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.

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.

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

The probability of an Indian mother dying during childbirth is roughly 10 times that of her Chinese counterpart. Reducing the Maternal Mortality Ratio (MMR) by three-quarters in 10 years is now a Millennium Development Goal. Why is MMR in India so high and how far are we from the goal? INNLIVE unravels the many challenges to saving mothers' lives.

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.

Dying of Indifference

By M H Ahssan

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.

"She gave birth, died. Delhi walked by". This was the headline of a six-column news item on the top of an inside page in Hindustan Times (29 August 2010). Illustrated with four telling photographs, the story was about a pregnant and destitute woman, who lay on the footpath of Delhi's busy and well-frequented Shankar Market, which is adjacent to the iconic Connaught Place. Thousands of people must have passed her, but no one spared a glance at what appeared a bundle of rags covered in a red cloth.

On 26 July, this woman gave birth, unaided by anyone. The cries of the newborn infant caught the attention of some of the shopkeepers and one of them, the owner of a garment shop, picked up the baby. The mother apparently refused help and died on that same spot where she had given birth, four days later. The police came and removed her body and took the child, who had been in the care of the Good Samaritan until then, to a foster home.

This is an item that should have been on the front page of all our newspapers because it illustrates two things. One, the increasing indifference of people who live in our metro cities, who are so absorbed with their own lives that they don't even look around to see how other people survive or die. We have lost our ability to see, to feel. No one wants to get involved. There is a fear that you might be asked to commit more of your time, your resources, your emotions than you are willing to do. So our eyes glaze over, we look the other way and we walk away.

And two, it brings home the reality of maternal mortality in this country where even as we boast of becoming an economic super power and the media celebrates the few Indians who are joining the list of the richest in the world, millions of our women are dying in the process of giving birth to a child.

Of course the story of this woman, whose name we do not know, is one extreme. But it should remind us that this is the reality that we have to address in this country.

Countless more
One can just imagine with rains and the floods that have taken place in the last months how many more such nameless women there must be on the streets of Mumbai, Delhi, Chennai, Bangalore, a part of the thousands who have no shelter, who have to sleep out in the open. All our cities, particularly Delhi but other cities too, are in the midst of a huge construction boom. This is bringing in thousands upon thousands of people from the surrounding areas. Those who have a skill and find regular work in these construction sites are possibly provided temporary shelter by the contractors. But many more do causal work, as and when it is available. The rest of the time they do what they can to earn a few rupees everyday, sometimes send their children out to beg and find whatever place they can to sleep.

In Mumbai, for instance, the fancy new skywalks that have been built connecting railway stations to business hubs have become temporary homes for these homeless people. It is an eerie spectacle to see these bodies laid out in a row, all ages, men, women and children, some sleeping under mosquito nets strung to the side of the skywalk, somehow catching a few hours rest under the relentless yellow light that shines all night. By morning the skywalk reverts to being what it is meant to be, a pedestrian walkway. No one can complain or say anything because there is no solution. But what happens to the children, especially the small babies, what happens to the women, some of them fairly young who become pregnant and have no recourse to any healthcare?

For the other side of this tragic story from a busy street in our national capital is that 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. But such help is hard to come by if you live in a remote area or if you are poor woman in city or village. Even if you get some help, it is often too late to make a difference between life and death.

India's current Maternal Mortality Rate (MMR) is 254 in 100,000 live births. According to the World Health Organisation (WHO), half of all maternal deaths in South Asia occur in five Indian states - Rajasthan, MP, UP, Bihar and Orissa. We have committed ourselves as part of the UN's Millennium Development Goals (MDGs) to bring the MMR down to 109 by 2015, in just five years. Is that possible?

The central government has launched the Janani Suraksha Yojana (JSY) to specifically address the problem. It provides cash incentives to women who choose institutional delivery in the belief that this will reduce maternal mortality. If we believe official data, then it would appear that many poor women are benefitting from the scheme. For instance, according to one report, two months before the destitute died in Delhi's Shankar Market, another poor woman living in an open park near the Nizamuddin Dargah was lucky enough to be found by an NGO that helped her get the benefits under this scheme. As a result, the baby girl she delivered in the park has a chance to live, she has a birth certificate unlike others like her, and the mother too is receiving healthcare.

Different reality
Sadly, just as the exception in the case of the woman who died on the street does not make the rule, neither does the woman who survived in the park. Cash incentives in this country have usually led to corruption and fudging of data. This is already evident from reports from Bihar and Jharkhand. Also, the media often remains content with reporting official figures without investing in investigating what is actually happening on the ground. The few investigative stories that do appear on healthcare tell a very different story. They inform us of the struggle poor women face to reach a hospital, how they are either turned away or have to wait as there are no trained personnel around. As a result, regardless of new schemes or incentives, they are either too weak to survive childbirth or die because the promised help never turns up.

