62966 RepRoDuctIve HealtH at a GLANce June 2011 INDIA country context India: MDG 5 Status India has experienced remarkable growth over the past de- MDG 5A indicators cade and now has the fourth largest economy in purchasing Maternal Mortality Ratio (maternal deaths per 100,000 live 230 power parity terms.1 It is home to 15 percent of the world’s births) UN estimatea population—a population of great diversity in culture, lan- guage and religion. India has also made progress on most Births attended by skilled health personnel (percent) 52.7 of the Millennium Development Goals (MDGs) and has MDG 5B indicators invested resources generated from growth into programs to Contraceptive Prevalence Rate (percent) 54.0 deliver services to the poor.1 Poverty is widespread in India Adolescent Fertility Rate (births per 1,000 women ages 15–19) 67.1 with 42 percent of the population, or 456 million people,2 Antenatal care with health personnel (percent) 75.2 subsisting on less than US $1.25 per day.3 Unmet need for family planning (percent) 12.8 India’s large share of youth population (32 percent of the country population is younger than 15 years old3) provides Source: Table compiled from multiple sources. a Sample Registration System estimate for the period 2004–06 is 254. a window of opportunity for high growth and poverty re- duction—the demographic dividend. But for this opportu- nity to result in accelerated growth, the government needs MDG target 5A: Reduce by three-quarters, between to invest in the human capital formation of its youth. 1990 and 2015, the Maternal Mortality Ratio Gender equality and women’s empowerment are impor- India has been making progress over the past two decades on ma- tant for improving reproductive health. Higher levels of ternal health but it is not yet on track to achieve its 2015 targets.8 women’s autonomy, education, wages, and labor market participation are associated with improved reproductive Figure 1 n Maternal mortality ratio 1990–2008 and 2015 target health outcomes.4 The ratio of females to males ages 0-6 is 600 91.4 to 100 which is the lowest since 1947.5 This a result 570 of the natural sex ratio at birth, combined with sex-selec- 500 470 tive abortions and discrimination against girls resulting in 400 390 higher mortality for females than males.6 300 280 MDG 230 Target In India, the literacy rate among females ages 15 and 200 140 above has increased from 65 percent in 2001 to 74 per- 100 cent in 2011.5 Fewer girls are enrolled in secondary schools 0 compared to boys with a ratio of female to male second- 1990 1995 2000 2005 2008 2015 ary enrollment of 86 percent.3 36 percent of adult women Source: 2010 WHO/UNICEF/UNFPA/World Bank MMR report. participate in the labor force3 that mostly involves work in agriculture. Gender inequalities are reflected in the coun- try’s human development ranking; India ranks 113 of 157 World Bank Support for Health in India countries in the Gender-related Development Index.7 The Bank’s new Country Assistance Strategy Progress Report under preparation (P121340) was approved by the Bank’s executive Board on Economic progress and greater investment in human November 30, 2010. capital of women will not necessarily translate into bet- current projects: ter reproductive outcomes if women lack access to repro- P071160 Karnataka Health Systems ($119.14m) ductive health services. It is thus important to ensure that P078538 Third National HIV/AIDS Control Project ($180m) health systems provide a basic package of reproductive P094360 National VBD Control&Polio Eradication ($521m) health services, including family planning.4 P118830 Tamil Nadu Health Additional Financing ($109.46) P078539 TB II ($141.1) pipeline projects: P121731 ICDS Syst. Strength. & Nut. Imp. Prog. Appraisal date 12/9/2010 P10034 SECOND UTTAR PRADESH HEALTH SYSTEMS STRE Appraisal date THE WORLD BANK 3/15/2011 n Key challenges is the most commonly used method (34 percent), followed by the pill (4 percent). There are socioeconomic differences in the use of modern contraception among women: modern contra- Fertility is declining ceptive use is 58 percent among women in the wealthiest quintile Fertility has been declining over time but remains high among and 35 percent among those in the poorest quintile (Figure 4).9 the poorest. Total fertility rate (TFR) decreased from 3.4 births There is less difference by education level, but a similar trend can per woman in 1990–92 to 2.9 births per woman in 1996–98 to 2.7 be seen: 46 percent of women with no education use modern in 2005–06.9 Fertility remains higher among the poorest Indians contraception as compared to 50 percent of women with second- at 3.9 in contrast to 1.8 among the wealthiest (Figure 2). Similarly, ary education or higher. TFR is 1.8 among women with secondary education or higher compared to 3.6 among women with no formal education. It is Figure 4 n use of contraceptives among