 4 62 Travel costs; distance 5 50 91 28 Rude staff behavior 54 36 19 21 Lack of supplies, drags, or facilities 23 35 60 62 Long waits 11 7 11 8 Absence of staff - 13 5 - - Not available. Note: Percentages nay exceed 100 because of multiple answers. Soure: For Bihar and Gujarat. ICMR (1988ai, for Andhra Pradesh, ORG 1988a): for Uttar Pradesh, ORG (l988c). 132 IMPROVING WOMEN'S HEALTH IN INDIA APPENDIX TABLE 3.4 COVERAGE OF ANTENATAL CARE, INDIA AND MAJOR STATES, 1992-93 (percent) Received antenatal Home i4sit checkup by heallh by health worker State projessional' during pregnancy India 49.2 21.0 Rural 41.1 24.3 Urban 76.8 9.8 Kerala 96.6 26.5 Punjab 85.9 7.8 Tarnil Nadu 78.2 40.4 Maharashtra 69.4 23.3 West Bengal 68.4 13.7 Haryana 67.0 11.9 Andhra Pradesh 65.6 41.0 Karnataka 64.8 41.9 Gujarat 50.0 36.6 Orissa 38.4 30.5 Madhya Pradesh 36.3 19.7 Uttar Pradesh 30.2 16.5 Bihar 26.4 11.1 Rajasthan 23.1 11.5 Nwte. States are listed in descending order of percentage of anteiatal checkup by health professional. a. Allopathic doctor, ayurvedic or homeopathic doctor, nurse-midwife. or other health professional. sourc(e(: tips (I 99 i APPENDIX 133 APPENDIX TABLE 3.5 ANTENATAL CARE: TETANUS TOXOID COVERAGE OF PREGNANT WOMEN, INDIA AND SELECTED STATES, 1992-93 Percentage receiving two doses of tetanus State toxoid vaccine India 53.8 Tamil Nadu 90.1 Kerala 89.8 Punjab 82.7 Andhra Pradesh 74.8 Maharashtra 71.0 Karnataka 69.8 West Bengal 70.4 Haryana 63.3 Gujarat 62.7 Orissa 53.8 Madhya Pradesh 42.8 Uttar Pradesh 37.4 Bihar 30.7 Rajasthan 28.3 Note: States are listed in descending order of percentage receiving vaccine. Source: 11PS (1995). APPENDIX TABLE 3.6 ANEMIA PROPHYLAXIS COVERAGE AMONG PREGNANT WOMEN, INDIA AND SELECTED STATES, 1992-93 Percentage receiing iron State and folic acid tablets India 50.5 Kerala 91.2 Tamil Nadu 84.1 Andhra Pradesh 76.4 Karnataka 74.9 Punjab 73.6 Maharashtra 70.6 Gujarat 69.3 Haryana 59.9 West Bengal 56.3 Orissa 49.9 Madhya Pradesh 44.3 Uttar Pradesh 29.5 Rajasthan 29.2 Bihar 21.4 Note: States are listed in descending order of coverage. Source: lIPS (1995). 134 IMPROVING WOMEN'S HEALTH IN INDIA TABLE 3.7 PLACE OF DELIVERY AND DELIVERY ATTENDANCE, INDIA AND SELECTED STATES, 1992-93 Not in institution Other Institution health Public Private profey- State Doctor Other Doctor Other Total Doctor sional TBA Other India 9.8 4.9 9.4 1.5 25.6 2.4 6.7 35.1 30.2 Tamil Nadu 17.8 15.9 24.3 5.6 63.6 0.5 7.9 21.2 6.8 Gujarat 9.5 5.7 16.3 4.1 35.7 2.8 4.7 44.9 11.9 Maharashtra 13.4 9.4 18.0 3.4 44.1 2.4 7.4 19.9 26.1 Kerala 33.8 5.2 46.4 3.1 88.4 0.2 1.6 8.3 1.4 Punjab 7.1 2.7 11.9 3.1 24.8 4.1 19.5 49.6 2.1 Karnataka 13.9 7.8 13.6 2.3 37.6 3.0 10.8 21.8 26.8 Andhra Pradesh 11.4 2. 3 17.9 1.3 33.0 7.1 10.1 33.8 16.1 Haryana 6.4 2.8 6.3 1.2 16.7 4.7 9.2 66.2 3.1 Bihar 4.4 1.4 5.5 0.8 12.1 2.8 4.3 58.2 22.6 Madhya Pradesh 8.6 3.4 3.2 0.8 16.0 2.2 12.3 29.8 39.7 West Bengal 13.7 12.6 4.6 0.7 31.5 1.8 0.5 36.2 30.0 Uttar Pradesh 5.3 1.7 3.7 0.6 11.3 0.9 5.3 33.3 49.1 Orissa 9.2 2.9 1.8 0.3 14.2 20 4.9 37.3 41.7 Rajasthan 6.9 2.6 1.7 0.3 11.6 2.6 8.1 40.5 37.2 Nowe TBA. traditional birth attendant. States are tisted in descending order of institutional detiverv Source: 1lPS I11994). APPENDIX 135 APPENDIX TABLE 3.8 AWARENESS OF CONTRACEPTIVE METHODS AMONG CURRENTLY MARRIED WOMEN OF REPRODUCTIVE AGE, INDIA, 1992-93 Mlethod Percent Any method 96 Any modern method 96 Any modern temporary method 76 Pill 66 tUD 61 Injection 19 Condom 58 Female sterilization 95 Male sterilization 85 Any traditional method 39 Periodic abstinence 35 Withdrawal 20 Other methods 4 Soune. rP'S(1995L. APPENDIX TABLE 3.9 UNMET NEED FOR FAMILY PLANNING, INDIA AND MAJOR STATES, 1992-93 Unie netied State (percent) India 19.5 Uttar Pradesh 30.1 Bihar 25.1 Orissa 22.4 Madhya Pradesh 20.5 Rajasthan 19.8 Karnataka 18.2 West Bengal 17.4 Haryana 16.4 Tamil Nadu 14.6 Maharashtra 14.1 Gujarat 13.1 Punjab 13.0 Andhra Pradesh 10.4 Note: The unmet need for famiy planning services .s defined as The percentage of couples not desiring additional children and not practicing family planning. States are listed in descending order of unmet need. Source: ttPS (1995). APPENDIX TABLE 4.1 PACKAGE OF