Spotlight: Should Hospitals Give Patients 'Unbanked Blood' To Save Lives?.

By MITHILESH MISHRA | INNLIVE

Unbanked blood transfusion is illegal. But short of blood, rural hospitals in Chhattisgarh say it is not unethical.

In April, a woman walked into a hospital in Baitalpur in Bilaspur district of Chhattisgarh, bleeding heavily. She was in her thirties, and had ruptured her uterus while delivering a baby at home in a nearby village. She needed urgent medical attention. When a van dropped her off on the highway, she trudged two kilometres to Baitalpur's Evangelical Mission Hospital – only to be turned away.

The hospital had an operation theatre and a gynaecologist, but no blood.

With buses plying only once in two-three hours from Baitalpur to Bilaspur, the district headquarters, getting blood from the blood bank takes at least four to five hours, if not a day. Without a quicker way to access blood, the hospital is not equipped to handle an emergency.

“She had a ruptured uterus and was anaemic," said Dr Kusum Masih, the medical superintendent of the hospital who is also a gynaecologist. "We could not operate without blood."

The doctors sent her to Bilaspur about 35 km away – but she died on her way there.

Eleven districts with no blood banks
There are 16 blood government-run blood banks and 30 private ones across 27 districts of Chhattisgarh.

The deficit of blood in the state is about 48%, said Dr SK Binjhwar, from the State Blood Transfusion Council. According to the World Health Organisation, a country should have a stock of blood equivalent to 1% of its population. By this standard, Chhattisgarh alone needs 25 lakh units of blood at any given point – but it usually collects 16 lakhs units a year.

What's more, 11 out of 27 districts in Chhattisgarh do not have blood banks – the largest deficit in any state in the country. In all, there are 81 districts in the country without blood blanks, according to data from the Union Ministry of Health and Family Welfare. Most of them are concentrated in Chhattisgarh, Jharkhand, Bihar, Uttar Pradesh and the North East.

For Chhattisgarh, a state with very high rates of anaemia, especially among women and children, the shortage of blood throws up multiple challenges.

According to the National Family Health Survey, more than half of the women of the state – about 57% – suffer from anaemia, as do nearly three-quarters, or 71.2% of children aged 0-5. About 2% of both women and children have severe anaemia, with a haemoglobin level below seven grams per decilitre of blood, for which most patients need blood transfusions.

Apart from this, about 60,000 children are estimated to have sickle cell anaemia, a severe form of the condition caused by a genetic blood disorder.

Anaemic women additionally face a higher risk of postpartum haemorrhage, which is a leading cause of maternal mortality in India. The maternal mortality rate of Chhattisgarh is 230 deaths for every 1,00,000 live births, as compared to the national average of 178.

Unbanked blood
For a rural hospital in Chhattisgarh, there is just one option in case of emergencies where blood is required – to refer a patient to a bigger facility. This often means that the person reaches the hospital in a critical condition, or dies on the way, as in the Baitalpur case.

Some hospitals are countering this by opting for an illegal way of giving blood, called unbanked direct blood transfusion. Under this, the blood of a willing donor’s that matches with the recipient’s group is collected, tested for infection with a rapid blood kit and then transfused without roping in a blood bank.

Take the case of a 40-year old woman from Shahdol district in Madhya Pradesh, who had been having extremely painful menstrual bleeding for nearly four months.

“Khoon girat rahe [I was bleeding all the time],” she said. “But, I would still have to work in our fields. How can I stop?” She was also not able to eat or walk and had severe chest pain.

On June 28, she somehow made it to a rural hospital in Chhattisgarh, which shares a border with Madhya Pradesh, travelling more than 200 km by train and bus with her husband and son.

When the doctors examined her blood, they saw she had a haemoglobin count of 4.6 – the normal range for women is between 12.1 and 15.1 – which meant she needed immediate transfusion. She also required an abdominal hysterectomy, as she had a large fibroid in her uterus.

In all, she needed three units of blood.

“I do not know how she managed to travel so far,” said a doctor at the hospital. “There is barely any oxygen reaching the organs. We have patients coming in with haemoglobin count of one as well. We can't direct such patients to other hospitals as their condition is already critical.”

The names of the hospitals and the doctors have been withheld because it is illegal to get blood from any other establishment other than a blood bank.

In this case, her son gave one unit of blood through unbanked direct blood transfusion, while two other units were arranged legally.

Doctors have been arrested in the past for using unbanked blood in other states.

