Reproductive Health Package CSR PFI Section I :: PFI Publication :: KNOWLEDGE MANAGEMENT CENTRE PORTAL, POPULATION FOUNDATION OF INDIA

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12. The right to health in all its forms and at all levels contains the following interrelated and

essential elements, the precise application of which will depend on the conditions prevailing

in a particular State party:

(a) Availability. Functioning public health and health-care facilities, goods and services, as well

as programmes, have to be available in sufficient number within the State.

(b) Accessibility. Health facilities, goods and services have to be accessible to everyone without

discrimination, within the jurisdiction of the State party. …

and culturally appropriate, i.e. respectful of the culture of individuals, minorities, peoples and

communities sensitive to gender life-cycle requirements, as well as being designed to respect

confidentiality and improve the health status of those concerned.

(d) Quality. As well as being culturally acceptable, health facilities, goods and services must

also be scientifically and medically appropriate and of good quality. This requires, inter alia,

skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment,

safe and potable water, and adequate sanitation.

Control over women’s reproductive abilities and

functions has been a key aspect of the domination of

women and their secondary status in society.

Movements for women’s rights from the earliest times

have included reproductive and sexual rights as some

key concerns. The terms “reproductive rights” (see Box

1.2) and “sexual rights” (see Box 1.3) are of recent

origin but women like Margaret Sanger in North

America and Stella Browne in England led the

movement around birth control as early as the mid-

1800s. In India too, the work on women’s uplift done

by the great social reformers of the nineteenth century

such as Pandit Ishwar Chandra Vidyasagar in Bengal

or Mahatma Jyotiba Phule in Maharashtra included

issues like widow remarriage, polygyny and child marriage, which are clearly within the realm of

reproductive rights.

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Over the last seventy-five years there has been a constant struggle in the arena of contraception. This

struggle has been between the proponents of the women’s movement who have called for greater

autonomy of women for “birth control” and between the politicians and demographers who have

called for “population control”. Birth control refers to voluntary limitation or control of the number

of children conceived, especially by planned use of contraceptive techniques. Population control is

a government programme to limit or slow down population growth, through means such as birth

control education, the wide availability of contraceptives, and economic incentives.

Gender and Reproductive Health

Reproductive health has been defined by WHO as a state of complete physical, mental and social

well-being, and not merely the absence of disease or infirmity in all matters relating to the reproductive

system and to its function and processes. Reproductive health includes men and women, older people,

youths, and includes sexuality education, sexually transmitted diseases, health issues related to

childbearing, family planning and safe sex (see Box 1.4).

Box 1.2. Reproductive Rights

• The right to decide about marriage and number of children

• The right to well-being throughout life, for all matters relating to the reproductive system

• The right to a responsible, healthy, safe and satisfying sex life

• The right to have unrestricted access to information in order to make informed choices

• The right to have safe, effective, affordable and acceptable family planning methods of choice

• The right to safe pregnancy and birth

• The right to be free from sexual violence and assault

• The right to privacy in relation to reproductive health

Box 1.3. Sexual Rights

Sexual rights, a fundamental element of human rights, encompass the right to experience a

pleasurable sexuality, which is essential in and of itself, and at the same time, is a fundamental

vehicle of communication and love between people. Sexual rights include the right to liberty

and autonomy in the responsible exercise of sexuality.

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Box 1.4. What Reproductive Health Means

Reproductive health is a state of complete physical, mental, and social well-being and not

merely the absence of disease in all matters relating to the reproductive system. It implies:

• A satisfying and safe sex life

• The capability to reproduce, and the right to decide if, when and how often

• To be informed and to have access to safe, effective, affordable and acceptable methods of FP

• Safe pregnancy, childbirth, and a healthy infant

• Methods, techniques and services that contribute to reproductive health and well-being by

preventing and solving reproductive health problems

• Sexual health, which is not merely related to care and counselling but the enhancement of

life and personal relationships

• A lifecycle approach

Population control has been the central concern of population scientists throughout the twentieth

century. The originator of this idea was Reverend Thomas Malthus, who predicted, a little over two

hundred years ago, that with the increase of population in geometric progression, it would soon be

impossible to feed the large number of people with limited increase in agricultural production. In

1883 Francis Galton, nephew of Sir Charles Darwin, enunciated the principles of ‘eugenics’ in which

it was argued that it was perfectly rational to restrict the reproduction of ‘inferior’ races. The fear that

population was primarily the concern of the upper classes was directed towards the poor. The fear

of large-scale growth of the poor because of ignorance and less access to healthcare services was the

core concern of John D. Rockefeller, who set up the Population Council and of Paul Ehrlich, who

wrote about the ‘Population Bomb’. Even though the stated concern of population scientists was to

improve the overall living conditions and quality of life of the people, the history of population

control abounds with episodes of repression and violation of the human rights of women.

A Fresh Breeze of New Thinking

The International Conference on Population and Development (ICPD), held in Cairo in 1994, resulted

in a paradigm shift as regards reproductive health and reproductive rights. It was acknowledged at the

ICPD that the ‘target approach’ to reducing population had been ineffective, and that gender inequality

and lack of reproductive rights and choices are key factors contributing to excessive population growth.

Reproductive rights as a concept gained legitimacy and the concept of reproductive health was adopted

at the ICPD. The ICPD also resulted in a consensus that reproductive health programmes have to have

commitment to quality of care.

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After the ICPD, the Fourth World Conference on Women at Beijing in 1995 had implications for

further policy changes on reproductive health. At this conference, the concept of sexual rights was first

visible, leading to a nuanced understanding of sexual health.

Millennium Development Goals

In September 2000, the UN General Assembly at its 55th session, called the Millennium Summit,

set certain global targets for poverty reduction, social development and environmental regeneration.

These targets were named the Millennium Development Goals (MDG). The Millennium Development

Goals commit the international community to an expanded vision of development, one that vigorously

promotes human development as the key to sustaining social and economic progress in all countries,

and recognizes the importance of creating a global partnership for development. The goals have been

commonly accepted as a framework for measuring development progress. Box 1.5 presents these goals.

Box 1.5. Millennium Development Goals

Goal 1. Eradicate extreme poverty and hunger

Goal 2. Achieve universal primary education

Goal 3. Promote gender equality and empower women

Goal 4. Reduce child mortality

Goal 5. Improve maternal health

Goal 6. Combat HIV/AIDS, malaria, and other diseases

Goal 7. Ensure environmental sustainability

Goal 8. Develop a global partnership for development

National Programmes

The Bhore Committee Report in 1946 was a significant turning point for the public health system in

India, which till then was only hospital based. Among other things, the report recommended a move

beyond hospitals to the establishment of primary health institutions in each sub-district unit. Accordingly,

in 1952 a programme for establishing a primary health centre in each community development block

was launched. Subsequently, the health services organization and infrastructure has changed and

expanded in stages.

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India’s Family Planning Programme was launched in 1951, essentially as a population control initiative.

The other major focus of the Ministry of Health was the Maternal Health Programme. Through the

1960s and the 1970s, several initiatives such as the All India Hospital Postpartum Programme (1969)

and the Medical Termination of Pregnancy Act (1971) were launched. In the light of the experience

of 1975–77, when coercive sterilizations peaked during the Emergency, the post-Emergency government

brought Family Planning, Maternal and Child Health and related primary healthcare services under the

umbrella of Family Welfare. In the 1980s, following the global trends, there was a change in focus

of the Maternal Health Programme. It began to emphasize antenatal care, risk approach for detection

of complications and large-scale training of Traditional Birth Attendants.

The 1990s were marked by many changes in the way the National Family Welfare Programme was

designed and delivered. In April 1996 the Target Free Approach (TFA) was announced, doing away

with method-specific contraceptive targets which had become a major controversial component of the

programme. In 1997 the government started the Reproductive and Child Health Programme with

financial assistance of the World Bank. In 1999 the TFA was renamed the Community Needs

Assessment Approach (CNAA), emphasizing the need to engage in bottom-up community-based

planning. The National Population Policy was adopted in 2000, which lays down the blueprint of

population and development programmes in India.

The RCH programme document acknowledged that “it is the legitimate right of the citizens to be able

to experience sound Reproductive and Child Health” and promised that “the services to be provided

will be client centred, demand driven, high quality and based on the needs of the community.” The

RCH programme drew part of its inspiration from the ICPD and incorporated the treatment of

reproductive tract infections (RTI) and sexually transmitted diseases (STD), adolescent health, information,

education and communication (IEC) for sexuality and gender, within the ambit of its activities. Box

1.6 presents the range of services provided under the RCH programme.

Box 1.6. Range of Services Provided under RCH Programme

Ante-natal care

• Registration of pregnancies within 12 to 16 weeks

• At least three antenatal visits, which includes timely tetanus toxoid

immunization

• Iron prophylaxis

• Detection and treatment of anaemia

• Referral/management of high risk pregnant women

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Natal care

• Delivery by trained personnel

• Increase in institutional delivery

Post-natal care

• Three post-natal visits, which includes timely immunization of the

child

• Monitoring and care of the new-born

• Referral/management of the high-risk new-born

Provision of care

for unwanted

pregnancies

• Referral and management of unwanted pregnancies through MTP

and safe abortion

Identification and

management of

child health

• Immunization against six diseases

• Vitamin A and iron prophylaxis

• Management of pneumonia

• Management of acute diarrhoea

Contraceptive

services

• Providing sterilization, IUD, oral pills and condoms so as to ensure

there are no unmet needs

Recording morbidity • Incidence of:

and mortality

Vaccine-preventable diseases

Pneumonia

Acute diarrhoea

RTI/STI

• Numbers of maternal and child deaths

Reproductive and Child Health Programme II, launched in 2005, aimed to improve the performance

of the Family Welfare Programme through four objectives. Three of them pertained to provision of

services:

• improvement in quality, coverage and effectiveness of services

• increase in the scope and range of services offered; and

• increasing access to reproductive health services.

The fourth objective pertained to strengthening management and institutional structures.

Some key features of the new programme, which go beyond the mere incorporation of the earlier

programme components, are:

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• integration of fertility regulation services and maternal and child health services with

reproductive health services for women and men;

• client-centred, demand-driven, high-quality services with basket of choices;

• upgradation of facilities for improving quality of services and variety of interventions with

focus on medical termination of pregnancy services, intra-uterine devices insertion and

counselling;

• improving access by decentralizing services and outreach;

• reaching services to special vulnerable groups such as scattered rural population, urban

slums, tribal populations and slums.

In order to reach the appropriate services to the appropriate clients and to focus on districts with

poorer reproductive and child health status, the districts were divided into A, B and C categories with

a different mix of practitioners of Indian Systems of Medicine.

India’s National Population Policy was enunciated in 2000 after many years of consensus building.

NPP 2000 recognized that:

• The overriding objective of economic and social development is to improve the quality of

lives that people lead, to enhance their well-being, and to provide them with opportunities

and choices to become productive assets in society.

• Stabilizing population is an essential requirement for promoting sustainable development

with more equitable distribution. However, it is as much a function of making reproductive

healthcare accessible and affordable for all, as of increasing the provision and outreach of

primary and secondary education, extending basic amenities including sanitation, safe

drinking water and housing, besides empowering women and enhancing their employment

opportunities, and providing transport and communications.

Box 1.7 presents brief details.

Box 1.7. NPP 2000: Statement of Objectives

The goal of this policy is to bring about the advancement, development and empowerment of

women, both economically and socially. The policy will be widely disseminated so as to

encourage active participation of all stakeholders for achieving its goals. Specifically, the objectives

of this policy include:

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(i) Creating an environment through positive economic and social policies for full development

of women to enable them to realize their full potential.

(ii) The de-jure and de-facto enjoyment of all human rights and fundamental freedoms by

women on equal basis with men in all spheres – political, economic, social, cultural and

civil.

(iii) Equal access to participation and decision-making of women in social, political and

economic life of the nation.

(iv) Equal access to women to health care, quality education at all levels, career and vocational

guidance, employment, equal remuneration, occupational health and safety, social security

and public office, etc.

(v) Strengthening legal systems aimed at elimination of all forms of discrimination against

women.

(vi) Changing societal attitudes and community practices by active participation and involvement

of both men and women.

(vii) Mainstreaming a gender perspective in the development process.

(viii) Elimination of discrimination and all forms of violence against women and the girl child.

