THREAT OF MATERNAL HEALTH IN INDIAN SOCIETY: A SOCIO-ECONOMIC APPROACH
Dr. Subhash Chandra Verma
Senior Lecturer
Department of Sociology
Government Post Graduate College, Rudrapur-263153, INDIA
(Affiliated to Kumaon University Nainital, INDIA)
Tel.- 0091 5944 243474, Cell. Phone- 0091 9411195542
Email- subhashvermaphd@yahoo.com
Abstract
This research paper deals with the problem of maternal health care in different segments of Indian societies. Vast difference is found in availing health facilities in different Social & Economic groups. There are many social, cultural and economic groups existing in Indian society simultaneously .Their standard of living and awareness varies according to their socio-economic status. There is very poor status of maternal health in rural and backward areas. This study is based on data of third National Family Health Survey (NFHS-3). Data have been analyzed with the help of related other literature. Maternal health care is studied in different groups of the Indian society such as Residential status, Cast, Economic status, Educational status etc. The study revealed that poverty, illiteracy, lack of communication and transportation are responsible for poor maternal health status in Indian rural society. In India a woman dies in child birth every 5 minutes…Indian accounts for more then 20 % of global maternal and child deaths. There are more requirements for improving maternal health care in Indian society. Government of India is trying to increase maternal health care with help of Third sector but situation is not so favorable.
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Key Words
Maternal Health, Third Sector, Cast, Group, Class, Poverty, Illiteracy, Rural, Urban, Birth, etc.
Introduction
There are many social, cultural and economic groups existing in Indian society simultaneously .Their standard of living and awareness varies according to their socio-economic status. There are two major parts of population in India 1- Rural Communities (70%) and 2-Urban communities (30%). Rural communities have lack of Economic, Educational progress. Indian society has four major social classes 1- General Casts, 2- Scheduled Cast, 3-Other Backward Cast, and 4-Schedualed Tribes. Every class has various social, economic and educational statuses; these are reasons of various status of awareness. Rural and Backward communities have not more awareness about Education and Health. Every class has different figure of health awareness. Same situation apply on matter of maternal health care in Indian society. Apart from household wealth status, educational level of individual women, religion, and cast have been shown to affect the uptake of maternal health and delivery services. Additionally parity, the experience of previous problems, actual need and traditional views of childbirth are all important in determining the care that a woman may ultimately receive at delivery (Matthews 2002) Third National Family Health Survey (NHFS-3) has been conducted in 2005-2006 by International Institute for Population Science, Mumbai it is supported by Ministry of Health and Family Welfare Government of India with great help of UNICEF, USAID, DFID, UNFPA and AVAHAN. Technical assistance for NFHS-3 was provided by Operation Research Group (ORC), National Aids Control Organization (NACO). NFHS-3 collected more information about health care and awareness in various social- economic classes of Indian society. We can say that this survey has been conducted with help of Third Sector.
Indian government and NGOs are trying to encourage awareness about Health and education in these rural and backward communities, but at least there is no enough progress in this matter. Health department of Indian government has not enough infrastructures for best health services that are why there are more needs of Third Sector Role. Promotion of maternal and child health has been one of the most important objectives of the Family Welfare Programme in India. The current Reproductive and Child Health Programme (RCH) was launched in October 1997. The RCH Programme incorporates the components covered under the Child Survival and Safe Motherhood Programme and includes an additional component relating to reproductive tract infection and sexually transmitted infections. In order to improve maternal health at the community level a cadre of community level skilled birth attendant who will attend to the pregnant women in the community is being considered.
