Lives sacrificed: Women and health in South Asia

By Deepti Priya Mehrotra

A new World Bank report looks at the state of reproductive health of poor women in five countries -- Bangladesh, India, Nepal, Pakistan and Sri Lanka -- and makes a case for decentralised planning, delivery and expansion of health services, with a clear focus on enhancing inclusion

‘Sparing Lives: Better Reproductive Health for Poor Women in South Asia’, by Meera Chatterjee, Ruth Levine, Nirmala Murthy and Shreelata Rao-Seshadri, the World Bank, MacMillan, 2008

This World Bank report, released on March 5, 2009, investigates the state of reproductive health of poor women in Bangladesh, India, Nepal, Pakistan and Sri Lanka. It also makes a case for increasingly decentralised planning, delivery and expansion of health services, with a clear focus on enhancing inclusion.

The report highlights a number of significant concerns. Sri Lanka, despite ongoing conflict, fares remarkably better than the other four countries in terms of maternal mortality, pregnancy and delivery care, infant weight and death rates, contraceptive acceptance and fertility rates. This is attributable to a high commitment to health on the part of successive governments. With decentralised planning the cornerstone of health delivery, services are provided at all levels, as an integrated package. The report notes that Sri Lanka’s relative success is “not because it spends more per capita, but because it uses resources more efficiently and equitably… Low unit costs in Sri Lanka contribute to high reproductive health access…”

Gopalakrishnan, a representative from the prime minister’s office, India, noted that the findings of the report are “disconcerting”; he reiterated the “urgency of concerns” to be addressed. Enormous disparities exist in India throughout the realm of maternal health and services delivery. For instance, while some antenatal care and tetanus toxoid reached 77-78% of women in 2005-06, only half of the poorest women received care as compared to the richest. Scheduled caste and scheduled tribe women have far lower maternal health service coverage levels than other women. While overall fertility reduction and contraceptive use have improved, the improvement is not as much as is desired. Between 1998-99 and 2005-06, fertility declined from 2.8 to 2.7 births per woman, the greatest change occurring among 15-19-year-olds. Kerala, Goa, Tamil Nadu, Himachal Pradesh and Punjab have achieved replacement-level fertility, while Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan and Orissa will contribute over 50% of the country’s increase in population over the coming decade. As for contraceptive use, only 48.5% of couples used modern methods of contraception (in 2005-06), one-fifth of these being temporary methods. Terminal methods, ie sterilisation, continue to be dominant. The average age for female sterilisation is amongst the lowest in the world (below 25 years). The poorest women in India are four times more likely than the richest women to have an ‘unmet need’ for contraception, underlining the urgency of ensuring wider access to temporary contraceptive methods. The gap between the poor and the rich in contraceptive use is much less in Bangladesh and Sri Lanka, as compared to India, Nepal and Pakistan.

The average risk of maternal death in these five South Asian countries (1 in 43) is almost a hundred times greater than that of a woman in the industrialised countries (1 in 4,000). Maternal mortality rates in India, Bangladesh, Nepal and Pakistan are still two to four times higher than the Millennium Development Goals (MDGs) set for 2015. While the lifetime risk of dying during pregnancy for a woman in Sri Lanka is 1 in 430, in Bangladesh it is 1 in 59, in India 1 in 48, in Pakistan 1 in 31, and in Nepal 1 in 24. India needs to reduce its maternal mortality rate by two-thirds to meet the MDG -- from the current estimate of 301 to 100 (by the year 2015).

Malnutrition contributes to maternal mortality, and infant and child deaths. Over two-fifths of all children under five in the region are malnourished, the figure even in Sri Lanka being as high as 22%. While 34.3% of women are acutely undernourished in Bangladesh, in India nearly half (47%) of mothers aged 15-19 years are undernourished. Compared to the richest quintile of urban women in India, the poorest urban quintile is 4.8 times more likely to be undernourished, and the poorest rural quintile, 5.6 times more likely. Over 45% of rural children under five years of age are undernourished, and almost one-third of urban children: a total of about 50 million undernourished young children in India.

The five countries together have a huge population of poor people: approximately 500 million. About four-fifths of the population of Bangladesh, India and Nepal live on less than 2 dollars a day, and two-fifths in Sri Lanka. Governments are certainly not directing sufficient resources into reproductive health services for the poor. Integrated health services and nutrition are critically needed and ought to be very high on the priority agendas of all the nations. Noting that poverty and poor reproductive health form a vicious cycle, the report emphasises the need for a renewed focus on adolescent health and nutrition, and accessible contraception, pregnancy and childbirth services. It also acknowledges that gender discrimination exists in society as well as in the health services sector, and that needs to be tackled.

While the report provides useful information on poor women’s reproductive health, it does not attempt correlations with macro factors like food security, unemployment, access to potable water, political participation and so on. Such correlations are needed, to arrive at a more comprehensive analysis of causes and policy implications. Several elements required to help South Asian poor women to climb out of the abyss may still be missing from the jigsaw.

During the video conference at the simultaneous release of the report in the five countries, Dr Mohammad Abdul Qayyum, director general of family planning, Bangladesh, gave voice to a woman-friendly policy understanding: “We want to provide and strengthen safe birth practices wherever the woman wants to be.” He noted that maximum births could take place at home, and spelt out Bangladesh’s commitment to community clinics, where referrals for high-risk and emergency services could be made available. Indu Capoor, a women’s health professional and director, CHETNA (Centre for Holistic Education, Training and Nutrition Awareness, Ahmedabad) pointed out that rejection of home births and traditional birth attendants, to be replaced wholesale by institutional births and ‘trained’ attendants, is a deeply flawed and highly questionable policy for South Asian countries.

Pakistan, India and Nepal would do well to heed the practical wisdom inherent in Bangladesh’s policy choice. This debate highlights the need for policymakers to listen far more to grassroots health activists who may have different points of view on how to handle issues. As Gouri Choudhury, director, Action India, remarked: “We have been saying much of this for the past 20 years. What is new?… The health volunteers appointed by the government are called ASHA now, but they are still underpaid and overburdened… This is not decentralised service delivery!”