(ix) Building and strengthening partnerships with civil society, particularly women’s organizations.

The immediate objective is to address the unmet needs for contraception, healthcare infrastructure,

and health personnel, and to provide integrated service delivery for basic reproductive and child

health care.

The medium-term objective is to bring the total fertility rate to replacement levels by 2010,

through vigorous implementation of inter-sectoral operational strategies.

The long-term objective is to achieve a stable population by 2045, at a level consistent with

the requirements of sustainable economic growth, social development, and environmental

protection.

The National Policy for Empowerment of Women was brought out in 2001. It recognizes the following:

• The principles of gender equality are enshrined in the Indian Constitution in its Preamble,

Fundamental Rights, Fundamental Duties and Directive Principles. The Constitution not

only grants equality to women, but also empowers the State to adopt measures of positive

discrimination is favour of women.

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• India has also ratified various international conventions and human rights instruments

committing to secure equal rights of women. Key among them is the ratification of the

Convention on Elimination of All Forms of Discrimination Against Women (CEDAW) in

1993.

• However, there still exists a wide gap between the goals enunciated in the Constitution,

legislation, policies, plans, programmes, and related mechanisms on the one hand and the

situational reality of the status of women in India, on the other.

The National Rural Health Mission (NRHM) was launched in 2005 with a view to bring about a

dramatic improvement in the health system and the health status of the people, especially those who

live in the rural areas of the country. The mission, extending over the period 2005 –12, seeks to

provide universal access to equitable, affordable and quality healthcare which is accountable and at

the same time responsive to the needs of the people, reduction of child and maternal deaths as well

as population stabilization and gender and demographic balance. In this process, the Mission would

help achieve the goals set under the National Health Policy and the Millennium Development Goals.

To achieve these goals NRHM will:

• Facilitate increased access and utilization of quality health services by all.

• Forge a partnership between the central, state and local governments.

• Set up a platform for involving the Panchayati Raj Institutions and community in the

management of primary health programmes and infrastructure.

• Provide an opportunity for promoting equity and social justice.

• Establish a mechanism to provide flexibility to the states and the community to promote

local initiatives.

• Develop a framework for promoting inter-sectoral convergence for promotive and preventive

healthcare.

• Public-private partnership in the health service delivery system.

References

Das, Abhijit, 2004. “Ensuring Quality of Care in Reproductive Health: An Advocacy Handbook”, New

Delhi: PFI.

Nanda, A.R., 2004. “Obsolescence and Anachronism of Population Control: From Demography to

Demology”, Demography India, 33(1): l–12.

UN, ICDD, 1994. “Programme of Action adopted at the International Conference on Population and

and Development”, Cairo, 5-13 September 1994.

UN, 2000. CESCR General Comment 14 (http://www.unhchr/tbs/d)

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chapter 2

SAFE MOTHERHOOD

Maternal mortality rate (MMR) is considered a key human development indicator. Complications

of pregnancy and childbirth are still the leading cause of death and disability among women of

reproductive age in developing countries. Over the world, maternal mortality is currently estimated to

be 529,000 deaths per year, or 400 maternal deaths per 100,000 live births. Between 11 and 17 per

cent of maternal deaths happen during childbirth; between 50 and 71 per cent deaths occur in the

postpartum period. About 45 per cent of postpartum maternal deaths occur during the first twenty-

four hours, and more than two-thirds during the first week. Severe bleeding is the primary cause of

maternal deaths. Postpartum bleeding can kill even a healthy woman within two hours, if unattended.

The second most frequent direct cause of death is sepsis; the third is unsafe abortion.

In 1987 the World Bank, in collaboration with the World Health Organization (WHO) and the United

Nations Population Fund (UNFPA) sponsored a conference on safe motherhood in Nairobi, Kenya to

help increase global awareness about the impact of maternal mortality and morbidity. The conference

launched the Safe Motherhood Initiative (SMI), which issued an international call to action to reduce

maternal mortality and morbidity by the year 2000. Under SMI the programmes developed by several

countries include:

• providing family planning services;

• providing post-abortion care;

• promoting antenatal care;

• ensuring skilled attendance during childbirth;

• improving emergency obstetric care; and

• addressing the reproductive health needs of

adolescents.

In India, about 450 mothers out of every 100,000

births die during pregnancy or childbirth as compared

to less than 10 in 100,000 in developed countries.

Two-thirds of Indian women go through pregnancy and childbirth without seeing a trained birth

attendant. Obstetric and gynaecologic disorders are widely prevalent and remain largely untreated.

The minimum age at marriage being 18 years for a girl, women become pregnant in their early

twenties. Lack of awareness about contraceptives, a worldview that sees more children as assets and

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increased hands to earn a livelihood, preference for a son and many other factors lead to frequent

childbearing at an early age. This affects maternal health. Maternal health is generally not considered

a priority among large sections of families in India. Home delivery by untrained dais and lack of good

quality emergency obstetric care are still prevalent even in urban areas. Figure 2.1 presents the causes

of maternal deaths in India. Box 2.1 presents a typical case study in rural India.

Figure 2.1. Causes of Maternal Deaths in India

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Box 2.1. The Story of Shanti

Shanti, 30 years old, was a resident of Rooppur village. She had been married at the age of 15.

Shanti and her husband were agricultural labourers. They had eight children, with seven girls;

the last was a boy, aged three years. There was only one bus in the morning to the district

headquarters, which was about 20 km away.

In her current pregnancy Shanti was feeling very tired. She was not even getting iron tablets as

the auxiliary nurse midwife used to come only once a month to immunize the children. Shanti

was also unaware about family planning methods.

In the ninth month of her pregnancy Shanti began to feel pains while working in the field. She

came home and sent for Mangala, a local dai. The pains increased and after three hours a boy

was born.

Mangala cleaned the new-born and wrapped him in a cloth. Even about half an hour after

delivery, the placenta did not deliver. Mangala pulled the cord, massaged Shanti’s abdomen and

made a “kada”, a decoction of spices. When this did not work Mangala suggested to Shanti and

her husband to go to the hospital. The couple borrowed money from relatives and arranged

transport to go to government hospital. But suddenly Shanti began to bleed profusely. The village

doctor, who was called, gave an injection but the bleeding continued. On the way to the

hospital, five hours after she gave birth, Shanti died.

Safe motherhood is an issue of right to life. Safe motherhood is recognized as a basic human right,

protected by a range of international human rights treaties and laws. Women have the right to receive

comprehensive reproductive healthcare, including family planning, nutrition, and basic health services

and health education. Ensuring women’s rights to life, liberty, and security of the person, health,

maternity protection, and non-discrimination would facilitate safe motherhood.

The Reproductive and Child Health (RCH) Programme in India envisages the involvement of men in

women’s reproductive health. Health workers are supposed to provide expectant fathers with information

on several aspects of maternal and child heathcare during their contacts with expectant fathers. Health

workers should ask the men about the antenatal check-ups their wives have undergone, and whether

they faced any complication in earlier pregnancies. They should accompany their pregnant wives for

antenatal check-ups. Men should also be sensitized to the problems that can occur, such as vaginal

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bleeding, convulsions and prolonged labour. Maternal health is also the responsibility of the whole

family and, in a broad sense, of the entire community.

Maternal healthcare is divided into three stages. Antenatal care (ANC) refers to the care taken during

pregnancy; intra-natal care to care given at the time of childbirth, and post-natal care to the care given

after childbirth.

Healthcare during Pregnancy and Childbirth

Prerequisites for Pregnancy

To ensure a healthy pregnancy and safe childbirth, it is important that

the woman is emotionally and physically matured;

she is healthy, with a fully developed physique;

she is not anaemic;

she is able to shoulder the responsibility of

motherhood and respond to the baby’s needs;

both the partners desire to have the child.

Nutrition during Pregnancy

• Calories. Increase the daily intake of calories

through healthy food choices.

• Protein. Eat more protein-containing foods.

• Vitamin supplement. Take a prenatal vitamin

that contains folic acid (as directed by a qualified healthcare provider).

• Iron. Iron-rich foods include leafy greens such as spinach, strawberries, meats, whole grains,

prune juice, dried fruit, legumes, and blackstrap molasses.

• Calcium. Calcium is essential for maintaining the bone integrity of the mother and for providing

the skeletal development of the foetus. Milk products are a good source of calcium.

• Folate. Folate is essential for protein synthesis, the formation of new cells, and the production

of new blood. It is required for a pregnant woman’s increasing blood supply and the growth of

both maternal and foetal tissues. Folate-rich foods include eggs, leafy vegetables, oranges,

legumes, and wheat germ.

Antenatal Care

Table 2.1 presents common health problems during pregnancy.

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Regular Antenatal Healthcare

• Regular check-ups – At least three check-ups

should be done – as soon as pregnancy occurs,

around the sixth month, and a month before the

baby is due.

• Ensuring nutrition – A pregnant woman should

have nutritious food at least four times a day.

• Intake of iron-folic acid tablets and calcium

lactate to help prevent anaemia.

• Tetanus toxoid vaccination – at least two doses.

• Medication to prevent malaria – if malaria is

common in the area.

High Risks during Pregnancy

• Anaemia makes a woman more likely to bleed

heavily (haemorrhage) during birth. As noted

earlier, severe bleeding is the primary cause of

maternal deaths.

• Diabetes in the mother can lead to stillbirth or

enlarged foetus leading to obstructed labour.

• High blood pressure can lead to severe headaches,

epilepsy, and even death.

• Older mothers who have had many childbirths often have long, difficult labour and heavy

bleeding after birth.

• Younger mothers under the age of 20 are more likely to have toxaemia (which causes epilepsy),

long, difficult labour, premature delivery, obstructed labour.

• Mothers who had problems with past pregnancies such as fits, birth by operation, heavy bleeding,

a too early or too small baby, or stillbirth, can face problems in another pregnancy or birth.

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• Physically challenged women, especially women with a loss of feeling in the body or difficulty

in walking, can have problems during both pregnancy and birth.

For women with any of these problems institutional delivery is imperative.

Danger Signs during Pregnancy

• Feeling very weak or tired. Anaemic women are

much more likely to have heavy bleeding after

the baby is born.

• Pain in the lower abdomen. Strong constant pain

in the first three months may be caused by a

pregnancy that is growing outside the womb in

the tube (a tubal or ectopic pregnancy).

• Strong pain in late pregnancy. This could mean

the afterbirth (placenta) is coming off the wall

of the womb. This requires immediate

admittance to hospital.

• Bleeding from the vagina. Pain accompanied by

bleeding could mean a pregnancy is developing

outside the womb. If the bleeding gets heavier

there are chances of losing the pregnancy.

• High fever along with shivering and body aches may be caused by malaria.

• Swelling of hands and face, bad headache and blurred eyesight are symptoms of toxaemia, which

can cause fits and lead to death.

Violence

Given the fact that violence against women is a common and insidious phenomenon in India, there

is a strong need for research on how to screen for physical violence early in pregnancy and to prevent

its consequences. Violence against a woman in pregnancy can result in (a) insufficient weight gain;

(b) vaginal/cervical/kidney infections; (c) vaginal bleeding; (d) abdominal trauma; (e) haemorrhage; (f)

exacerbation of chronic illnesses; (g) complications during labour; (h) delayed prenatal care; (i)

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miscarriage; (j) low birth weight; (k) ruptured membranes; (l) abruption placenta; (m) uterine infection;

(n) foetal bruising, fractures and haematomas; and (o) death.

Weight Gain

Weight gain is a normal and healthy part of pregnancy, especially during the second and third

trimesters (i.e., the 14th week through the end of pregnancy). Most women gain a normal amount

of weight by eating healthfully, staying active, and allowing their appetite to guide their food intake.

Every woman is different, depending on body type and weight before conception, but most women

who deliver healthy babies gain about 11 to 16 kg or more during pregnancy. Women who are

underweight prior to pregnancy should gain a little more, and overweight women, a little less.

Preparing for Birth (Advice to a pregnant woman)

A pregnant woman should have these things ready by the seventh month of pregnancy :

• cake of soap

• sterilized string to tie up the cord

• new blade

• washed and dried old cloth pieces to wrap the baby, to spread under the woman and to serve

as sanitary pads for her after the delivery.

• delivery kit if available at the health centre

• clean sheet to bundle these up.