Hospitals that practice unbanked blood transfusion usually have a list of donors in the community who can come and give blood when required. These donors are usually not paid – unless they demand payment and the situation is dire.

Insufficient blood
In 1996, the Supreme Court outlawed professional blood donation – that is, donating blood for money – and ordered the establishment of National Blood Transfusion Council to oversee and strengthen policies and systems governing blood transfusion in the country. In 1998, unbanked directed blood transfusion was disallowed.

In 2002, the council allowed the setting up of blood storage centres that were allowed to keep blood from licensed blood banks (but were not authorised to collect it). These storage centres could come up in villages and towns, while the mother blood banks would usually be in the district headquarters or cities.

In Chhattisgarh, there are 60 such storage units, mostly in community health centres, many of which do not use the blood at all and direct patients to go to other healthcare facilities. For instance, the community health centre in Gaurella, attached to the Chhattisgarh Institute of Medical Sciences in Bilaspur, has never approached the storage unit for blood. “I am not even sure it [the centre] functions,” said Dr VP Singh, who is in charge of the blood storage centre in the Bilaspur college.

Patients from community health centres often make their way to Jan Swasthya Sahyog, a non-profit in Ganiyari, near Bilaspur city. “Often, we see patients who are bleeding copiously after childbirth and are referred to us in that condition,” said Dr Yogesh Jain, one of the founders of the hospital.

Even hospitals that do use blood storage units, such as Jan Swasthya Sahyog, Shaheed Hospital in Dalli Rajahara in Chhattisgarh's Balod district and the mission hospitals, said they get insufficient units of blood.

“Our storage centre is attached to a mother blood bank in Durg,” said Dr Saibal Jana, chief physician of Shaheed Hospital. “We need about 150 units per month, but have barely about 35 units from the bank. Last month, they gave us only 10.”

Jan Swasthya Sahyog has an understanding with a private blood bank in the city, which gives them blood nearing its expiry date for free. This they use for scheduled surgeries, when the blood requirement is known.

Replacement donation
For every unit of blood taken from the bank, hospitals are supposed to send a replacement donor to the mother blood bank. This unwritten rule holds true even for hospitals that send relatives of patients to collect blood from a blood bank – private or public – for a planned surgery.

This is against the country’s National Blood Policy, which prohibits coercion in enlisting replacement donors and aims to phase replacement donations out.

Dr SK Binjhwar, from the State Blood Transfusion Council in Chhattisgarh, said that the state has 80% voluntary donation. Public health activists, however, said this figure is highly debatable and that more than 99% of the blood is likely collected through replacement donation.

“A hospital that has a blood storage unit organises blood donations camps for mother blood banks,” said Bhinjwar. “This is enough to meet the demands of the districts.”

The demand for a replacement donor for the mother blood bank hangs like a sword over the heads of patients’ family members.

Many donors from the hinterlands are not willing to travel to the nearest blood bank in the city to replace blood. It’s also difficult to find eligible donors in the immediate family – if a patient has anaemia, it’s likely that members of her family would also suffer from the condition.

Many also have an apprehension towards donating blood, fearing it causes weakness.

In such a scenario, touts who can provide ready donors for a price thrive. There are many such businesses in operation near blood banks in the state that provide donors for a sum of money to provide replacement units to the banks.

Rajesh Sharma, who runs the laboratory in Jan Swasthya Sahyog said that touts realise that people are looking for donors for replacement donation when they see an icebox in their hands. To combat this, Jan Swasthya Sahyog sends a patient's relative for replacement donation, they now send a letter (pictured below) that has to be signed by the blood bank.

People who are unaware about the dangers of remunerative blood donation – which has higher chances of infection – are willing to pay for the blood, despite having meagre resources.

In a rural hospital in Chhattisgarh, a 76-year-old was diagnosed with nectrotising fasciitis – a severe bacterial skin infection that spreads to the tissues quickly – on her arm. She had to be operated upon immediately to remove the infected tissues, but her haemoglobin count was just 6.3. During the surgery, the hospital collected blood via unbanked direct blood transfusion. But they were short of one unit.

“I do not know who will donate now...can we buy the blood?,” asked her daughter, who was tending to her.

While admitting that most units of blood are given only after a replacement donation, Dr Singh from the Bilaspur college's blood storage unit said: “We give blood to people who do not have replacements too."

"Usually if someone is an orphan with no family support, or someone comes without attendants, we give the bank without exchange too (referring to replacement donation)," he added.