married women by wealth also lower among urban women at 2.1, compared to rural women quintile at 3.0 births per woman.9 80 70 60 7.3 9.5 Figure 2 n total fertility rate by wealth quintile 50 7.6 7.0 55.2 58.0 40 49.8 4.5 7.6 43.5 4.0 3.9 30 34.6 3.5 3.2 20 3.0 2.6 2.7 overall 10 2.5 2.2 0 2.0 1.8 1.5 Poorest Second Middle Fourth Richest 1.0 0.5 Modern Methods Traditional Methods 0.0 Poorest Second Middle Fourth Richest Source: DHS Final Report, India 2005–06. Source: DHS Final Report, India 2005–06. The overall contraceptive use was 56.3% in 2005–06. Adolescent fertility adversely affects not only young wom- Unmet need for contraception is moderate at 21 percent11 en’s health, education and employment prospects but also that indicating that women may not be achieving their desired of their children. Births to women aged 15–19 years old have the family size.12 highest risk of infant and child mortality as well as a higher risk of Although it is illegal to opt for an abortion based on the gen- morbidity and mortality for the young mother.4, 10 In India, ado- der of the fetus, prosecution is uncommon.6 Unsafe abortion lescent fertility rate is moderate at 67 reported births per 1,000 accounts for about 9 percent of maternal deaths each year, ap- women aged 15–19 years. proximately 15,000. Further, estimates suggest that in 2002 and Early childbearing is more prevalent among the poor. While 2003, 3.6 million abortions, or 50 percent of the total number 50 percent of the poorest 20–24 years old women have had a child performed, were unsafe.13 before reaching 18, only 9 percent of their richer counterparts did Opposition to use, health concerns or fear of side effects are (Figure 3). The rich-poor gap in prevalence of early childbearing the predominant reasons women do not intend to use modern has increased across cohorts. contraceptives in future, not including fertility related reasons Figure 3 n percent women who have had a child before age 18 (such as menopause and infecundity). Nine percent not intend- years by age group and wealth quintile ing to use contraception cited health concerns or fear of side ef- 70% fects as the main reason while 15 percent expressed opposition 60% Poorest to use, primarily by themselves, their husband, or due to their 50% Poorest Poorest 40% religion.9 Cost and access are lesser concerns, indicating further 30% need to strengthen demand for family planning services. Richest 20% Richest 10% Richest 0% 20–24 years 25–34 years >34 years poor pregnancy outcomes While the majority of pregnant women use antenatal care, Source: DHS Final Report, India 2005–06 (author’s calculation). institutional deliveries are less common. Seventy-five percent Use of modern contraception is increasing. Use of contracep- of pregnant women receive antenatal care from skilled medi- tion among married women was 54 percent in 2007-08, up from cal personnel (Doctor/Nurse/midwife/Lady Health Visitor/ 48 percent in 1998-99 and 41 percent in 1992–93.9, 11 More mar- Auxiliary nurse Midwife/Other health personnel) with 50 per- ried women use modern contraceptive methods than traditional cent having three or more antenatal visits.11 However, a smaller methods (47 percent and 7 percent, respectively).11 Sterilisation proportion, 52 percent deliver with the assistance of skilled medical personnel.11 While 89 percent of women in the wealthi- and 70 percent of men know that condoms can help reduce risk est quintile delivered with skilled health personnel, only 19 per- of transmission. The proportion of Indians who know that the cent of women in the poorest quintile obtained such assistance risk of transmission from mother-to-child can be reduced by (Figure 5). Further, half of all pregnant women are anaemic (de- using medication is 19 percent for females and 20 percent for fined as haemoglobin < 110g/L) increasing their risk of preterm males.9 delivery, low birth weight babies, stillbirth and newborn death.14 There is a large knowledge-behavior gap regarding condom Figure 5 n Birth assisted by health personnel (percentage) by use for HIV prevention. While most young women are aware wealth quintile that using a condom in every intercourse prevents HIV, only 5 100 percent of 15–19 year olds report having used condom at last in- 88.7 tercourse (Figure 6). This gap widens among older aged women 80 67.2 likely due to the fact that the chances of using condoms as a form 60 46.6% overall 49.1 of contraception diminishes with marriage. 40 31.9 Figure 5 n Knowledge behavior gap in HIv prevention among young 19.4 20 women 0 30% Poorest Second Middle Fourth Richest 25% Source: DHS Final Report, India 2005–06. 