This is also the time for the family to:

• identify a trained birth attendant/trained midwife;

• identify a referral centre to take the woman in case of complications;

• arrange some money in case it is required;

• keep in mind the possibility of blood donation;

• plan transportation in case the woman needs to go to hospital.

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Keep the following ready :

• flashlight

• foetoscope

• blunt-tipped scissors for cutting the cord

• sterile gloves

• sterile syringe and needles

• several injections of ergonovine, ergometrine or oxytocin in case of postpartum haemorrhage

• magnesium sulphate injection in case of obstetric complications

• tetracycline or erythromycin ointment for the baby’s eyes

• suction bulb for sucking mucus out of the baby’s nose and mouth.

Intra-natal Care

• Clean the delivery surface to prevent infection.

• Clean hands of birth attendant with soap and let them dry in the air before delivery (if possible

use hand gloves).

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• Clean the blade for cutting cord.

• Clean the cord tie.

• Clean cord stump (without anything applied on it).

• Clean external genital area.

Post-natal Care

Post-natal check-ups soon after the delivery are particularly important for births that take place in non-

institutional settings.

Schedule of Post-natal Check-ups

Visit

First

Second

Third

Fourth

Timing

Immediately after the delivery (in less than four hours)

Between 4–23 hours of delivery

1–2 days

Anytime between 3–45 days of delivery

In the post-natal check-ups, the health worker should watch for heavy bleeding and fever. She should

also advise on the following:

• Encourage the mother to breast-feed the baby which will help her to stop bleeding sooner.

• To prevent infection the mother should not have sex or put anything in her vagina until the

bleeding stops.

• She should get full rest for at least six weeks; eat all kinds of food, more than usual; and drink

plenty of fluids.

Definitions

Institutional delivery refers to delivery in any referral hospital (city, district hospital, maternity home,

private and NGO nursing home or hospital).

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Skilled birth attendant is a person with midwifery skills who has been trained to proficiency in the

skills necessary to manage normal deliveries and diagnose, manage or refer complications. This term

is exclusive to a midwife, nurse, nurse-midwife or doctor who has undergone a prescribed course and

is registered or legally licensed to practise as skilled birth attendant. Ideally, the skilled attendant lives

in, and is a part of, the community she serves. Traditional Birth Attendants (TBAs), even if trained,

are not SBAs.

Basic Emergency Obstetric Care (Basic EmOC)

Basic EmOC functions are performed in a health centre without the need for an operating theatre.

Basic emergency obstetric and new-born care, provided in health centres, large or small, includes the

capabilities for:

intravenous/intra-muscular antibiotics

intravenous/intra-muscular oxytoxics

intravenous/intra-muscular anticonvulsants

manual removal of placenta

assisted vaginal delivery

removal of retained products following miscarriage or abortion

new-born care.

Comprehensive Emergency Obstetric Care (Comprehensive EmOC)

Comprehensive EmOC functions require an operating theatre and are usually performed in district

hospitals. Comprehensive EmOC includes all six Basic EmOC functions plus:

caesarean section

blood transfusion

care of sick and low-birth-weight new-borns, including resuscitation.

For a facility to meet these standards, all six or eight functions must be performed regularly and

assessed every three to six months. Guidelines jointly issued in 1997 by WHO, UNICEF, and UNFPA

3.4 Page 24

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are that for every 500,000 people there should be at least four facilities offering Basic EmOC and one

facility offering Comprehensive EmOC (appropriately distributed). To manage obstetric complications

a facility must have at least two skilled attendants covering 24 hours a day and seven days a week,

assisted by trained support staff. To manage complications requiring surgery, the facility must have

a functional operating theatre, more support staff and must be able to administer blood transfusions

and anaesthesia.

Some Concerns Related to Maternal Health

Three Delays

Dr Deborah Maine promoted the idea of ‘Three Delays’ in pregnancy-related mortality. The ‘Three

Delays’ model proposes that pregnancy-related mortality is overwhelmingly high due to delays in:

• deciding to seek appropriate medical help for an obstetric emergency;

• reaching an appropriate obstetric facility; and

• receiving adequate care when a facility is reached.

Promotion of the awareness of the three delays and their specific manifestations will increase awareness

at the household and community level and among both health professionals and TBAs, and encourage

the development of locally appropriate solutions.

Caesarean

Caesarean section is the delivery of a foetus by a surgical incision through the abdominal wall and

uterus. The decision whether to perform a caesarean section is based on the judgement of the

obstetrician. Increases in caesarean section rates world wide have raised questions about the economic

implications of caesarean section and alternative modes of delivery.

The acceptable standard for caesareans is between 5 and 15 per cent of all deliveries occurring in a

community. A caesarean section rate less than 5 per cent indicates that women who need a caesarean

are not getting it. In India it is observed, however, that in institutional deliveries, many private

hospitals do unnecessary caesareans. The reasons are:

It is convenient for the obstetrician to deliver during the day, rather than waiting for the woman’s

normal labour pains to start.

Obstetricians make more money through caesarean sections than normal deliveries.

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Use of Oxytocin

Oxytocin is a natural hormone responsible for uterine contractions and the ejection of breast milk.

It has three primary uses during delivery:

• labour induction;

• labour augmentation;

• controlling postpartum haemorrhage

Oxytocin is used mainly to prevent postpartum haemorrhage, with a few precautions. Cases for using

oxytocin for induction and augmentation should be assessed very carefully and cannot simply be

injected to any birthing mother. Though intra-muscular administration of oxytocin is generally not

advised, in many rural and urban areas of India unmonitored intra-muscular oxytocin injections are

commonly given both by unregistered local male practitioners and Auxiliary Nurse Midwife (ANM)

during home deliveries. India’s Reproductive and Child Health policy needs to address the inappropriate

use of oxytocin.

Government Policies

Under the Maternity Benefit Act, 1961, every woman shall be entitled to, and her employer shall be

liable for, the payment of maternity benefit, which is the amount payable to her at the rate of the

average daily wage for the period of her actual absence. Expectant mothers can avail of maternity leave

during six weeks immediately following the day of delivery or miscarriage.

The National Maternity Benefit Scheme (NMBS) came into effect in August 1995 as part of the

National Social Assistance Programme (NSAP). NMBS provides Rs. 500 in cash assistance to pregnant

women living below the poverty line for the first two births provided the woman is 19 years or older.

The benefit is to be given several weeks before delivery and used for nutrition and other needs.

Janani Suraksha Yojana (JSY) is sought to be a modification or replacement of NMBS. Under JSY cash

assistance is provided to women from BPL families, to enable them to deliver in health institutions.

To the BPL women in rural areas Rs. 700 are given as Assistance Package and Rs. 600 to BPL women

in urban areas. JSY is a safe motherhood intervention under the National Rural Health Mission

(NRHM), with the objective of reducing maternal and neo-natal mortality by promoting institutional

delivery among the poor pregnant women. Each beneficiary registered under this Yojana should have

a JSY card along with a Mother and Child Health card, which is expected to effectively help in

monitoring antenatal check-up and the post-delivery care. Pregnant women from households having

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below-poverty-line cards or SC/ST certificate issued by the tehsildar concerned, delivering in government

health centres are eligible for the benefits under JSY. The scale of cash assistance for institutional

delivery is as follows:

Rural area: mother’s package Rs. 1400; ASHA’s package Rs. 600; total Rs. 2000.

Urban area: mother’s package Rs. 1000; ASHA’s package Rs. 200; total Rs. 1200.

There is a strong critique of the distortion of the NMBS and its replacement by the JSY. The view

has been expressed that the JSY does not fulfil the nutritional needs of the pregnant woman in the

way that the NMBS was designed to do. A Supreme Court order directs all state governments to keep

implementing the NMBS.

What the Corporate Sector Can Do

Understand the urgency of bringing down MMR in India.

Make the issue of avoidable maternal deaths visible by undertaking maternal death audits,

confidential enquiries, verbal autopsies.

Implement comprehensive safe motherhood programmes in defined areas.

Provide Comprehensive EmOC of high quality through referral healthcare facilities.

Ensure skilled attendance for all deliveries happening in the field areas.

Provide ambulance and transport services for women in obstetric emergencies.

Undertake advocacy and education initiatives at all levels – with the local government, health

department, professional associations (FOGSI, IMA, and anaesthetists), and the community.

References

http://www.who.int/whr/2005/media_centre/facts_en.pdf (World Health Report 2005)

http://www.safemotherhood.org/init_facts.htm

http://www.womenshealthchannel.com/nutrition/index.shtml

http://www.whiteribbonalliance-india.org/definitions.htm

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http://nrhmrajasthan.nic.in/Panchamrit.htm

http://www.sciencedirect.com/science?_

http://www.unfpa.org/mothers/obstetric.htm

http://www.unfpa.org/upload/lib_pub_file/150_filename_checklist_MMU.pdf

http://pdf.dec.org/pdf_docs/Pnacn953.pdf

http://www.kerala.gov.in/dept_lab/act12.pdf (for Maternity Benefit Act, 1961)

Government of India. Ministry of Health and Family Welfare, “JSY Guidelines for Implementation”.

Government of India. Ministry of Health and Family Welfare, “National Program Implementation Plan

RCH Phase II” - Program Document.

Newberger E. et al., 1992. “Abuse of Pregnant Women and Adverse Birth Outcome”, Journal of the

American Medical Association 267.

Patricia, Jeffery et al., 2007. “Unmonitored Intrapartum Oxytocin Use in Home Deliveries: Evidence

from Uttar Pradesh, India”, Reproductive Health Matters.

Safe Motherhood, Section 2, Module 4, Pg. 11, Reproductive and Child Health Services.

VHAI 2001. “Where Women have so doctor : A Resource Guide for Women’s Health”, Chapter 6 :

Pregnancy and Child Birth, New Delhi; Voluntary Health Association of India.

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chapter 3

SAFE ABORTION

The right to abortion is a key reproductive right of women. In India, abortion is available under the

Medical Termination of Pregnancy Act (MTPA), 1971. The Act was pioneered as part of a population

limiting exercise and packaged as an integral part of the Family Planning Programme. Under the MTPA

abortion was permitted if:

(a) Continuation of pregnancy would involve risk to the woman’s mental or physical health.

(b) The child has the risk of being born with serious physical or mental abnormality.

(d) Pregnancy is due to failure of contraceptives.

Medical termination of pregnancy (MTP) can be carried out legally within twelve weeks of pregnancy

by a registered medical practitioner having training and experience in gynaecology and obstetrics at

a government-approved and licensed clinic. MTP can also be done legally after twelve weeks and

before twenty weeks of pregnancy. This is called second trimester termination. But because of the risk

involved for the mother’s life, it requires the consent of two registered medical practitioners having

training and experience in gynaecology and obstetrics. Termination of pregnancy after twenty weeks

is illegal. If at all there is an emergency requiring termination of pregnancy after twenty weeks, this

needs immediate attention at a well-equipped district hospital.

Even after the MTP Act, 1971, was enacted, over 90 per cent of the abortions continued to take place

outside the legal framework. Partly this was because of the restrictive definition of the MTP Act,

specifying what provider in which facility is recognized as a legitimate provider of MTP services.

Recognizing the failure of the MTP Act to make legal abortions widely available, the government

amended the Act in 2002. The authority for the approval of registration of MTP centres has been

decentralized to the district level. The Reproductive and Child Health Programme and the National

Population Policy 2000 have also specified strategies to increase access to safe abortions at the primary

healthcare level.

A pregnancy can be terminated only with the informed consent of the pregnant woman; no other

person’s consent is required. In the case of a pregnant woman less than eighteen years old, and in

the case of a pregnant woman more than eighteen years old but of unsound mind, the consent of her

guardian must be obtained in writing.

The Reproductive and Child Health Programme II has initiated steps for ensuring safe abortions.

Assistance has been provided for skill-based training to doctors in MTP techniques and the supply of

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MTP equipment. The guidelines for MTP up to eight weeks, using the Manual Vacuum Aspiration

technique, have been developed to enable Medical Officers to provide safe abortion services using this

simple and safe technique at the PHC level and above. Likewise, guidelines for the use of RU-486

with Misoprestol have been developed to ensure safe medical abortion in early pregnancy.

Definitions

Medical Termination of Pregnancy (MTP) applies to

safe and legal abortions under the MTP Act, 1971.

Unsafe abortion is a procedure for terminating an

unwanted pregnancy either by persons lacking the

necessary skills or in an environment lacking the

minimal medical standards, or both.