Dr Singh said he had instituted a rule that no sickle-cell patients should be asked for replacement donors as he found out that the patients' families were bringing in professional donors, especially when the patient needed immediate treatment.

Unbanked blood ethical?
In a scenario where lack of access to blood banks has resulted in deaths that could have been avoided and helped touts flourish, doctors and healthcare activists practicing in rural areas have pushed for unbanked direct blood transfusion to be legalised, even as other activists argue that it shouldn't.

In June, Dr Yogesh Jain and Dr Raman Kataria from Jan Swasthya Sahyog wrotein favour of the practice in Indian Journal of Medical Ethics. They said that unbanked directed blood transfusion, if done by trained and certified healthcare teams, meets ethical standards and helps fulfil emergency blood requirements in rural areas.

In 2014, the Ministry of Health and Family Welfare met a delegation from the Association of Rural Physicians that sought to legalise this practice. Though the Drug Technical Advisory Board considered the proposal, it was eventually rejected.

The delegation argued that there the Drugs and Cosmetics Act allows unbanked directed blood transfusion for Armed Forces in border areas and peripheral hospitals, which should be extended to the same in emergency situations in rural areas too.

The Drug Technical Advisory Board, however, said that testing of safe blood requires a lot of infrastructure and trained manpower, without which the blood is likely to be infected. Besides, they said, it would be difficult to monitor them. They also said that the exemption given to Armed Forces cannot be given to rural hospitals.

“Are soldiers' life more important than a woman giving birth?" asked Dr Jain. "The implication of this policy is that either people go to the cities for treatment, or choose to die wherever they are. People who have to handle emergencies have to be equipped with technology and regulations should look into the ethical requirement of safe blood.”

An ideal solution, said doctors, would be to increase blood availability in the country by having a central blood bank in each district, with well-equipped storage centres.

However, activists working towards ensuring voluntary blood donation said that unbanked direct blood donation should not be allowed.

“All hell will break loose," said Vinay Shetty, from Think Foundation, Mumbai and a member of Voluntary Blood Donation Committee of Maharashtra State Blood Transfusion Council. "There will be no control over the blood in this country and we will go back in time."

The state has to take responsibility for the shortage of blood and has to ensure that no bank is short of blood, he said.

“The only answer to this is blood sufficiency," said Shetty. "Organising blood is not the responsibility of the patient. It is the responsibility of society at large. This is happening because there is no value to human life. Somebody in the state has to take charge."

Swachch Bharat's Mothers, Babies In Peril: 343 Hospitals In 6 States Struggle With Hygiene, Toilets

By LIKHAVEER | INNLIVE

Swachch Bharat Abhiyaan is acheived by Modi's government but the reality is quite different,  as many as 19% of the facilities did not have wash basins near toilets and patient-care areas.

Half the post-natal wards of primary healthcare centres lacked toilets, as did 60% of larger community health centres in Madhya Pradesh, which has a higher maternal mortality rate than war-torn Syria.Open defecation was allowed within 38% and open urination in 60% of health facilities (PHCs, CHCs, area and district hospitals) in Odisha’s Ganjam district, which has the same maternal mortality rate as the impoverished African country of Gabon.

Dying Young Mothers In Assam’s Tea Gardens – At A Rate Higher Than Anywhere In India.

By NEWS KING | INNLIVE

The tea industry and the government joined hands but failed to stem the deaths in the predominantly tribal community.

Babita Jayram has beaten the odds. The 21-year-old sits in one corner of the hospital bed, brushing her hair with the slow, steady strokes of a purple comb. The nine months of pregnancy mostly spent at a tea garden on the eastern fringes of Assam were uneventful. There were no complications during the delivery. A healthy newborn, curled gently on her lap, sleeps quietly.

A Special Note To AP CM Chandrababu Naidu: 'Family Planning Is Not About Class But About Women's Rights And Choices'

By NEWS KING | INNLIVE

Andhra Pradesh chief minister Chandrababu Naidu recently asked rich people in the state to have more than one child.

Determining the size of her family is every woman’s right. For individuals in leadership positions, to make comments to the contrary is regressive and can push back the country’s progress on many fronts. These include India’s goal for population stabilisation, FP2020 – an international partnership of more than 20 governments on family planning – and the Sustainable Development Goals commitments. The debate is not whether the rich should have more children; it is about choices and rights.