The need for bringing down maternal mortality rate significantly and improving maternal health in general has been strongly stressed in the National Population Policy 2000. This policy recommends a holistic strategy for bringing about total intersectoral coordination at the grass root level and involving the NGOs, Civil Societies, Panchayati Raj Institutions and Women’s Group in bringing down Maternal Mortality Ratio and Infant Mortality Rate. Reduction of maternal mortality is an important goal. The Department of Family Welfare has taken several new initiatives, during the current Ninth Plan period, to make the programme broad based and client friendly. The focus was, accordingly, shifted from individualized vertical interventions to a more holistic and integrated life cycle approach giving more focused attention to the reproductive health care. The Maternal Health Programme which is a component of the Reproductive and Child Health Programme aims at reducing maternal mortality to less than 100 by the 2010. The major interventions include:
In India a woman dies in child birth every 5 minutes…Indian accounts for more then 20 % of global maternal and child deaths. (Bakshi, 2006).One of the major goals of Government of India’s Department of Health and Family Welfare is to reduce maternal mortality and morbidity. The focus has shifted from individualized interventions to attention to the reproductive health care, which includes skilled attendance at birth, operationalising Referral Units and 24 hours delivery services at Primary Health Centers. And initiation of Janani Suraksha Yojna (National Maternity Benefit Scheme).Improvement of maternal health is also a major goal in Millennium Declaration. UNICEF is working to achieve the international community’s commitment to the Millennium Development Goals (MDG) that speaks directly to the rights and needs of women and children. The fifth MDG seeks to reduce maternal mortality by three quarters by 2015. The proposed framework for action has been designed and implemented to support the GOI and State governments in the acceleration of the second phase of the National Reproductive and Child Health Programme (RCH II) for the period 2004 – 2007. As one of its priority activities, UNICEF is supporting the development and implementation of Maternal and Perinatal (child death within 7 days of birth) Death Inquiries (MAPEDI) as a tool to strengthen community participation in evidence-based district-level(Bakshi 2006). Profile survey of 1994 yields an estimate of maternal mortality of 544 per 100,000 births in rural India for a period roughly 12 years before the survey. Maternal mortality ratio was more than 600 in east and north central India, while it was 300 to 400 in north-western and southern India (Mari Bhat 2007). Improving women’s maternal health and literacy are critical to building stronger families and communities in India. Yet today twice as many women as men are illiterate. More than 100.000 Indian women die in pregnancy and childbirth each year (CEDPA 2007). USAID,s goal is to help India reduce the number of people living in poverty by half by 2015,but India’s alarming population growth poor health. India has one sixth of the world’s population and one third of the world’s poor (USAID 2007). The earlier efforts of the government to promote balance regional development have failed to yield result. NGOs can play a crucial role in this regard, not directly but indirectly. In recent years NGOs are playing an important role in the rural development (Thimmaiya 2006). High maternal mortality rate is serious problem of India, study says that nearly 90 per cent of abortions in India are performed under potentially unsafe conditions in unapproved facilities, by providers ranging from qualified doctors to those who without any training or qualifications. About 9 per cent of maternal deaths in rural India are due to complications of abortions (Pallikadavath & Stone 2006).
Methodology
In this study secondary Data have been used. Primary survey has been conducted by Department of Health under Government of India (National Family Health Survey-3, year 2005-06). Data of NFHS-3 is the main base of this study but other related literature used also in describing of maternal health status and role of Third Sector in this matter. The National Family Health Survey-3 provided information about population, health and nutrition in India and each of 29 states. The survey is based on a sample of households which a representative at the national and state levels. That is why I used DATA of NFHS-3 for this study of maternal health care situation in India. The Statistical Tools have been used in analysis of Data like Tables; Graph etc. Data have been analyzed with the help of related literature. The Research Design selected for this Study is Exploratory and Descriptive. Reported related literature has taken from websites, Journals etc. It’s very helpful in writing of introduction of this study. For required help available Departmental and Government’s reports have also used. Some statements are based on personal observations on related matter. Author is belonging to rural Indian society and he is working as Programme Officer in National Service Scheme also. That’s why he has Grass Root observation of rural Indian society. Some facts of this study are based on other researcher’s approach. The overall this study is explaining the real fact of maternal health care in various Indian communities.
