93603 Knowledge Brief Health, Nutrition and Population Global Practice INDIA: MATERNAL AND REPRODUCTIVE HEALTH AT A GLANCE Sameh El-Saharty, Naoko Ohno, Intissar Sarker, Federica Secci, and Vikram Rajan November 2014 Country Context KEY MESSAGES: India includes 28 states and 7 union territories. It has • India is the third largest economy and has the second largest population in the world (1.2 billion people) and is the third largest economy in the world the second largest population in the world. in purchasing power parity. On average, real GDP It achieved MDG1 on poverty reduction; expanded 7.9 percent annually between FY2003-04 and however, gender inequality still persists. FY2012-13. 1, 2 India achieved MDG 1 by halving the proportion of • Maternal mortality rate is 190 deaths per people earning less than $1.25 a day. Nonetheless, 100,000 live births, representing a 65 one-third of the world’s poor live there. Structural percent decline from 1990. inequalities by gender, caste, and tribe persist in spite of accelerated growth and social mobility. India’s large youth • Fertility fell to 2.5, while contraceptive population could provide a demographic dividend through prevalence rate increased to nearly 55 high growth and poverty reduction; 29 percent are 1, 2 younger than 15. percent. Seventy-four percent of women sought ANC from a qualified provider and The country has progressed on most MDG targets, 52 percent of births were attended by investing resources from growth into programs to deliver services to the poor. Access to primary qualified providers. education is largely universal: net primary school enrollment is 93 percent and the completion rate is 96 • Wide gaps in CPR and access to skilled- percent for boys and girls. Child survival rates are birth attendance remain by geography and improving: U5MR and IMR were 56.3 and 43.8 per 1,000 wealth quintile. live births in 2012, compared with 84.7 and 62.2 in 2002. However, malnutrition has declined little during the past 1, 2 • India would focus on preventing decade. unwanted pregnancies especially among Gender equality and women’s empowerment are adolescents; improving demand-side important for improving reproductive health. The ratio strategies; strengthening access and of females to males has slightly improved to 940 from 933 quality in public and private sectors; in 2001, with a wide variation from 818 in Chandigarh to 1,084 in Kerala (2011 census). The ratio of girls to boys in improving antenatal, intranatal, and primary and secondary education is nearly equal. 1, 2 India postnatal care; strengthening M&E ranks 132 of 148 countries in the Gender Inequality Index systems and reducing inequities; and (2012). 3 improving nutrition. Page 1 HNPGP Knowledge Brief  choice and are used by 48.5 percent of currently married women. Female sterilization (37.3 percent) and condoms (5.2 percent) are the most commonly used form of modern methods. Traditional methods are used by 7.8 percent of currently married women. But 12.8 percent of married women still have an unmet need for 5 contraception. MDG Target 5a: Reduce the MMR by three-quarters, between 1990 and 2015 India has made solid gains over the past two decades on maternal health. The MMR declined from 560 deaths per 100,000 live births in 1990 to 190 in 2013 (figure 1). According to the latest Interagency estimates, India is “making progress” toward achieving MDG5.i Maternal mortality declined 65 percent with an average annual 4 decline of 4.5 percent between 1990 and 2013. Birth intervals of less than 24 months are considered too short: 27.7 percent of children are born within 24 months of the previous birth in India. The median number 5 of months since the preceding birth is 31.1 months. The median age at first marriage among women age 20-49 is 17.2 years and the median age at first birth among the same cohort is 20 years. The share of women age 15-19 that have begun childbearing is 16 percent. 5 The adolescent fertility rate is 32.8 births per 1 1,000 women age 15–19. Pregnancy Outcomes Complete and timely antenatal care (ANC) is a necessary component for positive pregnancy outcomes. As of 2006, 74.2 percent of women sought ANC from a qualified provider; 37 percent of women received the recommended four or more ANC visits; 59.5 percent of women had their blood pressure measured (a 5 component in a package of ANC services). Fertility Fertility has been declining in India. Between 1990 and Skilled birth attendance (SBA) is critical reducing 2012, the total fertility rate (TFR) declined from 3.9 to 2.5 maternal deaths. SBA by a qualified provider increased 1 (figure 2). from 34.2 percent in 1993 to 52.3 percent in 2008 (figure 3).1 The majority of births are delivered at home with The contraceptive prevalence rate (CPR) has been institutional delivery for 38.7 percent of all births (18 1 increasing over the past 20 years. The CPR (any percent in public sector facilities, 0.4 percent in NGO/trust 5 method) increased from 40.7 percent in 1993 to 54.8 facilities and 20.2 percent in private sector facilities). percent in 2008 (figure 2). Modern methods are the main Page 2 HNPGP Knowledge Brief  The main reason for not delivering in a facility is the There is wider variation in wealth quintiles for the belief that it is unnecessary (71.8 percent). Other CPR. The CPR in the richest quintile is 67.5 percent but 5 reasons include: costs too much (26.2 percent), too far/no only 42.2 percent in the poorest quintile (figure 5). transport (11 percent), not customary (6.3 percent), and 5 husband/family do not allow (5.9 percent). Disparities across residence and wealth quintiles are also found in SBA: More than two thirds (73.5 percent) of urban women are assisted during delivery by a Postnatal care is another important component for qualified provider but only half that rate (37.5 percent) maternal health, especially for managing post- among rural women (figure 6). 5 delivery complications. It is recommended that postnatal care for mothers occur within the first two days of delivery. Of women, 37.3 percent sought this type of care from a qualified provider within the first two days of 5 delivery. Equity in Access to Maternal Health Services Inequity in access to maternal health services is a barrier in the progress toward achieving MDG 5 . While contraceptive use and SBA has been increasing throughout the years, disparities remain. The gap between the CPR in urban and rural areas is fairly small. The CPR in urban areas is 64 percent and 5 53 percent in rural areas (figure 4). Considerable variations in SBA also exist among wealth quintiles. Women in the richest quintile are more likely than women in the poorest quintile to have SBA. Only 19.4 percent of women in the poorest quintile 5 receive SBA but 88.8 percent in the richest (figure 7). Page 3 HNPGP Knowledge Brief  Key Strategies to Improve Maternal and Reproductive Health Outcomes Preventing unwanted pregnancies with a focus on adolescents by providing safe abortion and FP services; doorstep delivery of FP products; delaying age at marriage; delaying first pregnancy; creating adolescent friendly clinics; expanding the basket of FP products; increasing the uptake of male contraception — considering the very low participation of men; continuing education of girls—perhaps through CCTs building on JSY; and providing post-partum counseling for FP. Improve use of demand side strategies, including financing and behavior change communication. Strengthening the supply side response (access and quality) using public and private sector by increasing the number of delivery points; mapping of public and private facilities to provide comprehensive EmONC services within 30 minutes; promoting institutional One program that aims to improve institutional deliveries; and ensuring an effective referral system. delivery and postnatal care among the poor is the Janani Suraksha Yojana (JSY) Safe Motherhood Improving antenatal, intranatal, and postnatal care Program. JSY provides incentives on both the supply and by identifying complications and high-risk pregnancies demand sides and has been credited with increasing early, for example, anemia, line listing, screening for service utilization. NCDs; ensuring timely referral and treatment of high-risk pregnancies; ensuring post-natal visits; and building HIV/AIDS capacity for service providers to ensure quality of care. As of 2012, there were about 2.4 million people living with Strengthening M&E systems, including focus on HIV in India. The adult prevalence rate for HIV was 0.3 reducing inequities, by registering all pregnant women percent. Women’s share of HIV infections is 39 percent. early; and conducting maternal death audits. HIV infections are mainly transmitted through unprotected heterosexual intercourse and are largely driven by sex Improving nutritional status by addressing maternal workers and their clients. India’s response to HIV/AIDS is nutrition, for example, IFA supplementation; and post- delivered through more than 1000 nongovernmental and partum counseling for child nutrition. 6 community-based organizations. References: 1 World Bank. World Development Indicators 2014: Accessed 19 May 2014 2 India:Country Program Snapshot. March 2014, the World Bank 3 UNDP. 2013 Human Development Report Gender Inequality Index 4 WHO, UNICEF, UNFPA and The World Bank. 2014. Trends in Maternal Mortality: 1990 to 2013: World Health Organization 5 International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS. 6 World Bank. 2012. “HIV/AIDS in India”. http://www.worldbank.org/en/news/feature/2012/07/10/hiv-aids-india For more information on this topic, go to: www.worldbank.org/health. Page 4