ESSENTIAL REPRODUCTIVE AND CHILD HEALTH SERVICES FOR INDIA, BY LEVEL OF THE HEALTH SYSTEM Primary health center First-referral unit (FRU) Health intervention Community level Subcenter level (PHC) level or district hospital level Prevention and rnanag. - 1. Sexuality and gender 1. As for community level 1-7. As for subcenter level 1-10. As for Pa level mnent of unwanted information, education, ren and counseling 2. Provision of oral contra- 8. Performing tubal ligation by 11. Provision of services for pregnancy ceptives and condoms, minilaps on fixed datesh medical termination of 2. Community mobilization pregnancy in the first and and education for high-risk 3. Provision of tLI after 9. Performing vasectomies second trimesters (up to 20 adolescents, newly married screening for contraindications 10. Providing first-trimester weeks) where indicated 10.Lh Provdin fisntiese weeksn (troidcae youth, men, and women (to 4. Counseling and referral medical termination of be piloted) for medical termination of pregnancy up to 8 weeks 3. Community-based pregnancy contraceptive distribution 5. Counseling, management, through panchavars, village and referral for side effects. health guides. mahila method-related problems; swasthva sanghas, and the change of method where like. with follow-up indicated (panchayats would distribute only condoms) 6. Addition of other methods 4. Motivate referral for to expand choice sterilization 7. Provision of treatment for minor ailments and referral for 5. Social marketing of problems condoms and oral pills through community sources (oral pills to be distributed through health personnel, including general practition- ers, to women who are starting pills for the first time) 6. Free supplies to health services Muternif cole Prenatal serNices 1. Awareness raising concerning 1-5. As for community level 1-9. As for subcenter level I-11. As for PHI level importance of appropriate care during pregnancy and identi- 6. Three antenatal contacts 10. Treatment of tuberculosis 12. Diagnosis and treatment fication of danger signs with women either at the 1. Testin of syhilis for of RTIs/STDS subcenter or at the outreach T o i 2. Mobilize community support village sites during high-risk group and provision for transport referral and blood immuniation/MCH sessions of necessary treatment' transtUMOn 7. Early detection of high-risk 3. Counseling and education for factors and maternal conpli- breastteedng. nutrition, family cations and prompt referral planning. rest, exercise. personal hygiene, and so on 8. Referral of high-rik wvomen for institutional 4. Early detection and referral delivery of problei pcenancies 9. Treatment of malaria 5. Delivery planning (facilities including drugs to be made available at (There is a need for IEC support sUbcenters) and establishment of FRUs) Delivery services 1. Earls recognition of danger 1-5. As for community level 1-8. As for subcenter level I-11. As for PHC level signals in pregnancy (rupture of membranes of more than 12 6. Supervision of home 9. Modified partograph 12. Treatment of severe hours' duration, prolapse of delivery 10. Dehvery services infection the cord, hemorrhage) 7. Prophylaxis and treatment 1 13. Delivery of referred cases 2. Conducting clean defi%er- for infection 11. Repair of episiotomy and perineal tears 14. Treatment of high-risk les with delivery kits by 8. Routine prophylaxis for cases trained personnel gonococcal eye infection 15. Services for obstetrical 3. Detection of complications: emergencies, anesthesia, referral for hospital delivery cesarean section, blood 4. Provision of transport for transfusion through close referral relatives, linkages with blood banks and mobile services 5. Resuscitation for asphyxiated newkborn (Table conrinues on the follotving page.) Ca APPENDIX TABLE 4.1 (continued) Primary health center First-referral un11it (FRU) Health interventon Communits level Slibcenter level (PHC) level or district hospital lcvel Maternity care (conmnued) Postpartum services 1. Breastfeeding support 1-6. As for community level 1-8. As for subcenter level 1-9. As for PHC level 2. Family planning counseling 7. Referral for complications 9. Referral to FRUS for 10. Management