There is very poor maternal health awareness in India especially in rural areas. Table-1 shows that rural people are very poor in maternal health care; only 42.8 per cent mothers had at least three antenatal care visits for their last birth. In urban areas this figure is 73.8 it’s more than rural but it’s not enough. In the matter of IFA (iron folic acid) 90 days dosage only 34.5 per cent mothers in urban and 18.1 per cent in rural consumed IFA dosage for 90 days or more.. Institutional birth rate is very down in rural India, it’s only 31.1 percent and in urban areas this figure is 69.4. That is why only 39.1 per cent births assisted by doctor/nurse or other trained health personnel in rural areas. People of rural society are very lazy in matter of postnatal care, only 28.1 per cent mothers received postnatal care within tow days of their last birth, in urban areas this figure is 60.7 it means urban people are more careful in this matter. There are 70 per cent population is living in rural and 30 per cent in urban areas but maternal health care figure in rural is near to half of urban, it is mark able fact. Rural people are poor in maternal health care. Problem of convention is also responsible for this poor figure in rural areas. Rural women don’t like to eat more medicines or other related health care things. Maximum people of rural Indian society like traditional birth at home with help of traditional birth personnel. She is called as “Dai”. This may be due to fact that poverty, illiteracy, lack of transportation etc. are the main reasons for this poor figure.
There are four main social classes in Indian society approved by constitution of India scheduled cast, scheduled tribes, other backward casts, and general (also called “others” in table-2). Hindu religion has largest population in India. Scheduled cast are lower casts of Indian Hindu society, other backward casts are middle casts but these are backward in educational and economic status, General or others are high casts of Hindu society including other religious communities. In other backward casts some poor Muslims are also included. Scheduled Tribes are independent communities who living in forest and rural areas mostly. Every social class has different figure about maternal health care, table -2 shows that Generals or Others have more awareness in maternal health care and Scheduled Cast, Scheduled Tribes and Other Backward Casts are very poor in maternal health care. In Others or Generals maximum figures are more then 50 per cent but in SC, ST, and OBC all figures are blow 50 per cent. In the matter of consuming IFA 90 day’s dosage all communities have poor figures (Blow 30 per cent) and all communities are also poor in receiving postnatal care within 2 days after birth, this figure is blow 50 per cent in all. Scheduled Tribes have lowest figure in institutional birth because they like traditional birth procedure and care. There are many other factors (like Poverty, illiteracy, transportation problem) also responsible for this poor figure.
In the National Family Health survey-3 Indian society has divided in five main income groups, lowest, second, middle, fourth and highest. The Blow Poverty Line (BPL) people are including in lowest income group. There are maximum population is existed in lowest, second, and middle income groups in India. Table -3 shows that type of maternal health care in all groups are increasing according to economic groups. In the matter of IFA 90 days dosage every group have poor figure blow 50 per cent, in lowest income group this figure is only 9.7 this is mark able fact. This figure is near to half of all other figures. The women of all income groups do not like to take the more and regular medicines; this may be a reason for these poor figures in all groups. In the lowest income group institutional birth figure (13.8) and postnatal care (13.3) are found to be equal. This may be due to facts that mothers who have born their child in hospital or other institution, only they had postnatal care in lowest income group. In the fourth income group figure of antenatal care and birth assistance by doctor or other health personnel are found to be equal. The reason may be mothers who had at least three antenatal care visits for their last birth only they assisted by doctor/nurse/other health personnel. Economic factor is effecting very much in matter of maternal health care in Indian society. Table-3 shows that poor people have not well and enough maternal health care but rich people are advanced in this matter. Figures of maternal health are very poor in lowest income group.
There is the positive relationship between the economic and educational groups. People who are rich they are also well educated and who are poor they are maximum illiterate or have low status of education. That is why in the table -3 and 4 have near to same figures in lowest income group 26.2, 9.7, 20.4, 13.8, & 13.3 and Illiterate group 29.8, 9.5, 27.2, 19.8, & 17.6 respectively. Same trend is also seen between highest income group and high educated class. High income groups are mostly high educated so they know about maternal health care very well. They have more communication’s systems for getting knowledge about health and care but in rural and poor communities have lack of well communication. Institutional birth rate is very down (19.8%) in illiterate groups but in well literate group this figure is high (80.6).