Vulnerable Children: On Time Delivery – The Large Blind Spot In India’s Immunisation Policy

By M H AHSSAN | INNLIVE

Only a third of India's children are vaccinated on time under the government immunisation programme. One reason is that families don’t keep proper records.

The majority of children immunised under the government’s universal immunisation programme don’t get their vaccinations on time. New research shows that two-thirds of children under the age of five had either not been vaccinated at all, or received their vaccine shots much later than prescribed.

Rabies Is Just One Reason Why Stray Dogs Are A Snarling Menace In India

By SOWMYA RAJ | INNLIVE

Last week, six-year-old Ramya was mauled badly by a pack of stray dogs in a suburb in Bengaluru. She was badly injured and is recovering in a hospital.

This was a few days after the TCS World 10K marathon in the city that was marred when the lead Ethiopian runner, Mulle Wasihun was bitten by a stray dog.

There have been several such incidents in the city, where stray dogs have attacked children and adults, morning walkers, two-wheeler riders and pedestrians.

An Objective Report Card: One-Year-Old Modi Government Virtually Struck Between 'The Cup And The Lip' Situation

By M H AHSSAN | INNLIVE

The present government completed one year in the office in May this year. It came to power by promising to bring achhe din for the Indians, who were frustrated with high inflation, corruption and policy paralysis during the last government. INNLIVE objectively analyses the performance of the Modi government in its first year.

Lovers and haters of the ruling Narendra Modi government at the Centre will concur on one thing: this government has not been at a loss for ideas and schemes!

Bangladeshi Girls Forced By Parents Into 'Child Marriage'

Sanjita had very little to say on the subject of how she felt about getting married. Maybe that’s because she’s 10 years old.  She had married 18 days earlier, to a boy who is 14 or 15 years old—he works in a garment factory in Dhaka and as a rickshaw driver.

Her mother Mariam (this and Sanjita’s name are pseudonyms) had quite a bit to say: I don’t have any sons who look after my husband and I. We’re getting old and fall sick all the time. My husband says ‘I can die anytime—before I die I want to make sure I carry out my duty to my daughter.’

Investigation: 'They Still Die In The Govt Labour Rooms'

INNLIVE team goes undercover to see how women are treated in a large government facility in Kolkata and found the unimaginable truths and dwell the reality behind these practices direct under the governmental controlled medical services.

Munmun Mukherjee is a good patient. She lies quiet on the white stone delivery table of the government hospital in Kolkata but for an occasional low moan. Even this is muted, the edge of her voice flattened, as if she knows that she needs to be on her best behaviour. A slim, dusky woman, she looks tidy even in her tired, crumpled nightie.

Statistical Lies: How India’s UP State Fudges Crime Data

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UP has a reputation for widespread mis-governance, but official data reveal lower disease outbreaks, lower crimes and lower accidents than the other states we mentioned. And so unfolds a story of lies, damned lies and statistics.

India’s 13 Million Child Brides And Their 6 Million Children

States with higher child marriage rates report higher maternal as well as infant deaths.

Nearly 17 million Indian children between the ages of 10 and 19 – 6% of the age group – are married, many of them to older men, newly-released census figures reveal.

This is an increase of 0.9 million from the 2001 census figure.

The legal age for marriage is 18, so some involved may have been adults, but it is unlikely both partners were.

Concern: India's Maternal Mortality - Dying Of Indifference

One woman dies every eight minutes due to complications arising due to pregnancy such as sepsis, haemorrhage or obstructed labour. These deaths could be avoided if there is timely medical intervention.

It is estimated that 117,000 women die from pregnancy-related causes in India each year.With a rate of an estimated 450 deaths per 100,000 live births, India has the highest number of maternal deaths in the world. 

What’s Turning Women In Labour Away From Hospitals?

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The birth of the first baby should be an occasion for celebration but Sama Parveen's memory of her first delivery is a sad one. This 21-year-old, who lives with her husband in a one-room tenement on the banks of River Yamuna in north-east Delhi, has been married for two years.

Special Report: 'Who Cries When A Mothers Die?'

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Lhamu, a mother of twelve, lives in a remote village in Western Tibet. Three of her children died within a month of birth and the four year old strapped to her back looked as small as a one year old. She gave birth all alone, at home, all twelve times.

Why India Has Woken Up To The Importance Of Toilets?