of referred complications after starting casesd 3. Nutrition counseling 8. Injection of ergometrine intravenous fluids and giving 4. Resuscitation for after delivery of placenta initial dose of antibiotics asphyxiated newborn 10. M of 5. Management of neonatal asphyxiated newborn hypothermia 6. Early recognition of postpartum infection and excessive bleeding and referral Child surviial 1. Health education for breast- 1-6. As for community level 1-8. As for subcenter level 1-9. As tor PHC level feeding. nutrition, immunization, utilization of services. and so on 7. Treatment of dehydration 9. Management of referred 10. Handling of all pediatric and pneumonia and referral Cases Cases, including encephalo- 2. Detection and referral of high- of severe cases pathy risk cases such as low birth- weight, premature babies with 8. First aid for injuries, and asphyxia, infections, severe the like dehydration, acute respiratory infection (ARI). and the like 3. Immunization by ANNI 4. Vitamin A supplementation by ANM 5. Detection of pneumonia and referral 6. Treatment of diarrhea cases and ARi cases Meageiet of RTJI/SJ DA I. it-c counseling for assareness I. 2 A, for community level 1--4. As for subcenter level 1-7 As for PIC level and prevention 3. Identification and referral 5. Pilot testing of the 8. Laboratory diagnosis and 2. Condom distribution for vaginal discharge. lower syndromatic approach treatment of RTIs/STDS. abdominal pain, genital ulcers in women. and urethral 6. Treatment of RTIS/5TDs (Syndromatic approach to discharge, genital ulcers, 7. Syphilis testing in detecting and treating STDs in swelling in scrotum or groin antenatal women ntenatal. postnatal. and risk i0 men groups 4. Partner notification/referral NOte \NM. atlirliar nuie-rmidW if, IFC. infornanoni, education. and communication, ItD. intrauterine device: MC H., iraternal and child health: RnT reproductive tract infection: STD. sexuall liansmitted disease. a Social Triarketing ot pills and condons thiough ANM may be explored by permitting the ANI to retain the money. b. PHCs 'hould have facilines. IrCliding operating theaters, for tubal liganon and inilaps. c. Training for Whoiatorv techinicians. equipment. and reagents required d Piics andl FRus would require additional equipment and training foi management of asphyxisted newborns and hypothermia These include a resuscitation bag and mask and rantdiant arners Notes Notes to chapter 1 1. The ratio of women to men in a population is determined by the sex ratio at birth and sex-specific mortality and migration throughout the life cycle. In all human popula- tions, more males are born than females, but more males die; that is, male deathrates are higher than female death rates at every age. In low-mortality populations, these two factors balance out as follows: through age 50 or so, the initial male numerical advan- tage is evident in higher numbers of males, but after that age, the biological female advantage increasingly asserts itself, and the relatively larger numbers of females at older ages result in more females than males in the total population. 2. According to the most recent figures supplied by the United Nations, most South Asian countries and China have female/male population ratios of 0.92-0.94. All other countries have higher ratios-for example. Sri Lanka. 1.0; Indonesia, 1.01; Nigeria, 1.02: and Japan, 1.04 (United Nations 1994a). 3. The figures in appendix table 1.1 and much of the other demographic data in this report are taken from Sample Registration System estimates published by the Office of the Registrar General. India (RGI). The RGI. India's national recording system, was instituted more than two decades ago to provide estimates of key indicators. since vital records are often unreliable, particularly in rural areas. The RGI now generates annual demographic estimates that are probably unique in the developing world. However. particularly with regard to age- and sex-specific death rates, these estimates exhibit inexplicable variations from year to year. Wherever possible, then, the RGt death rates used in this report are based on three-year averages rather than on the published annual rates. Although this "smoothing procedure" improves the reliability of the data, varia- tions are still substantial, and for many age groups it is difficult to detect whether mortality has declined over time. Death rates for the second half of the 1970s are generally higher than the corresponding rates for the first half, but this trend is almost certainly a reflection of improved reporting rather than of decreased mortality. 