Role of Third Sector
India is one of those countries where existed more gap between required and available health infrastructure. The existing infrastructure is not adequate even if we take into account the Census 1991 population. The gaps within the existing infrastructure and the services both within and outside the public sector need to be addressed. (Satpathy & venkatesh 2006). The number of SCs, PHCs and CHCs required and the shortfall as per 1991 rural population and as per the projected rural population for 2002 (End of 9th Plan), at all India level is indicated below (NCP, 2002). That’s why the role of third sector is most important for improving health services in India. In rural areas, the government delivers reproductive and other health services through its network of Primary Health Centers (PHCs), sub-centers, and other government health facilities. In addition, pregnant women and children can obtain services from private maternity homes, hospitals, private practitioners, and in some cases, nongovernmental organizations (NGOs). In urban areas, reproductive health services are available mainly through government or municipal hospitals, urban health posts, hospitals and nursing homes operated by NGOs, and private nursing and maternity homes.
The private sector plays a big role in delivery of health care, catering to 46 % of hospitals inpatients and 81% of outpatients (NCMH, 2005). There are many hospitals or other health institutions are servicing under the Non-Profitable Sector in India, for example – Christian Mission Hospitals, Rotary Club Hospitals and others many. International Organizations also helping financially and morally to health programmes in India, WHO, USAID, UNICEF, CEDPA, and UNICEF are main organizations of those. As per data available with the Planning Commission, there are 12265 NGOs in the country of which 91% are involved in social sector activities- 52.75% in Rural Development (RD), 17% in Human Resource Development (HRD), 10.15% Social Justice & Empowerment (SJ & E), 6.2% in Health & Family Welfare (H & FW), and 4.8% in Youth Affairs & Sports (YA & S) (NCP, 2002).The figure shows that There are only 6.2 % NGOs working in health and family welfare field. So we can say that there are more requirements of NGOs in health and family welfare field.
(Source: National Commission on Population, India Report-2002)
The National Population Policy of India-2000 Strongly recommended a holistic strategy for bringing about total intersectoral coordination at the grass root level and involving the NGOs, Civil Societies, Panchayati Raj Institutions and Women’s Group in bringing down Maternal Mortality Ratio and Infant Mortality Rate. The UN Millennium Development Goals call for reducing maternal mortality by three-quarters by 2015.As India works toward helping the world meet this goal, MAPEDI(Maternal and Parental Death Inquiries) data will provide concrete evidence that maternal mortality should be a national health priority(Bakshi,2006). USAID has been sanctioned enough financial help for improved health and reduced fertility in India. The figures are as followed- $ 90,669,000 (Year 2004), 93,385,000 (2005), 94,218,000 (2006), and 93,366,000 (2007). USAID’s goal is to help India reduce the number of people living in poverty by half by 2015 (USAID, 2007). This may be very helpful in improving maternal health because poverty is a main reason of poor maternal health in India. Centre for Development and Population Activities (CEDPA) –India helped from the White Ribbon Alliance for Safe Motherhood India (WRIA) in 1999 to bring critical attention and action to the need to make motherhood safer. CEDPA has provided technical assistance to the Innovations in family Planning Services project, training and empowering over 16,000 female community workers to provide counseling, contraceptive services and maternal and child health information in India’s most populous state of Uttar Pradesh(CEDPA-2007).
India’s mostly health schemes and programmes are running with great help of NGOs, Civil Societies and other Non-Profitable organizations. At present there are many schemes and programmes are conducting by Government of India under the National Rural Health Mission with help of Third Sector Role, For example- Janani Suraksha Yojna (Maternity benefit scheme). Main objectives of Janani Suraksha Yojna are Reduction in MMR & IMR and Focus of Institutional Delivery. Main features of this scheme are as followed – Encouraging Small Family Norms, Provision for Caesarean Section, Encouraging Pregnant Women to Undergo Tubectomy/Laparoscopy, Trained TBA to be Effective Link Between Field Level Health Functionary & the BPL Woman, Payment Of Incentive to Dai/ASHA,(Accredited Social Health Activists) Fund to be Released Through State Department of Family Welfare, Benefit to be Disbursed by ANM (Auxiliary Nurse Midwife) through Recoupable imprest. ASHAs are playing main role in this scheme. They are working at village or community level as link personnel between people and health care centers. We can say that ASHAs are working as guide to assess the health facilities for Anti-natal care, Institutional delivery, Post-natal care and counseling on nutrition and Family Planning Services.