20% The overall contraceptive use was 56.3% in 2005–06 15% 10% Among all women ages 15–49 years who had given birth, 59 5% percent had no postnatal care within 6 weeks of delivery while 0% 4 percent received postnatal check-up from a traditional birth 15–19 years 20–24 years attendant.9 Knowledge Condom use at last sex Source: DHS Final Report, India 2005–06 (author’s calculation). Janani Suraksha Yojana(JSY) scheme Introduction of Janani Suraksha Yojana(JSY) scheme (Conditional Cash Transfers to poor pregnant women for in- stitutional delivery) resulted in a surge in demand for obstetric correspondence Details services. JSY beneficiaries availing public sector facilities have increased about 110 times from 0.704 million in 2005–06 to This profile was prepared by the World Bank (HDNHE, PRMGE, and 7.841 million in 2009–10.15 The number of institutional deliver- SASHN). For more information contact, Samuel Mills, Tel: 202 473 ies reported by public sector facilities has increased from 10.841 9100, email: smills@worldbank.org. This report is available on the million to 13.356 million during the same period. However, suc- following website: www.worldbank.org/population. cessive Joint Review Mission (JRM) reports indicate that provi- sion of quality services on the supply side has not kept pace. The provision of cost effective evidence based services are critical to translation of this increased demand into the desired outcome of technical Notes: an accelerated decline in maternal mortality. Improving Reproductive Health (RH) outcomes, as outlined in the Human resources for maternal health are limited with only RHAP, includes addressing high fertility, reducing unmet demand for contraception, improving pregnancy outcomes, and reducing STIs. 0.6 physicians per 1,000 population but nurses and midwives are slightly more common, at 1.27 per 1,000 population.3 The RHAP has identified 57 focus countries based on poor reproductive health outcomes, high maternal mortality, high fertility and weak health systems. Specifically, the RHAP identifies high priority countries as HIv prevalence is low in India although knowledge of those where the MMR is higher than 220/100,000 live births and TFR is greater than 3.These countries are also a sub-group of the Countdown risk reduction is poor to 2015 countries. Details of the RHAP are available at www.worldbank. HIV prevalence is low in India at 0.3 percent of the population org/population. ages 15–49 years.3 The Gender-related Development Index is a composite index developed by the UNDP that measures human development in the same dimensions Knowledge of HIV and HIV prevention methods is gener- as the HDI while adjusting for gender inequality. Its coverage is limited ally low. Sixty-one percent of women and 83 percent of men in to 157 countries and areas for which the HDI rank was recalculated. India have heard of AIDS. Thirty-six percent of Indian women n Key Actions to Improve RH outcomes Strengthen gender equality • Expand the use of private sector capacity for provision of vari- • Support women and girls’ economic and social empowerment. ous services Increase school enrollment of girls. Strengthen employment Reducing maternal mortality prospects for girls and women. Educate and raise awareness on the impact of early marriage and child-bearing. • Strengthen the referral system by instituting emergency trans- • Educate and empower women and girls to make reproductive port systems training health personnel in appropriate referral health choices. Build on advocacy and community participation, procedures (referral protocols and recording of transfers). • Improve quality of services (basic and comprehensive obstetric and involve men in supporting women’s health and wellbeing. care) by introducing and using standard treatment protocols and Reducing high fertility guidelines to be used by skilled attendants at birth at all levels • Address the issue of opposition to use of contraception and • Utilize services of newly introduced village level workers promote the benefits of small family sizes. Increase family plan- (ASHA) for improving access to quality antenatal services, nu- ning awareness and utilization through outreach campaigns trition and management of anemia among pregnant women and messages in the media. Enlist community leaders and and improving access to home level postnatal and neonatal care. women’s groups. • Build capacity in public sector and engage with the private sec- • Leverage the increasing number of women coming to institu- tor to provide quality services. tions for delivery under JSY scheme by providing postpartum • Address the inadequate human resources for health by train- counseling and voluntary services for family planning. ing more skilled birth attendants and deploying them to the • Provide quality family planning services that include coun- poorest or hard-to-reach areas. Multiskilling of health profes- seling and advice, focusing on young and poor populations. sionals at all levels including training of general physicians in Highlight the effectiveness of modern contraceptive methods anesthesia and cesarean sections for providing comprehensive and properly