By Sukanya Mehta | INNLIVE Bureau

SPOTLIGHT Building toilets holds the key to reducing India’s malnutrition burden. Commenting on the Indian elections in his satire show, British humorist John Oliver remarked, “(Narendra) Modi has managed to inspire people with his populist platform including a pledge to put a toilet in every home. That’s a bold move, coming out as pro-toilet.”

Oliver’s wisecrack may have deliberately exaggerated Narendra Modi’s pitch on toilets but the focus on sanitation has been one welcome change in the 2014 election campaign. In a public rally, Modi had exhorted, “pehle shauchalay, phir devalay” (first toilets, then temples).

New Challenge To The Supremacy Of AIADMK And DMK With Emergence Of Narendra Modi And Arvind Kejriwal

By Shastri Ramachandaran (Guest Writer)

Political theatre in Tamil Nadu promises more entertainment in 2014. Regardless of how party games play out in the general elections, the state’s economic development is unlikely to be affected adversely. With development long delinked from the fortunes of the fratricidal Kazhagams — the AIADMK and the DMK — electoral outcomes have had little bearing on survival issues for the state’s 7.2 crore people.

Whether it remains Jaya-nadu or turns in to Stalin-grad in the power contests between the DMK and the AIADMK, Chennai would remain India’s second-most prosperous city — as shown in rating agency Crisil’s study — for some more years. Tamil Nadu, with the country’s third highest GDP, has a per capita net domestic product of $1,800 a year — 50 per cent more than the national average ($1,200). 

Shamed and Scarred: Stories Of ‘Legal’ Abortions In India

By Neha Dixit / Delhi

Abortion is legal in India, but it’s only when a woman goes to the clinic that she discovers the hurdles and the stigmatising that is so common among doctors and others in authority.

A newly-constructed three–storied building stood behind the mesh of electric wires hanging from a half-bent pole in Nangloi. The exterior was tinted silver glass fitted into copper panels. A yellow board declared the name of the doctor, boasting several international degrees and medals in gynaecology. 

Exclusive: 'The Makeover And Marketing Of Narendra Modi'

By Siddharth Shukla / INN Bureau

The European diplomats gathered at the German ambassador's residence in New Delhi's lush green embassy enclave quizzed the guest of honour on everything from the economy and communal violence to his political ambitions. But nobody, the representatives from most of the 28 European Union states agreed, could publicly mention the man they were meeting that day: Narendra Modi, country's most controversial politician and, possibly, the next prime minister.

It was a moment that captures the paradox at the heart of Modi, and the caution with which the outside world approaches him. The January lunch at Ambassador Michael Steiner's residence ended a decade-long unofficial EU boycott of the 62-year-old politician, who had just won his third straight term as chief minister of Gujarat. The boycott stemmed from 2002 riots in Gujarat.

Food Security Bill To Criminalize Opposition For GM Food

By Ranjit Devraj / Delhi

India's environmental and food security activists who have so far succeeded in stalling attempts to introduce genetically modified (GM) food crops into this largely farming country now find themselves up against a bill in parliament that could criminalize such opposition. 

The Biotechnology Regulatory Authority of India (BRAI) bill, introduced into parliament in April, provides for "single window clearance" for projects by biotechnology and agribusiness companies including those to bring GM food crops into this country, 70% of whose 1.1 billion people are involved in agricultural activities. 

Planning Families, Planning Progress

As India moves closer to the deadline for achievement of its Millennium Development Goals, the critical need for effective family planning interventions and greater awareness of the same become more pronounced. 

Matlab, a riverine sub-district in Bangladesh, about 50 kilometres from capital Dhaka, has attracted the attention of the world for some time now because of the data it provided on an important social trend. In fact, the reputed medical journal, ‘The Lancet’, in a special focus on family planning last July, trained the light on Matlab yet again.

So what is the Matlab story and why is it so important? Over a period of 19 years, from 1977 to 1996, family planning programmes had reached 71 of Matlab’s 141 villages. What was striking was that while the figures from the 1974 census - conducted before the programmes had begun - indicated a uniform level of human development in all of its villages, whether in terms of fertility, average schooling or housing, the scenario was very different 19 years later.

According to the evidence gathered, family sizes declined by 55 per cent in the villages that had access to family planning programmes, while it declined by only 39 per cent in those that did not. This, of course, is not surprising. What, however, does warrant pause for thought is the fact that the level of child mortality was significantly lower in the villages accessing the services and the body mass index (BMI) of the women here was higher.