Safe abortion is abortion by a qualified, trained doctor

having requisite experience; with the proper

instruments; under clean conditions; up to three months

(twelve weeks) after the last monthly bleeding; in government-approved licensed clinics.

Incomplete abortion is when part of the pregnancy remains in the womb after an abortion. The signs

are heavy bleeding for more than one day after the abortion, cramping pains, and passing tissue and

clots or lumps of blood. This requires an immediate hospital visit to have the pregnancy completely

removed. If not, serious complications can result. Immediate complications could include septicemia

due to severe infection, perforation (tear) of uterus, shock and death. Long-term complications could

include reproductive tract infection, pregnancy in the tubes (ectopic pregnancy) and secondary infertility

(inability to conceive).

Legal abortion implies termination of pregnancy by trained provider in government-approved health

facility for the purpose and fulfilling the conditions mentioned in the MTPA.

Illegal abortion implies termination of pregnancy in contravention of the MTP Act.

Methods of Safe Abortion

• Dilatation and curettage (D&C). The pregnancy is scraped out with an instrument called curette.

D&C takes about fifteen to twenty minutes and is done under anaesthesia.

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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - S- A- -FE- -A-B-O-R-T-I-O-N- - - - - - - - -

• Manual Vacuum Aspiration (MVA). The pregnancy is removed by suction using a canula.

Vacuum aspiration is simple and safe and takes about five to ten minutes. MVA should

preferably be done in the first trimester.

• Medical abortion. Abortion by orally administered regimens of mifepristone and misoprostol has

been accepted as an effective and safe option for early abortion.

Medical abortion does not require extensive infrastructure and is non-invasive. Further, as the client

does not need to be hospitalized, medical abortion offers women greater independence, control and

privacy. However, the potential for misuse exists. Although abortion tablets are required to be sold

by medical prescription and consumed under medical supervision, these pills are reportedly widely

available over-the-counter and unsupervised consumption is rising.

What a Safe Abortion Entails

• A healthcare provider or a counsellor should talk

to the woman about her decision and explain

how the abortion would be done, what the risks

are.

• The woman should be asked about the time of

her last menstrual period and whether she might

have a sexually transmitted disease.

• A medical examination should be done to see

the size of the uterus and duration of the pregnancy.

• During MVA and D&C, the woman will feel strong pains in the lower belly. After the abortion,

the pains will decline.

• The woman’s genitals should be cleaned and she would be allowed to rest under observation

for an hour.

• She should be informed of post-abortion complications and who to go to, if these occur.

• Contraceptive methods to avoid an unwanted pregnancy should be discussed with her. She

should be asked to come back for a check-up within fifteen days.

4 Pages 31-40

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4.1 Page 31

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Danger Signs Requiring Medical Attention

• heavy bleeding from vagina due to incomplete abortion

• high fever due to infection

• severe pain in the abdomen due to internal injury or infection

• fainting and confusion due to shock resulting from heavy bleeding

• smelly discharge from the vagina due to infection.

Post-abortion Care and Advice

• Do not have sex or put anything in the vagina for at least five days after the procedure.

• Drink plenty of fluids to help you recover faster.

• Some bleeding from the vagina for up to two weeks is normal. The next monthly period will

be after four to six weeks.

• The risk of pregnancy exists as soon as intercourse is resumed regardless of monthly period.

Therefore contraceptives should be used.

Health Education and Counselling

• Need to educate men, women and the community on how to prevent unwanted pregnancies.

Discuss contraceptives and their use widely.

• Need to educate women and girls about the dangers of unsafe abortion. Identify with them

certified centres where they can access safe abortion services.

• Spread awareness about the MTP Act and that abortion is legal.

• Discuss with women and girls that they have a right to confidential and private quality abortion

services. Discuss aspects of consent also with them and that healthcare providers are bound not

to provide MTP services conditional on acceptance of contraceptives.

• Discuss about the responsibility of the partner in the situation that led to the unwanted

pregnancy and the decision to seek abortion. He has a role to play in supporting the woman

through the abortion and the post-abortion phase.

• Reproductive health communications should include specific messages highlighting the importance

of girl children and discouraging sex selection.

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Box 3.1. Sex-selective Abortions

A deep-seated bias against women and son preference has been resulting in gross misuse of new

medical technologies to detect the sex of the foetus, and more recently, to conceive only male

babies. The central government legislated the Pre-Natal Diagnostic Techniques (Regulation and

Prevention of Misuse) Act (PNDT Act), 1994, regulating the use of ultrasound and amniocentesis

and forbidding providers from revealing the sex of the foetus. The Act was amended in

2003 to bring the pre-conception sex selection and pre-implantation procedures also under its

purview.

Unfortunately, many facilities still offer both sex determination and abortion services. Public

debate against sex determination and sex-selective abortion has resulted in a ban on abortion in

many states, denying safe abortion services even to women with a legitimate need for terminating

unwanted pregnancies, forcing them to take recourse to illegal and unsafe abortions. There is an

urgent need for the differences in the two issues to be highlighted.

SAY ‘YES’ TO SAFE ABORTION! – SAY ‘NO’ TO SEX SELECTION!

Box 3.2. Some Facts about Abortion in India

• Only about 10 per cent of abortions are conducted by qualified providers in approved

institutions.

• Official figures report 0.6 million induced abortions per year. Indirect estimates project

induced abortions annually at 6.7 million.

• A conservative estimate places the number of abortion-related deaths in a year in India at

15,000–20,000. Official figures indicate that unsafe abortion accounted for 9 per cent of

maternal deaths in 1998. Evidence from facility-based studies suggests that abortion-related

complications account for 25–30 per cent of maternal deaths taking place in hospitals.

• Abortion-related incidences of morbidity are many, such as menstrual irregularities, backache,

excessive bleeding. Sequlae or complications are pelvic inflammatory disease (infection),

secondary infertility (inability to conceive after MTP) and risk of future ectopic pregnancy

(pregnancy at wrong site, e.g. tubes).

• Unmarried adolescents, women who are illiterate and those living in rural areas are perhaps

more prone to major abortion complications because they seek late abortions or use services

of unqualified providers.

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Problem Statement

Despite the liberalization of abortion services, abortion continues to be unsafe for the vast majority

of women in India. Some of the reasons are:

• Lack of awareness of the legal status of abortion. Only a small minority of men and women

know that abortion is legal. According to one study, nearly four in five men and more than one

in two women believe that it is illegal.

• Lack of awareness about pregnancy itself may contribute to many women, especially adolescent

girls, delaying seeking abortion services and obtaining care from unqualified providers.

• Limited access to services. Although the number of approved abortion facilities in India has

increased significantly over the years, women’s access to safe abortion services continues to be

limited, owing to the restrictive clauses of the 1972 MTP Act, uneven distribution of approved

facilities between and within states, lack of services in the public sector due to lack of trained

human resources and/or equipment.

• Poor quality of services. Available evidence highlights the poor quality of abortion services –

inadequately trained providers; their judgemental attitudes, lack of respect for privacy and

confidentiality of women seeking abortion; low priority to pre- and post-abortion services.

• Cost of services. Economic constraints compel many poor women and those dependent on others

to seek services from unqualified providers. In public sector facilities, women incur hidden costs

in the form of cost of medicine and illegal fees to the staff.

• Gender roles and norms. Many women, especially unmarried and married young women, find

it difficult to take decisions on their own regarding abortion. The stigma attached to abortion,

especially of unmarried women, compels women to delay seeking abortion services.

• Delay in decision-making. Delaying decisions related to seeking abortion jeopardizes safety.

• Sex-selective abortion. Increasing practice of sex-selective abortion (where generally the sex of

the child is determined after twelve weeks of pregnancy) also tends to place women at risk of

undergoing unsafe and repeated abortions.

What the Corporate Sector Can Do

• Undertake awareness-raising initiatives on the legality of abortion services and women’s right to

safe and confidential abortion services.

• Undertake provision of quality abortion services.

• Monitor quality of care in public and private health facilities.

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References

Chhabra, R. and S.C. Nuna, 1993. “Abortion in India : An overview”. New Delhi : Virendra Printers

Ganatra, B.R. 2000. “Abortions Research in India : What we know, what we need to know”.

Hirve, Siddhivinayak, 2004. “Abortion Policy in India : Lawnae and Future Challenges”. CEHAT,

Mumbai. Abortion Assessment Project-1

Jejeebhoy, S.J. 2000a. “Adolescent Sexual and Reproductions Behavious : A Review of the Evidence

from India” In Women’s Reproductive Health in India, Ramasubban and Jejeebhoy, eds. Rawat

Publications.

Jejeebhoy, Shireen J. (ed.), 2004. “Looking Back, Looking Forward: A profile of Sexual and Reproductive

Health in India”, Jaipur/New Delhi: Rawat Publications and Population Council.

Johnston, H.B., 2002. “Abortion Practice in India : A Review of Literature”. Mumbai : CEHAT &

Health Watch.

Khan M.E., S. Barge & G. Philips, 1996. “Abortion in India : An Overview”. ‘Social Change’ 26 (3-

4) : 208-225.

Registrar General of India, 2000

Seminar December 2003, Special Issue on ‘Abortion’, New Delhi.

S. Jejeebhoy and R. Ramasubban (eds) “Women’s Reproductive Health in India”. New Delhi, Rawat

Publications, 186-235.

Universal Law Publishing Co. Pvt. Ltd., 2003. “The Medical Termination of Pregnancy Act, 1971”.

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chapter 4

FAMILY PLANNING OR

PLANNED PARENTHOOD

India became the first developing country to initiate a state-sponsored ‘family planning’ programme

in 1951 with the goal of lowering fertility and slowing the population growth rate. Since the inception

of the programme, fertility levels have declined throughout the country. Table 4.1 depicts that in the

beginning of the family planning programme, men’s response to the programme was more compared

with women’s response but with the passage of decades men’s response decreased and women became

the receptors of family planning methods.

Table 4.1. Trends of Modern Contraceptive Prevalence Rate by Gender-specific Use

Gender-specific Use

Female

Male

Total

1970-71

3.7

6.2

9.7

1992-93

30.4

5.8

36.3

1998-99

37.9

5.0

42.8

2002-04

39.7

5.7

45.7

Source: Md. Irfan Khan et al., “Challenges for Population Stabilization Programme: A Critical Analysis

of Acceptance of Male Contraceptive Methods in India”, Bhopal: Taleen Research Foundation, 15

November 2006.

Towards the end of 1959, family planning clinics were set up and the Cafeteria Approach was

officially adopted, which has become popular in government programmes. In this approach, the

programmes have a bouquet of products for a woman to choose from, with few choices available

for the man. For the most part, the prospective acceptor tended to be apprised of the method

considered appropriate by the service provider and did not participate in the selection of the method

she will use. By and large, neither were supplies regularly available nor were women offered the

option of selecting a spacing method.

The government introduced method-specific family planning targets in the mid-1960s, wherein state

targets were set by the central government and then pursued at the local level. The programme focused

primarily on sterilization, largely obviating client choice and limiting availability to a narrow range

of services. The programme subsequently evolved into the Family Welfare Programme, which currently

administers family planning and maternal and child health services through various primary and

community health centres and district and sub-district hospitals.

Perspective

Reproductive rights rest on the recognition of the basic right of all couples and individuals to decide

freely and responsibly the number, spacing and timing of their children and to have the information

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and means to do so, and the right to attain the highest standard of sexual and reproductive health.

They also include the right of all to make decisions concerning reproduction free of discrimination,

coercion and violence.

The purpose of ‘family planning’ is to plan the number, frequency and timing of pregnancies, which

ultimately affect the family size and health of the mother and the infant. It includes taking conscious

and informed decisions on: at what age to marry, when to have the first child, the timing of

subsequent children and the total number of children desired. All these decisions come under the

purview of reproductive rights.

Reproductive health implies that women and men are able to have a safe sex life and that they have

the right to decide if, when and how to reproduce. Access to contraceptives and protection from high-

risk sexual behaviour are important factors in reproductive health, as well as the right of men and

women to be informed and to have access to safe, effective, affordable and acceptable methods of

family planning of their choice. Women should have control over their bodies and should be able

to take decisions with regard to reproduction. Men are equally responsible for family planning. They

should be aware of the need to be responsible for use of contraceptives and prevention of pregnancy.