4. The phrase "northern states" as used here includes Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh. In the literature, the terms "BIMARU states" and "large northern states" are also used to refer to these states. 141 142 IMPROVING WOMEN'S HEALTH IN INDIA 5. Maternal mortality, which can be measured by rates or ratios, refers to the death of a woman during pregnancy or within 42 days of the termination of pregnancy from any cause related to or aggravated by pregnancy. The maternal mortality ratio measures the risk a woman faces of dying once pregnant (the number of maternal deaths per 100,000 live births). The maternal mortality rate reflects the maternal mortality ratio and the fertility rate (maternal deaths per 100,000 women ages 15-49). 6. Estimating maternal mortality rates in a country like India is problematic be- cause of incomplete registration of births and deaths, particularly in rural areas. 7. The term abortion here includes both spontaneous abortion (miscarriage) and induced abortion. The use of the term in other parts of the report refers only to induced abortion: spontaneous abortion is referred to as miscarriage. 8. Calculated from the 1972 RGI fertility survey. However, the 1971 census found that 55 percent of women ages 15-19 were married. Census figures for the proportion of women married at these ages are consistently higher than those calculated from RGI data, presumably because the ongoing RGI enumeration is better able to distinguish between those girls who have been formally married but are only subsequently sent to live with their husbands and those who are already cohabiting. The RGI counts only the latter as married, since the former are not yet exposed to the risk of pregnancy (Bhat 1984). Notes to chapter 2 1. Marriage practices among Muslims in the north tend to resemble those in south- ern India. in that spouses may be closely related (the preferred husband for a Muslim woman is a paternal relative) and the families may be resident in the same village, so the couple and their families know each other well. Interestingly enough, these similarities do not appear to have improved the status of Muslim women in northern India (Jeffery, Jeffery, and Lyon 1989). The reason, at least in part. may be that northern Hindu and Muslim cultures are both strongly patrilineal and patrilocal, in contrast to their counter- parts in the south. 2. Caldwell, Reddy. and Caldwell (1983) report that their informants in rural southern Karnataka gave two reasons for the increased interest in dowries: the current surplus of marriageable girls in relation to the number of potential husbands looking for wives, and the desire to find educated husbands with urban jobs. Epstein (1973), observ- ing the beginnings of the dowry system in the same area a generation earlier. gave two reasons for the practice: a desire on the part of the upwardly mobile to adopt Brahmin customs (a tendency known as "Sanskritization"). and the need to substitute dowry for bride price for educated girls, who could not be asked to perform agricultural labor. There is no doubt that the relatively high fertility levels of recent decades. com- bined with an age gap between the bride and bridegroom that typically averages seven years. has in fact created a "marriage squeeze" for women-that is, more families of potential brides are seeking husbands among fewer potential bridegrooms. This situa- tion will change as recent declines in fertility make themselves felt in the relative numbers of marriageable young men and women and may to some extent ease dowry pressures in both north and south. In addition, as Caldwell, Reddy. and Cald)well point out, both the bride price and the dowry reflect traditional marriage systems based on NOTES 143 alliances and exchanges between families made by the older generation without the consent or even involvement of the bride or groom. In contrast, the more modern system in the south allows the marriage partners, who are generally older, to have some say in the arrangements. 