That was not all. Women in these villages also reported earning 40 per cent more in terms of monthly income than their counterparts in villages not serviced by family planning. Income, we know, translates into assets – and indeed the households in the villages that had family planning services reported 25 per cent more physical assets per adult. The multiplier effects of such access were many and included healthier children and higher levels of schooling.

In other words, the message from Matlab was clear: In the long term, effective reproductive health services translated into positive changes in terms of health and human – particularly women’s – development. It was evidence like what emerged from Matlab that had led John Cleland, Professor of Medical Demography, London School of Hygiene and Tropical Medicine, and his colleagues to conclude that access to family planning can reduce maternal deaths by 40 per cent, infant mortality by 10 per cent and childhood mortality by 21 per cent.

Examples from India also suggest an important link between human development and effective family planning interventions. Tamil Nadu, for instance, could bring down its total fertility rate (TFR) – defined as the average number of children born to a woman during her reproductive period – from 3.8 in the mid-seventies to 2.0 by 1997, thanks to an effective family planning programme. By 2001, it figured as the third best performing state, behind only Kerala and Punjab, in terms of human development, according to the National Human Development Report 2001.

This transformation could only have happened because the family planning programme was an enlightened and community-friendly intervention. Noted development academic, Leela Visaria, has written at length about how Tamil Nadu was able to achieve replacement levels of fertility. Discarding the target-oriented and coercive approaches that had made family planning interventions in the country so controversial in the mid-1970s, the Tamil Nadu government crafted a holistic approach that expanded the basket of contraceptive choices available to people, raised levels of awareness, addressed fears of side-effects and introduced new technologies, like non-scalpel vasectomies.

Today, the Government of India, anxious to leave the negative perceptions about family planning firmly behind, is consciously adopting a more broad-based approach through its National Rural Health Mission (NRHM). In a recent speech, Union Minister of Health and Family Welfare, Ghulam Nabi Azad, flagged various factors – including delaying marriage and spacing birth – as crucial to pegging down India’s numbers. But what he saw as particularly crucial was the need to raise awareness about the issue.

As the Minister put it, “Vast numbers of people cannot avail of family planning services due to problems of knowledge and access. There is therefore a need for the NRHM to respond with appropriate family planning counselling and services that focus on the individual’s choice and decision-making in planning the timing of a pregnancy and number of children desired. In particular, NRHM should design a way to reach comprehensive health information and services to young girls, which will prevent marriage under the legal age of 18, early childbearing and keep girls in school.”

It is an approach that Poonam Muttreja, Executive Director of the Population Foundation of India, would advocate. As she puts it, “There are also many far-reaching, catalytic effects of women being able to control their fertility. Girls, who marry as adults, delay their first pregnancy and space child births, are more likely to complete their education and join the work force. Enhanced household income helps in meeting the nutritional needs of their families.”

Such an approach assumes urgency as concerns that India will fail to meet some of its commitments on the Millennium Development Goals (MDGs) grow by the day, even as the deadline year of 2015 draws steadily closer. According to MDG 4, countries are required to reduce by two thirds, between 1990 and 2015, the mortality rate of children under five years of age. Similarly, MDG 5 enjoins them to peg down by three-quarters, between 1990 and 2015, the maternal mortality ratio (MMR). Going by current indications, the figures on both counts do not stack up for India.

Data from the Statistical Year Book 2013 reveal that while India is required to reduce its child mortality rate to 42 per thousand live births by 2015, going by the current rate of decline the level would be around 52 per thousand, which is ten points short. As for its MMR, India will achieve a figure of 139/100,000 live births by 2015, which would miss the target by 29 points.

According to ‘The Lancet’s analysis, access to reproductive health and family planning helps to bring down not just infant and maternal mortality levels but helps in achieving other MDGs, like eradication of extreme poverty and hunger (MDG 1), universal primary education (MDG 2), gender equality and empowering women (MDG 3) and environmental sustainability (MDG 7). In fact, it was this realisation that led to the inclusion of a new MDG target – universal access to reproductive health – in 2006.

For a young country like India, this is an extremely important target. With half its population in the reproductive age – the reason why the population continues to grow despite its growth rate having declined considerably – access to contraceptive choices and care has become a critical need.

Elaborates Muttreja, “To take advantage of the demographic dividend, India must focus on providing family planning services to its young people along with reproductive and sexual health education, skills development and education. Access and choice to quality family planning is not only a human right, it is critical to the health and well being of individuals and the country's development."