Gender Issues in Contraception

• In the socio-cultural conditions prevailing in India, women have little decision-making authority,

including control over their own reproduction or the numbers and spacing of children.

• Women do not have control over using contraceptives.

• They also have less access to basic information because of less exposure to the outer world.

• More than half of the family planning methods are for women than men.

• What is inequitable however is that although condom is cheap and has little side-effects, it is

often not the preferred tool for temporary birth control. Men are reluctant to use it because it

reduces their sexual enjoyment.

• No-scalpel vasectomy (NSV) is an outpatient procedure, but because it supposedly interferes with

men’s virility, it is not popular. So tubectomy, a comparatively more complicated procedure

which is invasive, is used, and women undergo sterilization.

• The burden of sexual and reproductive ill-health is much greater for women than men.

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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -F-A-M-I-LY- -P-L-A-N-N-IN- -G-O- R- -P-L-A-N-N-E-D- -P-A-R-E-N-T-H- O- -O-D- - - - - - - - -

• The undue stress on sterilization is a well documented fact – over three in five contraceptive

users are sterilized.

Definitions

Methods to prevent pregnancy are also known as family planning methods, child spacing methods,

or contraceptive methods.

Vasectomy is male sterilization to prevent pregnancy.

Tubectomy is female sterilization to prevent pregnancy.

Total Fertility Rate (TFR) refers to the total number of childbirths an individual woman undergoes in

her entire reproductive life.

Contraceptive Prevalence Rate (CPR) is the proportion of women of reproductive age who are using

(or whose partner is using) a contraceptive method at a given point in time.

Net Replacement Rate (NRR) refers to the potential reproductivity of a population by calculating the

average number of daughters born to mothers. The assumption being that if there are more daughters

born to the succeeding generation the overall population is bound to increase, because there will be

more child-bearers in the future. Where NRR is less than 1 the population can be expected to

decrease. NRR = 1 is referred to as Replacement Level Fertility because at this rate total number of

current child-bearers/mothers is being replaced by an equal number of future child-bearers/daughters.

India had a goal of NRR = 1 by 2000.

Unmet need: Percentage of currently married women aged 15–49 who want to stop having children

or to postpone the next pregnancy for at least two years, but who are not using contraception. In its

definition of unmet need, the DHS programme includes women who are currently married who say

they prefer not to have another child either within the next two years or ever again, as well as women

who are pregnant or less than six months postpartum who did not intend to become pregnant at the

time they conceived and were not using a contraceptive method. The definition excludes women who

declare that they are infecund, have had a hysterectomy, or are in menopause.

Contraceptive Methods

Table 4.2 presents details of contraceptive methods. Table 4.3 presents the different options for

contraceptive methods, depending upon personal preferences and needs.

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4.10 Page 40

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5 Pages 41-50

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5.1 Page 41

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5.2 Page 42

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5.3 Page 43

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Problem Statement

• The quality of contraceptive services is a big issue in India. Sterilization operations ‘fail’ many

times.

• Awareness of the non-terminal methods tends to be poor among both men and women; in fact

family planning is frequently seen as synonymous with sterilization.

• Supplies are scarce many times; the providers do not provide information in ways that women

understand.

• Because of the target-driven programme, IUDs may be inserted when women are anaemic or

have infections.

• On a nation-wide basis the family planning programme currently offers three modern spacing

contraceptive options. The methods currently available for spacing are – oral contraceptive pills,

condoms and intra-uterine devices. Three other conventional contraceptives, foam tablets,

spermicide and diaphragms which were found to have been quite well received in the earlier

stages of the programme are rarely available through programme sources.

• Women have greater preference for terminal methods than the spacing methods. Instead of

choosing one of the spacing methods to prevent pregnancy, they feel it is safer to undergo

sterilization which fully removes their mental stress.

In 2000 the contraceptive prevalence rate (CPR) among married women was 48.3 per cent. Contraceptive

use in India is characterized by: (a) the predominance of non-reversible methods, particularly female

sterilization; (b) limited use of male/couple-dependent methods; (c) high discontinuation rates; and

(d) negligible use of contraceptives among both married and unmarried adolescents. Less than 7 per

cent of currently married women use the officially sponsored spacing methods (pills, IUD and

condoms). The reported use of traditional contraceptive methods and male/couple-dependent methods

is low (see Figure 4.1).

• The diaphragm, the sponge, IUDs, the pill, cervical caps, “morning after” pills, natural methods,

ovulation detectors, the female condom, foams, jellies, suppositories, sterilization, and more,

sell the message to women that birth control and contraception are fundamentally women’s

issues.

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Figure 4.1. Contraceptive Method Use by Married Women in India

• Women’s sexual autonomy and thus their pregnancy and disease prevention practices are limited

by gender inequalities at both individual and structural levels. More gender-sensitive approach

is needed in the contraceptive programmes. The programmes should also seek to strengthen

women’s skills to negotiate with male partners for condom use.

• The inclusion of ‘sexuality connection’ is also needed in the family planning programme.

Besides the painful side of sexual relations, which is generally focused and targeted in the family

planning approach, it should also focus on the effect of various family planning methods on

women’s sexuality and their sexual pleasure.

• Establishing the “sexuality connection” in reproductive health will acknowledge women as

sexual agents and not as sexual victims or as “targets” of contraceptive programmes.

• Most contraceptive research and development has failed to collect information on how various

methods influence women’s sexual functioning and enjoyment.

• The Family Planning Programme is restricted to provision of contraceptives to only ‘eligible

couples’, leaving out segments of population who may be sexually active – unmarried men,

adolescent girls, single women.

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• To increase access to services and address unmet needs, the pool of public sector providers needs

to be increased to deliver quality services. The current number of trained providers for sterilization

services is insufficient. Each community health centre and primary health centre having an

operation theatre facility needs at least one Medical Officer trained in one method of sterilization.

What the Corporate Sector Can Do

The programme orientation should be (a) to have an educational orientation to modify existing

attitudes to reproductive health, and (b) to encourage the use of contraceptives and to make quality

contraceptive services available to all sections of society.

• Change of terminology. The use of contraceptives should come out of the ‘family’. Instead of

Family Planning Programme, it should be made a Contraceptive Programme.

• The youth should be made aware about various contraceptives and their participation in the

same. This will make them more responsible towards the “family planning” issue. A new

thinking needs to be developed among the youth on “masculinity”, “manliness” and make them

sensitive towards family planning and sexuality. There is also a need to educate the girls about

emergency contraception with other contraceptives.

• There is a need to talk to men on contraceptives. Gender bias in the contraceptive issue should

be removed by counselling couples. Often they do not know much about different methods of

family planning. The cafeteria approach should come into practice in reality.

• Provide education. Make sure information about contraceptives is available to everyone – boys

and girls as well as men and women. Arrange education programmes to show the benefits of

contraceptives and help couples choose the best methods for them. Also lead discussions with

women or couples about their concerns and experiences related to contraceptive use. Include

information about preventing STIs in the contraceptive discussions, especially in the area where

male migration is high.

• In the community education address local beliefs and values like male child preference and a

child soon after marriage. This will facilitate acceptance of contraceptive use.

• Address also local religious concerns about contraceptive use. It will create more acceptance of

it.

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• Make contraceptive methods accessible at a low cost. Have a local health worker trained to

provide contraceptive services, start a women’s health centre or include family planning services

at a local clinic.

• Contraceptive research and development is required for male methods, how to increase men’s

responsibility in contraceptive use.

• We also need to find more contraceptives that serve as dual protection – from conceiving and

from STIs. At the moment only the male condom and the female condom serve as dual

protection.

References

http://www.who.int/reproductive-health/gender/index.html

Family Planning (A global handbook for providers), World Health Organization.

Higgins, Jenny, et al., 2007. “Comment: The Pleasure Deficit: Revisiting the ‘Sexuality Connection’

in Reproductive Health”, Reproductive Health Matters, Vol. 33, September.

India Reproductive Health Survey, 2003.

Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (INFO

Project) and United States Agency for International Development Bureau for Global Health,

Office of Population and Reproductive Health, 2008.

Khan, Md. Irfan, et al., 2006. “Challenges for Population Stabilization Programme: A Critical Analysis

of Acceptance of Male Contraceptive Methods in India”, Bhopal: Taleen Research Foundation,

November.

Khan, M.E. et al., 1996. “Spacing as an Alternative Strategy : India’s Family Welfare Programme”,

New Delhi: B.R.

Ministry of Health and Family Welfare, Government of India, “RCH Phase II, National Programme

Implementation Plan - Programme Document”.

VHAI, 2001. “Where Women Have No Doctor, A resource guide for Women’s Health”, Chapter 12

Family Planning, New Delhi. Voluntary Health Association of India.

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chapter 5

INFERTILITY AND ASSISTED

REPRODUCTIVE TECHNOLOGY

Women generally bear the societal brunt of being childless, becoming ‘sacrificial goats’ of involuntary

childlessness, without the cause of infertility being established. There is little social research on

infertility. Since the Indian government is concerned about overpopulation, the reproductive issues and

the situation of individual women remain largely hidden. Yet research on childlessness and infertility

could inform population policy by demonstrating the strength of the motherhood mandate and the

stigma faced by those who cannot conceive. Perceptions of infertility differ across various sections of

society; nonetheless, the childless couples become a ‘target’.

Infertility may be primary (by birth) or secondary (acquired). The World Health Organization (WHO),

using a two-year reference period, defines primary infertility as “the lack of conception despite

cohabitation and exposure to pregnancy”; and secondary infertility as “the failure to conceive following

a previous pregnancy despite cohabitation and exposure to pregnancy (in the absence of contraception,

breast-feeding or postpartum amenorrhoea)” (WHO 1991). The societal definition of infertility would

appear to be “inability to prove virility for a man and fertility for a woman”. The causes of primary

and secondary infertility relate to both males and females, and the conditions that directly contribute

to infertility vary widely by region and culture (WHO 1991).

World wide, 5 to 10 per cent of couples are currently affected by infertility (Singh et al. 1996).

Infertility experienced by couples at some point of time is reported to be between 8 and 12 per cent

around the world, affecting nearly 50 to 80 million people. The prevalence is cited to be about 5 per

cent due to anatomical, genetic, endocrinological and immunological problems (Daar and Merali

2001). India accounts for nearly 5 to 10 million of infertile couples. This number is rising by 5 per

cent every two years (Nagaraj 2000).

In most cultures, marriage is associated with two aspects – a cordial relation between husband and

wife, and the blessing of children. The rites and rituals of marriage and social customs are also geared

towards the fulfilment of these two aspirations. In India, from childhood itself the nuances of

motherhood are inculcated into the personality of a girl child. The reproductive role of women is

zealously recognized; the onset of puberty is an occasion for rejoicing, celebrating her fertility and

capability for future motherhood (Dube 1998).

Infertility has never been addressed as a public heath issue, thus limiting the accessibility to artificial

reproductive technologies to the rich. Treatment for infertility should be given higher priority owing

to the dire consequences related to stigma, blame, isolation, economic hardships and even loss of

social status (Sundby 2002; Daar and Merali 2001; Toubia 1994).

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Society’s expectation of attaining parenthood after marriage fosters a feeling of incompleteness in

childless couples. Thus, the experience of infertility has significant consequences on the marital life

of the couple as well as their individual identities as woman or man in a highly gendered culture like

ours. A noteworthy comment in this regard is by Bharadwaj (2000), who highlights the distinction

between “stigma” and “blame”. He says that women may be primarily blamed for not having children,

but stigma essentially “penetrates and attaches itself to a married body” (p. 75).

Causes of Infertility

Infertility may be caused by medical causes in the

woman or the man, social causes, and behavioural

and occupational factors. Infertility may also result

from hormonal, mechanical or psychological problems.

A common cause of infertility is sexually transmitted

infections (Jeejeebhoy 1995) and pelvic inflammatory

diseases. Infections caused due to sexually transmitted

bacteria such as chlamydia trachomatis and neisseria

gonorrhoea may lead to blockage of tubes or pelvic

adhesions involving the fallopian tubes and ovaries.

In cases of infection, where there is no tubal obstruction, the passage of the fertilized ovum from the

tube to the uterine cavity may get hampered, resulting in implantation of the ovum in the tube,

causing a life-threatening condition known as ectopic pregnancy.