3. George. Abel, and Miller (1992) reported that the six villages where female infanticide occurred were populated primarily by a middle cultivator caste (Gounder). All but one of the eighteen cases of infanticide took place in households of this caste. There were no cases of infanticide among Harijan families, members of another caste living in the same villages. Only one case involved a firstborn daughter: in all the others the family had at least one other female child at the time. and usually two. The villages in which the female infanticides occurred were more remote, were located in hilly areas. and had less educated populations than the villages with no cases of infanticide. Of the six villages where female infanticide occurred, only two had bus service, while all but one of the other six villages had bus service. 4. The data on associations between the educational levels of women and rates of fertility and child survival indicate only a limited effect for primary education alone: the effect of secondary education is more significant. 5. It is important to distinguish between traditional practitioners who study text- based systems and local healers who do not: these healers may in fact not practice "medicine" in the conventional sense. All of these practitioners, plus all allopathic physicians (whether or not fully qualified) can be termed "private practitioners.- The term, however, is often used to designate only qualified private allopathic physicians. 6. Evidence regarding the widespread belief that smallpox and related diseases are divinely caused is 2iven for three states (Bibar, Gujarat. and Kerala) in iCMR (1988a). 7. This section is based primarily on Griffiths. Lynn. and Brems (1991): Jeffery, Jeffery, and Lyon (1989): Khan and others (1989): and Nichter (1989). 8. In much of the country. including Punjab and eastern and southern India, the opposite is true. For her first delihery, a young wife will return to her parents' house only later in her childbeaw inn career will she remain at her marital home throughout the pregnancy and delivery. The area where the custom of delivering at the husband's home prevails is not known with any certainty but probably includes Uttar Pradesh north of the Ganges and Bihar. Note to chapter 3 1. The ORG and tiPs survey figures confirm what was already clear from internal evidence-that MOHFW estimates of the prevalence of temporary methods are substan- tially too high. The sterilization figures, however, match quite well in most cases. Notes to chapter 4 1. Any national package of interventions designed on the basis of cost-effective- ness and the disease burden must include family planning, maternity care, and preven- tion and control of STDs and AIDS. Examples of essential services with characteristics of public goods include iEcon available services and desirable health practices, immuniza- 144 IMPROVING WOMEN'S HEALTH IN INDIA tion at high levels of coverage, and disease surveillance and vital registration systems. Examples of essential ,ervices with externalities include maternity care, family plan- ning. and STD management. 2. It is worthwhile noting that both projects have substantial training components and have also developed rationalized work routines for fieldworkers. Glossary Medical terms Ankvloses. A stiffness or immobility of the joints caused by disease or surgery. DYsienorrhea. Painful menstruation. Eclampsia. Convulsions and coma that occur during pregnancy, childbirth. or immediately following childbirth. Eclampsia is associated with a condition known as preeclampsia, whose primary symptoms are hypertension. edema, or proteinuria. Ecropic pregfnancv. A life-threatening condition in which the fertilized egg develops outside the uterus. often in the fallopian tube. Filaria. Parasites in the blood or tissues that can cause a number of diseases. Fistula (obstetric fistula). A rupture that results in an abnormal passage linking two areas such as the vagina and rectum or the bladder and abdominal cavity. Obstetric fistulae are caused by difficult labor, unsafe abortion, and traditional practices such as female genital mutilation. Pelvic inflammatory disease. A severe infection of the upper reproductive tract (Uterus, ovaries, and fallopian tubes) that can lead to infertility and ectopic pregnancy. Puerperiun. The six-week period following childbirth. 