educate women on the health risks and benefits emergency obstetric care of such methods. • Promote institutional delivery through provider incentives and • Promote the use of ALL modern contraceptive methods, in- implement risk-pooling schemes. Provide vouchers to women cluding long-term methods, through proper counseling which in hard-to-reach areas for transport and/or to cover cost of de- may entail training/re-training health care personnel. livery services. • Secure reproductive health commodities and strengthen sup- Reducing StIs/HIv/AIDS ply chain management to further increase contraceptive use as • Integrate HIV/AIDS/STIs and family planning services in rou- demand is generated. tine antenatal and postnatal care. • Strengthen post-abortion care (treatment of abortion compli- • Focus HIV/AIDS providing information, education and com- cations with manual vacuum aspiration, post-abortion family munication efforts on adolescents, youth, married women, and planning counseling, and appropriate referral where necessary) other high risk groups including IDUs, sex workers and their and link it with family planning services. clients, and migrant workers. References: 1. World Bank. India Country Profile. http://go.worldbank.org/ZUIBUQT360. 10. WHO 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: WHO. 2. The Hindu (Chennai, India). August 28, 2008. World Bank’s new pov- http://www.who.int/making_pregnancy_safer/topics/adolescent_pregnancy/ erty norms find larger number of poor in India. http://www.hindu. en/index.html. com/2008/08/28/stories/2008082856061300.htm. Accessed June 8, 2011. 11. International Institute for Population Sciences (IIPS), 2010. District Level 3. World Bank. 2010. World Development Indicators. Washington DC. Household and Facility Survey (DLHS-3), 2007–08: India: Key Indicators: 4. World Bank, Engendering Development: Through Gender Equality in States and Districts, Mumbai: IIPS. Rights, Resources, and Voice. 2001. 12. Samuel Mills, Eduard Bos, and Emi Suzuki. Unmet need for contracep- 5. Preliminary findings of the 2011 India Census. tion. Human Development Network, World Bank. Available at http://www. 6. Christian Science Monitor. Gender selection: In India, abortion of girls on worldbank.org/hnppublications. the rise. March 8, 2010. http://www.csmonitor.com/World/Asia-South-Cen- 13. Hindustan Times. Most unsafe abortions in India. August 9, 2008. tral/2010/0308/Gender-selection-In-India-abortion-of-girls-on-the-rise/ http://www.hindustantimes.com/Most-unsafe-abortions-in-India/ (page)/2. Article1-330041.aspx>. Accessed June 8, 2011. 7. Gender-related development index. http://hdr.undp.org/en/media/ 14. Worldwide prevalence of anaemia 1993–2005: WHO global database on anae- HDR_20072008_GDI.pdf. mia/Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell. 8. Trends in Maternal Mortality: 1990-2008: Estimates developed by WHO, http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf. UNICEF, UNFPA, and the World Bank. 15. All India Summary of National Rural Health Mission Programme-31/1/2010, 9. International Institute for Population Sciences (IIPS) and Macro International. Ministry of Health and Family Welfare. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS. INDIA RepRoDuctIve HeALtH ActIoN pLAN INDIcAtoRS Indicator Year Level Indicator Year Level Total fertility rate (births per woman ages 15–49) 2005/06 2.7 Population, total (million) 2008 1140 Adolescent fertility rate (births per 1,000 women ages 15–19) 2008 67.1 Population growth (annual %) 2008 1.3 Contraceptive prevalence (% of married women ages 15–49) 2007/08 54 Population ages 0–14 (% of total) 2008 31.7 Unmet need for contraceptives (%) 2005/06 12.8 Population ages 15–64 (% of total) 2008 63.5 Median age at first birth (years) from DHS — — Population ages 65 and above (% of total) 2008 4.8 Median age at marriage (years) 2005/06 17.7 Age dependency ratio (% of working-age population) 2008 57.5 Mean ideal number of children for all women — — Urban population (% of total) 2008 29.5 Antenatal care with health personnel (%) 2007/08 75.2 Mean size of households 2005/06 5 Births attended by skilled health personnel (%) 2007/08 52.7 GNI per capita, Atlas method (current US$) 2008 1040 Proportion of pregnant women with hemoglobin <110 g/L 2008 49.7 GDP per capita (current US$) 2008 1017 Maternal mortality ratio (maternal deaths/100,000 live births) 1990 570 GDP growth (annual %) 2008 6.1 Maternal mortality ratio (maternal deaths/100,000 live births) 1995 470 Population living below US$1.25 per day 2005 41.6 Maternal mortality ratio (maternal deaths/100,000 live births) 2000 390 Labor force participation rate, female (% of female population ages 15–64) 2008 35.7 Maternal mortality ratio (maternal deaths/100,000 live births) 2005 280 Literacy rate, adult female (% of females ages 15 and above) 2006 50.8 Maternal mortality ratio (maternal deaths/100,000 live