Medical Causes: Women

• vaginismus (vaginal spasm), where the vaginal muscles prevent the insertion of the penis

• cervical secretions may prevent the entry of sperm either by forming antibodies (which destroy

the sperm) or due to the nature (being thick) of the secretions

• medical conditions, such as fibroids, endometritis, Asherman’s Syndrome (where the uterine

walls stick together)

• uterine malformations (formation defects)

• tubal blockages due to pelvic inflammatory diseases, tuberculosis or any other infections or

damaged tubes

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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -I-N-F-E-R-T-I-LI-T-Y- -A-N-D- -A-S-S-IS-T-E- D- -R- E- P- -R-O-D-U-C- -T-IV-E- -T-E-C-H-N-O- -LO- -G-Y- - - - - - - - -

• annovulation (no egg is released)

• ovarian failure (failure of the ovary to produce eggs)

• polycystic ovary syndromes (the ovary has many small exits)

• hypogonadotrophic hypogonadism, that is, lack of production of either gonadotrophin-releasing

hormone or follicle stimulating and luteinizing hormone which has an effect on the release of

eggs from the ovary

• weight loss, strenuous exercise are also cited as probable causes.

Medical Causes: Men

• alteration in one or more semen parameters: sperm is absent in the semen (azoospermia) or is

not motile, or the concentration of spermatozoa is less than 20 million/ml of the ejaculate

(oligospermia); and similar other conditions

• impotence or ejaculatory failure

• premature ejaculation

• extra-vaginal ejaculation (ejaculation outside the vagina)

• immunological causes, such as antibodies that destroy the sperm

• iatrogenic cause, that is drug use for any other medical condition that may affect the production

of spermatozoa

• congenital abnormalities (birth defects)

• systemic cause: diabetes and other diseases that affect the function of the nerves in the body

may cause impotence or no ejaculation or retrograde ejaculation, where the bladder sphincters

are closed at the time of ejaculation, thereby preventing semen from passing backward into the

bladder

• acquired testicular damage: infection in the testes due to mumps or any other infections such

as gonorrhoea; varicocoele, a condition in which the veins that drain the testes become dilated

and engorged with blood due to poor flow of blood away from the testes

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• male accessory gland infection.

Social Causes

• exposure to radiation and unhygienic obstetric practices

• women’s poor health and nutrition status, which can lead to repeated miscarriages and foetal

wastage.

Behavioural and Occupational Factors

• Drug abuse, especially smoking. In men excessive smoking may lead to a drop in the sperm

count. In women it may reduce the chances of embryo implant.

• Psychodynamic stressors. The increasing competition for survival and the consequent stressful life

in contemporary society results in related health issues.

Assisted Reproductive Technology (ART)

The birth of Loiuse Brown in 1978 opened the path

of assisted reproductive technology (ART) for providing

joy to childless couples. ART is widely available at

private clinics all over the country, though it is

expensive.

In general, ART procedures involve surgically removing

eggs from a woman’s ovaries, combining them with

sperm in the laboratory, and returning them to the

woman’s body or donating them to another woman.

They do not include treatments in which only the

sperm is handled (i.e., intra-uterine – or artificial –

insemination) or procedures in which a woman takes

medicine only to stimulate egg production without the intention of having eggs retrieved (CDC 2007).

The success rates, though not clearly specified, are not high and the persons opting for these suffer

both psychologically and economically. Again, there are probable risks in opting for in-vitro fertilization

(IVF) and intra-cytoplasmic sperm injection (ICSI), such as multiple pregnancies, low birth weight,

major birth defects or long-term disabilities among surviving infants and even pregnancy complications,

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including ectopic pregnancy (reported to be as high as around 11 per cent following IVF in some

groups (Nagarsekar 2002). The “hi-tech” reproductive technologies marketed in the country, besides

the economic aspect, imply issues of the quality of treatment, misquoted success rates and unethical

procedures. Certain practices also increase the possibility of HIV-infected semen being injected into

unaware women. Ethically, this practice involves using women’s bodies as experimental sites (Klein

and Rowland cited in Cussins 2000).

Availability of Infertility Services: The Right to Parenthood

Attaining parenthood is a right that all individuals should get irrespective of their caste, class or

gender. Assisted technologies, even the simplest of infertility treatments, are often beyond the reach

of the poor. The government health delivery system, though available, may not be accessible to all.

There is also a mismatch of the available services. If in a hospital the equipment is available there

may not be an expert to operate it. Similarly, supplies of accessories may be erratic. The technicians

appointed may be incompetent. Or the machines may not be in working condition (Alexander and

Apte 2002). Most of the services are available only in the private sector, which are accessible to only

the middle and the upper classes of society. At the same time, the insurance companies are not

interested in covering infertility treatment.

Gender Issues in Infertility

In India, women are symbolized as the image of procreation. Motherhood is considered as a source

of power for woman that determines the strength of her marital bond. Infertility is viewed as a

deviation from the cultural norms and renders the woman helpless. It also provides ground for divorce

negotiable with the woman’s education and class structures, or the husband taking on other wives.

Although infertility is mainly perceived to be associated with females, all men are aware that there

could be ‘defects’ in men as well (Gujjarappa et al. 2002). But men are reluctant to seek treatment

as they fear disgrace in society. The ostracism goes to the extent of sidelining the men in employment

and degrading their social status (Papreen et al. 2000; see Boxes 5.1 and 5.2).

What the Corporate Sector Can Do

• Safe Motherhood Programmes managed by the corporate sector agencies should include issues

of infertility. The Community Needs Assessment should also identify couples with infertility and

counsel them.

• Referrals links should be built with government as well as private clinics. Couples who fail to

conceive often need help before as well as during the treatment (see Figure 5.1).

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• Laboratories run by the corporate sector should include semen test. These should be provided

at the primary level.

• Couples need support and guidance at each stage of the treatment, especially when they would

be undergoing certain painful procedures of diagnosis and treatment. The realization of infertility

could itself be disturbing and it becomes more severe with time and no positive results. They

should be provided with correct information and counselling as a holistic approach (see Figure

5.2). IEC materials should be used to help them understand the issue and be able to accept the

situation (see Figure 5.3). The corporate sector could provide counselling services, and print good

quality IEC material for infertility issues and assisted reproductive technologies.

Box 5.1. Case Profile 1

Mrs Meghani (37) has been married for twelve years. She has a postgraduate degree and holds

a good job. She became pregnant after two years of marriage, but miscarried. When even after

two years there were no signs of pregnancy she began visiting doctors, got sonography done,

underwent ovulation studies and hysterosalpinography (HSG). Everything seemed to be normal.

It was then suggested that the husband should get a sperm test done, which revealed azoospermia.

Mrs Meghani talks of the dreadful life that she led before the cause was determined. Her

husband was very supportive and made things easy for her. She felt relieved on finding that the

problem was not with herself. Yet, her inner self made her feel guilty: she was guilty of not

reproducing, of depriving her husband of the joys of fatherhood. She also blames society for

being prejudiced against women, and forcing them to be the first ones to approach the doctor.

Box 5.2. Case Profile 2

Rajesh was 30 years old when his wife Karuna conceived, but miscarried. When even after three

to four years they did not have a child, they consulted a doctor. It was diagnosed that there was

a problem in the sperm count, which could not be remedied medically. Karuna then met

someone who had adopted a child but Rajesh could not be convinced that he could develop

affection for an adopted child. Nor would his family accept the child, he said. Karuna kept up

her efforts to convince him, by coaxing him to attend birthday parties of children who had been

adopted, took him to the agencies to talk to other people who had adopted children. Finally,

when he saw that they were all happy after the adoption, he agreed. He was then also ready

to assert himself with his family if they did not accept the child.

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Figure 5.3. Tips to Overcome Childlessness

Do not be obsessed with the idea of conception; it may have adverse effects

Be happy and stress-free

Avoid tight clothing and wear clothes apt for

the weather

Treat any health problems at the earliest

Exercise and eat healthy food

Counter the myths:

It is not always

because of some

problem with the

woman

Try to have sex during the fertile days, that is

mid-cycle

if possible, stick to a doctor

Rituals do not solve

the problem,

consult a doctor

Demand your right to be informed about

everything during treatment

Do not be misled by misquoted success rates; seek authentic information

Realize that there are other alternatives to having biological children – Adoption

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References

Alexander, M. and H. Apte, 2002. “Are we geared for management of infertility? A study of public

and private health facilities in Maharashtra, India”. Paper presented at the International Conference

on Socio-Medical Perspective of Childlessness, Goa (September).

Balen, F.V., T. Gerrits and M. Inhorn (eds.), “Social Science Research on Childlessness in a Global

Perspective”. Proceedings of the Conference, 8–11 November 1999, Amsterdam, The Netherlands.

Amsterdam: University of Amsterdam.

Bharadwaj, A., 2000. “Infertility and gender: A perspective from India”. In Balen et al. (eds.), pp. 65–

78.

CDC (Department of Health and Human Services: Center for Disease Control and Prevention), 2007.

“Assisted reproductive technology: Home”. Atlanta: CDC, <http://www.cdc.gov/art/>, retrieved

16 January 2008.

Daar, A.S. and Z. Merali, 2001. “Infertility and social suffering: The case of ART in developing

countries”. Report of a meeting on Medical, Ethical and Social Aspects of Assisted Reproduction,

WHO Headquarter, Geneva (September). Retrieved 20 August 2005, from <http://www.who.int/

reproductive-health/infertilityreport-content.htm>.

Dube, L., 1998. “On the construction of gender: Hindu girls in patrilineal India”. In K. Chanana (ed.),

Socialization, Education and Women: Explorations in gender identity, New Delhi: Orient Longman.

Gujjarappa, L., H. Apte, L. Garda, and U. Nene, 2002. “The unseen side of infertility: A study of

male perspective on infertility in rural Western Maharashtra, India”. Paper presented at the

International Conference on Socio-Medical Perspective of Childlessness, Goa (September).

Gupta, J.A., 2000. “New Reproductive Technologies: Women’s health and autonomy, Indo-Dutch

Studies on Development Activities”, New Delhi: Sage.

Jejeebhoy, S.J., 1995. “Infertility in South Asia: Priorities for social science research. Reading material

for a proposal development workshop, Issues in women’s reproductive health”. Baroda: The

Klien & Rowland cited in Population Council (November).

Klien and Rowland cited in Cussins, C., 2000. “Fertile ground: Feminists theorize infertility”. In Balen

et al. (eds.), pp. 51–64.

Mehta, B., 2005. “Psychosocial Implication of Involuntary Childlessness in an Indian Cultural Context”.

Unpublished Ph.D. thesis, Department of Human Development and Family Studies, Faculty of

Home Science, The Maharaja Sayajirao University of Baroda, Vadodara.

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Meniru, G.I., 2001. “Cambridge Guide to Infertility Management and Assisted Reproduction”,

Cambridge: Cambridge University Press.

Nagaraj, A., 2000. “For a large number of childless couples, life begins in a petri dish”, Indian

Express.

Nagarsekar, U.L., 2002. “Infertility – assisted reproductive technology and ectopic pregnancy”. Paper

presented at the International Conference on Socio-Medical Perspective on Childlessness, Goa.

Papreen, N., A. Sharma, K. Sabin, L. Begum, S.K. Ahsan and A.H. Baqui, 2000. “Living with

infertility: Experiences among urban slum populations in Bangladesh”. Reproductive Health

Matters, 8(15): 33–44.

Reissman, C.K., 2000. “Stigma and everyday resistance practices: Childless women in South India”,

Gender and Society, 14(1): 111–35.

Sayeed, U., 1999. “Childlessness in Andhra Pradesh, India: Treatment-seeking and consequences”,

Reproductive Health Matters, 7(13): 54–64.

Singh, A., L.K. Dhaliwal, and A. Kaur, 1996. “Infertility in a primary health centre of North India:

A follow-up study”, The Journal of Family Welfare, 42(1): 51–7.

Sundby, J., 2002. “Infertility as a commodity for the wealthy: The history of the media debate in

Norway”. Paper presented at the Conference on Socio-Medical Perspective of Childlessness, Goa

(September).

Toubia, M.F., 1994. “Social pressure is not the only reason people want children. Infertility treatment:

Luxury, desire or necessity: Commentary”, Reproductive Health Matters, (4): 93–7.

UNDP, UNFPA, and WHO, 1993. “Prevention of infertility and sexually transmitted disease”. Progress

in Human Reproduction Research, 27, p. 2.