145 146 IMPROVING WOMEN'S HEALTH IN INDIA Reproductive tract itction. A general term for various types of infections affecting the female ovaries, uterus. vagina, and related areas, including vagi- nal and cervical infections, genital ulcer disease, and pelvic inflammatory dis- ease. These infections are transmitted through sexual contact and unhygienic practices during abortion, childbirth, and the insertion of intrauterine devices (lIUDs): they may also be caused by female genital mutilation. Sexuallv transnitred diseases (STDs). An umbrella term for various infections transmitted by sexual contact, including chancroid, chlamydia. genital herpes, gonorrhea. human papillomavirus. syphilis, and trichomoniasis. Uterine prolapse. A condition in which the uterus sinks into or extends outside the vagina. Uterine prolapse can be caused by injuries during childbirth or by aging. Other terms Burden of disease. The loss of healthy life from premature mortality and dis- ability. Child mortality rate. The annual number of deaths per 1,000 children ages 1-4. Child mortality rates sometimes include deaths among all children under age 5. Excess female mortality. Female mortality that is greater than it would be in the absence of gender bias. Excess female mortality reflects unfavorable social. cultural, and economic factors that affect the health of females relative to that of males. Infant mortality rate. The annual number of deaths among children under age I per 1,000 live births. lnterrention (in health care). A specific activity meant to reduce the incidence or prevalence of a disease, treat an illness. or reduce the consequences of disease and disability. Life expectancy. The average number of additional years a person can expect to live if current mortality trends continue. Life expectancy at birth is the most common measure used to assess trends and compare subgroups. Low birthweight. A weight at birth of less than 2,500 g (approximately 5.5 lbs). GLOSSARY 147 Maternal mortalir The death of a woman while pregnant or within forty-two days of the termination of a pregnancy from any cause related to or aggravated by the pregnancy or its management (but not from accidental or incidental causes). Maternal mortalitv rate. The annual number of deaths among women ages 15- 49 from complications of pregnancy and childbirth, per 100,000 women in this age group. This rate is influenced by the likelihood of becoming pregnant, as well as the risk of dying in childbirth. Maternal mortalitv ratio. The annual number of deaths among pregnant women from complications of pregnancy and childbirth, per 100.000 live births. This ratio measures a woman's chance of dying once pregnant. Neonatal death. The death of an infant born alive within the first twenty-eight full days of life. Neonatal deaths can be subdivided into earl' neonatal deaths, which occur during the first seven days of life, and late neonatal deaths, which take place after the seventh but before the twenty-eighth day. Neonatal death rate. The number of deaths per 1,000 live births during the first full twenty-eight days of life. Perinatal mortalitv rate. The number of late fetal deaths and early neonatal deaths per 1,000 live births. Late fetal deaths are those occurring at twenty- eight weeks of gestation or later. Early neonatal deaths are those that occur within the first seven days of life. Perinatal mortality is influenced by the health of the mother, the quality of care during pregnancy and delivery, and care of the newborn during the first week of life. Postneonatal mortality. Death of an infant between the ages of twenty-eight days and one year. Total fertilit, rate. The average number of children a woman will bear in her lifetime. Unsafe abortion. 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