ANMs (Auxiliary Nurse Midwife) are also main health personnel at grass root level in India. They are full filling the lack of Doctors in rural and backward areas. Government of India is providing good training and facilities for ANMs with help of NGOs & other Professional Bodies such as the Federation of Obstetrical and Gynecological society of India, the Indian Medical Association, Indian Association of Pediatrics and other many. (Satpathy & venkatesh 2006). ANMs are government employees but mostly NGOs of health sector are getting help from ANMs working in rural areas.
It is true that there are not enough and well maternal health care infrastructure and facilities in India but after all maternal health status is improving. Table-5 shows that figures of maternal health care are increasing continuously since NFHS-1 to NFHS-3. All figures such as antenatal care, birth assistance by doctor/nurse and institutional birth, are improving in this table. Some figures are not available of NFHS-1 & 2 such as IFA 90 day’s dosage and postnatal care in this table. National Family Health Survey is most important activity for health education and research in India. It is Mark able fact that this survey has been conducted by help of Third Sector Role.
Conclusion
After overall analysis we can say that maternal health care situation is not well and enough in present but it is better than past, it means status of maternal health care is improving but very slowly. Till now India has high rate of maternal and infant mortality. Poverty, illiteracy, lack of transportation, lack of communication, lack of infrastructure, and some other problems are main reason of poor maternal health in Indian rural society. Urban communities are more aware than rural about maternal health care. High educated and rich communities are very advance in maternal health care. Third Sectors (NGOs and other civil societies) are playing a big role in improving maternal health in India but number of NGOs in health and family welfare sector (6.20 % of all NGOs) is not enough. Government conducting many health schemes for maternal health with help of Third Sector. But speed of progress in maternal health is slow. The results are showing that poor and illiterate communities have lowest figure in every type of maternal health, approximately same situation in scheduled cats, scheduled tribes and other backward casts. After analysis of results we can say that there are more needs for improving economic, educational and social status of some Indian communities for increasing maternal health awareness. There are many challenges for Government and Third Sector in field of maternal health in Indian society.
References
Bakshi, 2006 UNICEF –India report www.unicef.org/infobycountry/india_33208.html
CEDPA, 2007 Report www.cedpa.org/section/wherewework/india
Mari Bhat P.N. 2007 Maternal Mortality in India: An Update (Article) Institute of Economic Growth Delhi.
Matthews Zoë 2002 Maternal Mortality and Poverty, DFID’s Resource Centre for Sexual and Reproductive Health (UK)
NCMH, 2005 Financing and Delivery of Health care services in India, National Commission on Macroeconomics and Health, Background Papers Ministry of health and Family welfare, Govt. of India. Page 89
NCP, 2002 National Commission on Population, India – Report: 2002 page -8
Pallikadavath, Saseendran & William Stone 2006 Maternal and Social Factors Associated with Abortion in India: A Population-Based Study, GUTTMACHER Vol.32 Number-3 September 2006 www.guttmacher.org/pubs/journals/3212006.html
Satpathy S k & S Venkatesh 2006 Human Resources for Health in India’s National Rural Health Mission; Dimension and Challenges, Regional Health Forum- Volume 10 Number 1, 2006
Thimmaiya,T.D. 2006 Elimination of regional disparities: Role of Third Sector( Paper presented in ISTR conference 2006 Bangkok.
USAID, 2007 USAID:India budget update June 2007 www.usaid.gov/policy/budget/cbj2007/ane/in.html
Appendix – (Tables)