UNFPA, 2002. “Prevention and management of infertility in primary health care settings”. An information

booklet for policy planners, programme managers and service providers in health systems. India:

UNFPA.

Vyas, R., G. Advanikar, L. Hathi, B. Vyas and R. Parikh, 2002. “Psychodynamics of unexplained

reproductive failure”, Journal of Obstetrics and Gynecology of India, 52(2): 35–8.

WHO, n.d. “Infertility”, at <www.searo.who.int/LinkFiles/Reporductive_Health_Profile_infertility.pdf>.

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chapter 6

REPRODUCTIVE TRACT

INFECTIONS

Infections of the reproductive system are called reproductive tract infections (RTIs). They include

sexually transmitted infections (STIs) and other infections of the reproductive system that are not

caused by sexual contact. These other infections may be the result of the overgrowth of the bacteria

and other organisms that normally live in the vagina. RTIs also include infections that result from

improperly performed procedures such as unsafe abortion, poor delivery practices and inadequate

infection prevention practices by healthcare providers during pelvic examinations and IUD insertions.

STIs are infections passed from person to person by sexual contact. Any type of sex, vaginal, oral or

anal can cause an STI. It can even be caused by simply the genitals of two people coming in contact.

They can also be passed from a pregnant woman to her baby. The following diseases can be

transmitted by sexual contact: chlamydia, gonorrhoea, HIV infection/AIDS, hepatitis B, hepatitis C,

herpes, human papillomavirus (HPV, genital warts), pelvic inflammatory disease, syphilis and

trichomonas vaginalis. RTIs are responsible for considerable ill-health throughout the world, both

directly and by increasing the risk of transmission of human immunodeficiency virus (HIV) infection.

Inherent problems of under-treatment because of stigma and inadequate treatment facilities lead to

rapidly developing antibiotic resistance, which increases the cost of second-line therapy. The increased

cost of therapy, in turn, results in further inadequate therapy, attritions and thus further failures. STIs

may lead to serious complications, including the risk of acquiring or transmitting HIV, the virus that

causes AIDS. STI-related sores provide an easy entry point for the HIV virus to enter the body during

unprotected sex.

The global disease burden of RTIs is enormous and a major public health concern. According to

figures published by WHO, nearly 1 million people become infected with an STI every day. Each year

there are an estimated 333 million new cases of curable STIs. Among clinic patients of STIs,

29.3–43.3 per cent women are infected with syphilis and 1.2–13.6 per cent with HIV. Among

gynaecological outpatients, 0.4–26.0 per cent women are infected with trichomonas vaginalis,

0.3–25.0 per cent with herpes simplex virus and 0.6–42.4 per cent with HPV. Among antenatal

patients 17.8 per cent women have trichomonas vaginalis. In India, each year 40 million new cases

of STIs occur. Among married women in the community 0.5–28.7 per cent have chlamydia trachomatis

and 4.3–27.4 per cent have trichomonas vaginalis. Among clinic patients of STIs, 29.3–43.3 per cent

women are infected with syphilis and 1.2–13.6 per cent with HIV. Among gynaecological OPD

patients, 0.4–26.0 per cent women are infected with trichomonas vaginalis, 0.3–25.0 per cent with

herpes simplex virus and 0.6–42.4 per cent with HPV. Among antenatal patients 17.8 per cent women

have trichomonas vaginalis.

Women feel inhibited talking about problems like vaginal discharge and ulcers and hence suffer

silently, including the associated abdominal or back pain. There is also the fear of being termed a

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loose woman because of the stigma associated with STIs. Women generally are less educated and have

less access to medical care. They are generally not the decision-makers at home and therefore their

health problems (unless pregnancy or infertility related) are considered least important by other family

members. It may be noted that only 0.2 per cent women as compared to 5 per cent men had indulged

in higher-risk sex (NFHS 2005-06).

Although RTIs affect both sexes, women are more susceptible to infection because they have a larger

exposed surface during sex and the semen stays longer in the vagina. Trapped in a web of male

domination and poor empowerment, women are poorly placed in the position of refusing sex or

negotiating safe sex. They are also less likely to seek treatment than men. In addition, complications

can be more serious in women and infections can be transmitted to the offspring of pregnant women.

Married women are vulnerable to STIs because of exposure to regular sex within marriage, exposure

to regular unprotected sex because of the pressure to prove fertility and presence of risky pre-marital

and within marriage sexual behaviours of husbands. It is seen that women lack awareness of HIV and

safe sex practices and have a low self-perception of risk. Once infected, they lack access to health

services and also are not in a position to take decisions. Evidence from the National Family Health

Survey of 2005-06 shows that only 5 per cent of married women used condoms.

Stigma and discrimination against people living with STIs and most at-risk groups, including in

healthcare settings, continue to prevent people accessing the services they need.

Symptoms

The symptoms associated with RTIs vary from none to

severe. Some STIs (for example chlamydia, gonorrhoea,

HPV, hepatitis B, and genital herpes) often cause no

symptoms. RTIs without symptoms are more common

in women. People without symptoms often transmit

the infection to others unknowingly. These infections

may lead to symptoms in the reproductive organs

themselves, and in the skin around the vagina, penis,

or anus. Some RTIs also cause systemic symptoms

that cause problems in other parts of the body. Some

common symptoms are:

• foul-smelling vaginal discharge

• ulcers or sores on external genitals

• lower abdominal pain

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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - R- -E-P-R-O-D-U- -C-T-IV-E- -T-R-A-C- -T-I-N-F-E-C-T-I-O-N-S- - - - - - - - -

• pain/bleeding during intercourse

• itching around the genitals

• burning pain on passing urine

• painful lumps in the groin.

Reproductive Tract Infections (RTIs)

Abnormal Vaginal Discharge: A small amount of discharge is normal but a change in the amount,

colour or odour of the discharge indicates infection which could be due to yeast or bacterial vaginosis.

These are not sexually transmitted but can cause discomfort and in a pregnant mother cause an early

delivery. SYMPTOMS: (a) white lumpy curd-like discharge; (b) redness and itchiness in and around the

vagina; (c) pain during intercourse; (d) burning sensation while urinating; (e) if yeast, mould-like

smell; if bacterial vaginosis, fishy smell. TREATMENT: medicines as advised by qualified medical person.

Pelvic Inflammatory Disease (PID) refers to an infection in any of the upper reproductive organs. This

can happen if an existing STI like gonorrhoea or chlamydia was not cured or abortion or miscarriage

was carried out in unhygienic conditions. If left untreated PID can cause chronic pain, illness and even

death. If the tubes are infected it can lead to sterility or an ectopic pregnancy. SYMPTOMS: (a) pain in

the lower abdomen or back; (b) fever and chills; (c) weakness; (d) discoloured and foul-smelling

vaginal discharge; (e) pain/bleeding during sex; (f) menstrual disturbances. TREATMENT: medicines under

supervision.

Sexually Transmitted Infections (STIs)

Trichomonas vaginalis causes discomfort due to severe itching. SYMPTOMS: (a) grey or yellow foul-

smelling discharge; (b) redness and itchiness around the genitals and the vagina; (c) pain or burning

sensation while urinating. TREATMENT: (a) medicines as advised by physician; (b) the partner needs to

be treated as well.

Gonorrhoea and Chlamydia are serious infections, but easy to cure if treated early. If left untreated

they can cause infertility. Sometimes the symptoms do not appear at all for weeks or months, thus

increasing the probability of infecting others. SYMPTOMS: (a) foul-smelling yellow or green discharge

from vagina or anus; (b) pain or burning sensation while urinating or frequent urination; (c) fever; (d)

pain in the lower abdomen; (e) pain/bleeding during sex; (f) abscesses. TREATMENT: medicines as advised

by physician.

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Warts on the Genitals are caused by HPV and grow on the vulva, inside the vagina or around the anus.

In women they increase the risk of cervical cancer and cause problems during childbirth. SYMPTOMS:

(a) small, painless, whitish or brownish bumps (warts); (b) itching. TREATMENT: application of gel or

medicine as advised by physician.

Syphilis is a serious bacterial infection which can last for years and affect the whole body. Untreated,

it can cause heart disease, paralysis, mental illness and even death. An infected pregnant woman can

have a premature delivery or a deformed or dead baby. SYMPTOMS: (a) initially, a painless sore (looks

like pimple or blister, a wet wart or an open sore) which after lasting for a few days or weeks

disappears; (b) later, sore throat, fever, rash on the palms and soles, mouth sores or swollen joints.

TREATMENT: medicines as advised by physician.

Chancroid is caused by bacteria and can be cured if treated early. SYMPTOMS: (a) soft sores on the

genitals or anus that bleed easily; (b) enlarged painful glands in the groin; (c) slight fever. TREATMENT:

(a) medicines as advised by physician; (b) sores on the genitals to be kept clean.

Genital Herpes is caused by a virus. Sores on the genitals or on the mouth appear and disappear. This

can continue for months or years. Subsequent infections are milder. Pregnant women who have sores

at the time of delivery can infect their offspring. SYMPTOMS: (a) painful and itchy skin in the genital

area or thighs; (b) small blisters that burst to form open sores (can last up to three weeks); (c) fever,

body ache and chilly feeling; (d) swollen lymph nodes in the groin. TREATMENT: (a) some treatments

like putting ice directly or a compress of black tea on the sore or sitting in a tub of cool clean water

give relief; (b) medicine as advised.

Hepatitis B is caused by a virus that infects the liver and can be dangerous if not treated. Sometimes

there are no symptoms. Hepatitis B spreads through saliva, blood, spit, semen or vaginal fluid.

Hepatitis B is vaccine-preventable. It is important that both the partners get treated. SYMPTOMS: (a)

fever; (b) loss of appetite; (c) fatigue and weakness; (d) yellow eyes and/or skin (jaundice); (e) dark

urine and whitish stools; (f) pain in the abdomen. TREATMENT: (a) eat easily digestible foods; (b)

adequate rest; (c) do not take alcohol for at least six months.

Since STI-related sores provide an easy entry for the HIV virus to the body during sex, abstention from

sex is strongly recommended while the sores are present.

HIV/AIDS: Since HIV/AIDS requires more extensive treatment it is discussed under a separate section

later.

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Association between RTIs and Family Planning Methods

Some family planning methods either protect from RTIs or have no effect. Other methods can cause

an infection or worsen an existing infection; examples: IUDs when not inserted with properly sterilized

equipment; sterilization carried out in unhygienic conditions or with unsterilized medical implements.

Injectibles, hormonal implants and oral contraceptives do not protect against STIs though they decrease

the risk of pelvic inflammatory disease (PID). Diaphragms and spermicides provide partial protection.

Condoms effectively protect against STIs, including AIDS.

Precautions for Preventing STIs

• Practise safe sex. Insist on the partner to always use condom; in the alternative, a spermicide

or diaphragm.

• Have sex with only one partner.

• Avoid kissing if there are sores in the mouth.

• Wash genitals after sex.

• Pass urine after sex.

• Do not douche as this dries the vagina, making it more susceptible to infection.

• Do not share injections.

Syndromic Approach

A group of symptoms is called a syndrome. In this approach health workers diagnose and treat patients

on the basis of their symptoms rather than for specific RTIs. This approach is advantageous most of

the time because it improves clinical diagnosis and health workers can easily learn it.

AIDS

AIDS – acquired immuno-deficiency syndrome – is caused by the human immuno-deficiency virus

(HIV). In AIDS the immune system begins to fail, leading to life-threatening infections which the body

cannot fight anymore. Full-blown symptoms of AIDS can take five to ten years to develop. Till then

a person can lead a full and healthy life.

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The HIV virus lives in the body fluids (semen, vaginal secretions, blood and breast milk) of the

infected person. Three main transmission routes for HIV are:

• Sexual route: Sexual transmission can occur when infected sexual secretions of one partner come

in contact with the genital, oral, or rectal mucous membranes of another.

• Blood or blood product route: This transmission route can account for infections in intravenous

drug users, haemophiliacs and recipients of blood transfusions (though most transfusions are

checked for HIV in the developed world) and blood products and substandard hygiene in the

use of injection equipment, such as the reuse of needles.

• Mother-to-child transmission (MTCT): This can occur during the last weeks of pregnancy and at

childbirth.