births) 2008 230 Total enrollment, primary (% net) 2007 95.5 Maternal mortality ratio (maternal deaths/100,000 live births) target 2015 140 Ratio of female to male primary enrollment (%) 2007 96.8 Infant mortality rate (per 1,000 live births) 2008 52.3 Ratio of female to male secondary enrollment (%) 2007 85.7 Newborns protected against tetanus (%) 2008 86 Gender Development Index (GDI) 2008 113 DPT3 immunization coverage (% by age 1) 2008 66 Health expenditure, total (% of GDP) 2007 4.1 Pregnant women living with HIV who received antiretroviral drugs (%) 2005 1.8 Health expenditure, public (% of GDP) 2007 26.2 Prevalence of HIV, total (% of population ages 15–49) 2007 0.3 Health expenditure per capita (current US$) 2007 40.3 Female adults with HIV (% of population ages 15+ with HIV) 2007 38.3 Physicians (per 1,000 population) 2005 0.6 Prevalence of HIV, female (% ages 15–24) 2007 0.3 Nurses and midwives (per 1,000 population) 2004 1.27 poorest-Richest poorest/Richest Indicator Survey Year poorest Second Middle Fourth Richest total Difference Ratio Total fertility rate DHS 2005/06 3.9 3.2 2.6 2.2 1.8 2.7 2.1 2.2 Current use of contraception (Modern method) DHS 2005/06 34.6 43.5 49.8 55.2 58.0 48.5 –23.4 0.6 Current use of contraception (Any method) DHS 2005/06 42.2 51.1 56.8 62.5 67.5 56.3 –25.3 0.6 Unmet need for family planning (Total) DHS 2005/06 18.2 14.8 12.8 10.6 8.1 12.8 10.1 2.2 Births attended by skilled health personnel DHS 2005/06 19.4 31.9 49.1 67.2 88.7 46.6 –69.3 0.2 (percent) Development partners Support for Reproductive Health in India The Reproductive and Child Health II program is led by the Ministry The pooling partners providing financial assistance through the common of Health and Family Welfare, Government of India and is supported pooled fund are: UNFPA, DFID (till 2010) and the World Bank. Other by various partners through pooled financial assistance or technical partners providing technical assistance include assistance to the program. All assistance is coordinated towards this USAID, UNICEF, WHO, GTZ, JICA, SIDA, EC and BMGF. The EC is also program with a common results framework and strategies to address RCH providing budget support to the MOHFW supporting some of the goals of related issues in India. the RCH II program. In addition, there are several NOGs (international and national) that work on several RCH related issues in India. National policies and Strategies that have Influenced Reproductive Health The Government of India has been focusing on improving reproductive health through a series of programs over the last two decades, including the Child Survival and Safe Motherhood Program (CSSM 1992–97), the Reproductive and Child Health (RCH) Phase I (1997–2004) and more recently through the RCH II Program, which is part of the flagship National Rural Health Mission (NRHM 2005–12). During this period India has made a perceptible shift from the high risk approach prior to CSSM Program to essential care for all pregnant women during CSSM and to ‘skilled attendance for all births’ during RCH II. The National Program Implementation Plan (NPIP) outlines the technical strategies, the goals, implementation plan and the results framework. Under the current programs (RCH II/NRHM), there are interventions to improve demand for overall RCH services, including obstetric services and also to strengthen and expand the supply side to provide quality RCH services. The demand side interventions include use of Conditional Cash Transfers to poor pregnant women for institutional delivery (JSY – Janani Suraksha Yojana) and use of community health workers (ASHAs – Accredited Social Health Activist). The supply side interventions include preparing standards of care at various levels, upgrading public sector hospitals, entering into partnerships with the private sector, provision of emergency referral transport and strengthening program management systems. National policies National population policy – 2000 The NPP 2000 provides a policy framework for advancing goals and prioritizing strategies to meet the reproductive and child health needs of the people of India, and to achieve net replacement levels (TFR) by 2010. It is based upon the need to simultaneously address issues of child survival, maternal health, and contraception, while increasing outreach and coverage of a comprehensive package of reproductive and child health services by government, industry and the voluntary non-government sector, working in partnership. National Health policy 1983 – Revised and Updated in 2002. Facilitating LAWS/ActS Medical termination of pregnancy Act – 1974, amended 2004 – Act permits MTPs under predefined circumstances – Purpose was to reduce/control unsafe abortions for reducing MMR. Maternity Benefit Act 1961 – For providing maternity leave and benefit to women employees. child Marriage Restraint Act – 1929 the Registration of Births and Deaths Act – 1969