HIV has been found in low concentrations in the saliva, tears and urine of infected individuals, but

there are no recorded cases of infection by these secretions and the potential risk of transmission is

negligible.

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Window period: This is the time gap between the first entry of HIV virus (i.e. infection) and when

the antibodies appear in the blood. The window period can vary between six and twelve weeks or

even as long as six months. During this period an infected person can transmit the disease to others

even if he/she may have tested negative for HIV.

HIV Test: When a person gets infected with the HIV virus the body starts producing antibodies to

fight the virus. The HIV test looks for these antibodies in the blood. The HIV test is important and

could be beneficial for receiving treatment, care and support if:

• one or the partner has had unsafe sex

• a person or the partner or the infant have signs of AIDS

• one is getting married or planning to have children.

Symptoms: When full-blown AIDS develops, loss of appetite, weight loss, constant fever, prolonged

fatigue, diarrhoea, constipation, changing bowel patterns, swollen glands, chills coupled with excessive

sweating, especially at nights, lesions in the mouth, sore throat, persistent cough, shortness of breath,

tumours, skin rashes, headaches, memory lapses, swelling in the joints, pain in various parts of the

body, vision problems and a regular feeling of lethargy and ill-health make up the litany of symptoms.

Treatment: There is currently no vaccine or cure for HIV or AIDS. The only known method of

prevention is avoiding exposure to the virus. However, an anti-retroviral treatment, known as post-

exposure prophylaxis, is believed to reduce the risk of infection if begun directly after exposure.

Current treatment for HIV infection consists of highly active anti-retroviral therapy (HAART, introduced

in 1996) consisting of at least three drugs. Treatment with anti-retrovirals, where available, increases

the life expectancy of people infected with HIV. Because AIDS progression in children is more rapid

and less predictable than in adults, particularly in young infants, more aggressive treatment is

recommended for children than adults.

The Global HIV/AIDS Scenario

• AIDS was first recognized on 1 December 1981.

• As of January 2006 AIDS has killed more than 25 million people, making it one of the most

destructive pandemics in recorded history.

• Between 33.4 and 46 million people currently live with HIV, i.e. about 0.6 per cent of the

world’s population.

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• 17.5 million are women living with HIV/AIDS.

• In 2005 alone, AIDS claimed an estimated 2.4–3.3 million lives, of which more than 570,000

were children. A third of these deaths are occurring in sub-Saharan Africa, retarding economic

growth and increasing poverty in that region.

The Indian HIV/AIDS Scenario

• NFHS-III estimated that 1.7 million, i.e. 0.28 per cent of the country’s population, age 15–49,

are HIV-positive. According to the revised estimates of the National AIDS Control Organization

(NACO), 2.47 million, i.e. 0.36 per cent of the country’s population, are living with HIV.

• This number is the third-highest in the world.

• More men are HIV-positive than women. According to NFHS-III, prevalence rate for women is

0.22 per cent and 0.36 per cent for men.

• The female-to-male infection ratio is 0.61. This ratio is higher in urban areas (0.71 per cent) than

rural areas (0.56 per cent) (NFHS-III).

• HIV prevalence is 40 per cent higher in urban areas than in rural areas.

• While adult HIV prevalence among the general population is 0.36 per cent, high-risk groups,

inevitably, show higher numbers. Among Injecting Drug Users (IDUs), it is as high as 8.71 per

cent, while it is 5.69 per cent and 5.38 per cent, respectively, among men who have sex with

men (MSM) and female sex workers (FSWs).

• Fifteen per cent of AIDS-infected are children under 15 years of age, the vast proportion of whom

have contracted the virus during birth or through breast-feeding.

• Women now account for 38 per cent of new infections, and the proportion of mothers giving

birth to HIV-positive infants rose from 2.7 per cent in 2003 to 3.5 per cent in 2004.

According to NACO, the bulk of HIV infections in India occur during unprotected heterosexual

intercourse. Consequently, and as the epidemic has matured, women account for a growing proportion

of people living with HIV, especially in rural areas.

National Response to HIV/AIDS

Shortly after reporting the first AIDS case in 1986, the Government of India established a National

AIDS Control Programme (NACP) within the Ministry of Health and Family Welfare. NACP is being

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implemented across the country since 1992. The activities are coordinated and monitored by the State

AIDS Control Societies established in all the states of the country. The programme lays specific focus

on high-risk population, local needs and nature of spread of the infection.

NACP has been evolving over the years and has gone through three phases of progress and expansion.

• NACP I (1992–99) focused on awareness generation, infrastructure development at states level

and promoting prevention programme, particularly blood safety.

• NACP II (2000–07) moved on further, scaling up of awareness building, prevention strategies

through voluntary counselling and testing, prevention of parent-to-child transmission, targeted

interventions for high-risk vulnerable groups, treatment of opportunistic infections, blood safety,

low-cost strategies for care and support, and introduction of anti-retroviral treatment (ART).

• NACP III (2007–12) aims at up-scaling these services, decentralizing implementation to district

level, developing public-private partnerships in various interventions, and mainstreaming various

activities with other sectors. It also focuses on integration with the National Rural Health

Mission (NRHM) and other national health programmes, notably the Reproductive and Child

Health (RCH) programme and Revised National Tuberculosis Control Programme (RNTCP). The

focus will be on prevention, since 99 per cent of the population are HIV-negative. Table 6.1

presents highlights of NACP III.

Table 6.1. NACP III Activities

Prevention

• Creating awareness about symptoms, spread, prevention and treatment

• Screening for STI and RTI and treatment

• Condom promotion

• Integrated counselling and testing (ICT)

• Promotion of voluntary blood donation and access to safe blood

• Prevention of parent-to-child transmission

• Promotion of safe practices and infection control

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Care, Support and Treatment Services

• Reducing stigma and discrimination

• Management of opportunistic infections

• Control of TB in people living with HIV/AIDS

• Anti-retroviral therapy (ART)

• Outreach: community/home-based care

Targeted Interventions for High-risk Groups

• Linking HIV-related care and support services

• Condoms – free and social marketing

• Behavioural change communication through peer and outreach

• Building enabling environment

• Community organizing and ownership building

• Additional components such as detoxification, de-addiction and rehabilitation

Issues and Challenges: Priority Areas

• Limited capacity: There are institutional constraints, both structural and managerial, which need

to be scaled up at the national and state levels.

• Donor coordination: There are over 32 large donor agencies working with NACO in different

states and on different programmes, apart from many more who support NGOs in states. There

is a need for better coordinating mechanisms among the donors and clear leadership by the

government.

• Use of data for decision-making: There is a need for greater use of data for decision-making,

including programme data and epidemiological data. A lot of data that are being generated are

not adequately used for managing the programme or informing policies and priorities. Results-

based management and linking incentives to the use of data should be explored.

• Stigma and discrimination: Stigma and discrimination against people living with HIV/AIDS and

those considered to be at high risk remain entrenched. Stigma and denial undermine efforts to

increase the coverage of effective interventions among high-risk groups such as men having sex

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with men, sex workers, and injecting drug users. Harassment by police and ostracism by family

and community drives the epidemic underground and decreases the reach and effectiveness of

prevention efforts. Though there is significant increase in awareness due to efforts by the

government, there is much room for improvement.

HIV Care and Support

Persons diagnosed as being HIV-positive are devastated and full of despair. The following measures

will help them lead a healthy life:

• Counselling the infected person and his family helps tremendously.

• Joining a support group (of people who have AIDS) to share problems.

• Taking medical care from health centres. It is advisable to visit the same doctor or clinic

whenever there is a health problem.

• Staying healthy as long as possible by eating nutritious food, exercising regularly, getting enough

rest and avoiding tobacco, alcohol and drugs.

• Staying mentally fit by living positively and being spiritual.

• Learning to be sexually active in a safe way.

• Planning for the future (self and family).

• People living with HIV, if they desire to have a child, must discuss with their doctor.

• If already pregnant, taking anti-viral drugs under medical supervision will reduce the risk of the

infection passing on to the baby. Consult a trained health worker before breast-feeding the baby.

• Care of the infected person by the family to make them feel loved and wanted.

What the Corporate Sector Can Do

The corporate sector can play an important role by supporting and ensuring that the following

interventions are carried out.

• Access to health facilities and resources, especially to women. Keeping in view the restraints on

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their mobility, home visits by health workers will help greatly.

• Routine screening of blood and blood products used in medicine and medical research, since

donors may be unaware of their infection.

• Increased access to anti-retroviral medication to those who need it.

• Supply of enough disposable gloves, sterile needles and syringes.

• Starting hospices and residential care facilities for people with AIDS.

• Removal of stigma: The misconception that AIDS only affects men who have sex with men, sex

workers, and injecting drug users strengthens and perpetuates existing discrimination. The corporate

sector can provide an example by employing people living with HIV.

• Addressing the issue of human rights violations: The most affected groups, often marginalized,

have little or no access to legal protection of their basic human rights.

• Public policy that states that an individual’s HIV status remains confidential and those who

make unauthorized disclosure are punished.

• Creating an enabling environment that increases knowledge about safe sex practices for both men

and women, knowledge about its spreading route and risk to even offspring and encourages

behaviour change is thus extremely important to containing the AIDS menace.

• Educational programmes that present factual information clearly, to change individual attitudes.

• Risk assessment: There is need to research what factors make people engage in risky behaviour.

• Social support and social response: A supportive system helps in adjustment to HIV infection,

ensures well-being of the infected during illness and during the progression of the disease.

Creation of a social climate which is conducive to a rational, effective and compassionate

response to this epidemic is as important as controlling the disease.

• Counselling service: All those who are infected and their families need to counselled to be able

to deal with the illness positively and rationally.

• Voluntary counselling and testing.

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• Need to address gender disparity and the prevailing norms of masculinity and feminity as these

contribute hugely to the woman’s lack of agency and negotiating power.

• The programmatic challenges lie in integrating RTI services in primary healthcare settings. Cost-

effectiveness of RTI treatment is another area of challenges. There is a gap between adapting

syndromic and laboratory testing for effective treatment of RTI.

References

Brunham, R.C. and J.E. Embree, 1992. “Sexually Transmitted Diseases: Current and Future Dimensions

of the problem in the Third World”. In A. Germain, et al. (eds.), Reproductive Tract Infections:

Global Impact and Priorities for Women’s Reproductive Health, New York: Plenum Press.

Herek, G.M. and E.K. Glunt, 1988. “An Epidemic of Stigma: Public Reactions to AIDS”. American

Psychologist (special Issue- Psychology and AIDS) 43(11) (November), The American Psychological

Association.

HIV/AIDS Prevention among Young People and Children in Gujarat: “An Overview. Report by Women’s

Health Training Research and Advocacy Cell (WOHTRAC)”, March 2007.

HIV/AIDS and Women’s RSHR 2006, WGNRR (Women’s Global Network for Reproductive Rights)

Newsletter 87. Pg. 26.

Joint United Nations Programme on HIV/AIDS, “Overview of the Global AIDS Epidemic”.

National Implementation Plan-RCH Phase II, Government of India, Department of Family Weyase,

Ministry of Health & Family Welfare, Source: <http//www.nacoonline.org> (retrieved on 6

February 2008).

Santhya, K.G. and S.J. Jejeebhoy, 2007. “Early marriage and HIV/AIDS: Risk factors among young

women in India”, Economic and Political Weekly, XL11(14) (7 April).

The National Family Health Survey (NFHS-3) Report, 2005-06, Ministry of Health & Family Welfare,

New Delhi.

UPSACS, FAQ_Sexually Transmitted Infections/Reproductive Tract at <http://upaidscontrol.up.nic.in>

(retrieved on 25 Janury 2008).

VHAI, 2001. “Where Women Have No. Doctor : A Resource Guide for Women’s Health”. Chapter

21; The Reproductive System, New Delhi, Voluntary Health Association of India.

Warvadekar, N.P.J. “Prevalence of Self Reported Symptoms of Reproductive Tract Infection among

Currently Married Women in Madhya Pradesh”, Population Research Centre, Ministry of Health

& Family Welfare, Government of India, <http://prcs-mohfw.nic.in/> (retrieved on 25 January

2008).

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POPULATION FOUNDATION OF INDIA

B-28, Qutab Institutional Area, Tara Crescent, New Delhi 110 016

Tel. No : 42899770, Fax : 42899795

Website : www.popfound.org, E-mail : popfound@sify.com