Maternal mortality means women are dying of causes not related to diseases or epidemics. Their ability to survive something like childbirth is inextricably linked to poverty, malnutrition and the absence of basic healthcare. We can set ourselves all kinds of targets but a realistic plan to improve the survival chances of millions of Indian women is to ensure that our systems of healthcare actually cater to those at the bottom of the economic pyramid, women like that poor, nameless destitute in Delhi.

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.

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!”

The Child Brides Of Mahboobnagar In AP

From unplanned pregnancies, high infant and maternal deaths to unregulated doses of growth hormone, Mahboobnagar’s child brides face vicious health repercussions.

As is the mother, so is her daughter, says an old adage. As profound as it sounds, it is also bewildering when the mother is a child herself. In India, the transition from wife to mother, in the case of child marriages, usually occurs nearly a year after marriage as young couples expect to have their first child soon after their wedding.

Such is the story of Sirisha* (all names changed). Just when she had begun figuring out the physical changes in her body after attaining puberty, 12-year-old Sirisha was married off to a man more than double her age. At 13, Sirisha is a mother. Not only a victim of child marriage but also of an early and unplanned pregnancy.

Malnourished and crippled, she lies on a bed after her delivery.  Her eyes fixated on the new-born baby girl, she says, “I do not know what to do with this baby. I don’t understand how to take care of her.” Sirisha’s helplessness is evident as her parents wanted her to deliver the baby at home – an example of how home deliveries are such a dominant part of child marriages.

Sirisha hails from Mudwyn village in Makhtal mandal of Mahboobnagar district in Andhra Pradesh. A district report says that one in four deliveries takes place at home, in the absence of a skilled birth attendant. Mahboobnagar has the highest number of child marriages in the state. Over 52 per cent of girls below 18 are married in the district, claims a National Rural Health Mission (NRHM) report.

Why child marriages?
The majority of child marriages take place in Golla, Kurma and Lambada communities in this district, reveals Mamatha Raghuveer, Founder-Director, Tharuni (an NGO) and a member of the state-level committee on child rights. With Mahboobnagar district being a severely drought-hit district of Andhra Pradesh and its population dependent majorly on agriculture, child marriages are inevitable, given that they are performed with an intention of providing a secure life for their daughters.

 “Drought is a normal thing here. What is unusual is the rain,” quips Yadaiah, a farmer, who reflects the plight of farmers in Mahboobnagar and their financial instability. Yadaiah also got his daughter married when she was 14.

Emphasis on virginity is also inherent in child marriages. “Most of them look at a girl’s body as a site of family’s honour that should be sold off as quickly as possible before it is violated (at the youngest age),” explains Mamatha Raghuveer, adding “the younger, the better.”

This also raises concerns over the age at which girls become sexually active. Women who are married before the age of 18 have more children than those who marry later in life, a UNICEF report claims.

Also, the pressure to demonstrate fertility and responsibility to raise children while still children themselves has drastic health repercussions on the physical and mental health of these young brides.

Complications of early, unplanned pregnancies
“Until a girl is 20 or 21, her body is not ready to bear a child,” says Dr Aparna Khulbey, General Physician. The physical and nutritional demands of pregnancy on still-maturing and inadequately nourished bodies can endanger adolescents’ health and increase the risk of their children falling sick or dying in infancy, said Guttmacher in her report on teen pregnancy.

UNICEF states that 66.6 per cent of the married girls aged between 15 and 19 are more likely to experience delivery complications compared to 57 per cent of women between 20 and 24 years. Neonatal and child mortality rates are much higher for younger (married) girls. Girls under 15 are five times more likely to die in childbirth than women in their 20s.

“Girls below 18 are at high risk of anaemia and pregnancy-related injuries like fistula and anal ruptures,” says Achyuta Rao, president of Andhra Pradesh Balala Hakkula Sangham.

According to the Mahboobnagar District Health Report for 2011-12, neonatal mortality rate constitutes 75 per cent of all the infant deaths in the state. Surprisingly, the study, states that no cases of maternal complications or high risk pregnancies were reported despite having one of the highest infant and maternal deaths in the state.

Teen pregnancies expose girls to high risk of HIV/AIDs and sexually transmitted diseases. With AP having the highest number of HIV positive cases, there is evidence that a significant number of these cases may be connected to child marriages. A study shows that only two per cent of men in Andhra Pradesh use condoms during sexual intercourse. Interestingly, men who had married child brides have had pre-marital sex, but their wives were virgins before marriage. “The risk of multiple sexual partners within and outside the institution of marriage exposes them to high risk of STDs,” explains Mamatha Raghuveer.

Genital ulcers, itching in the genitals, bad-smelling urethral and vaginal discharge are common symptoms,  says Dr. Khulbey.

Even their mental health goes for a toss. “Depression, isolation and stress is what they usually go through,” describes Jim De, a rights professional. Early pregnancy also limits them to the roles of wives and mothers, rendering them powerless.

“Unregulated doses of growth hormone are given to these girls if their physical attributes are not grown,” says Achyuta Rao, pointing out to the emerging trend in child marriages. Growth hormones are available at a few pharmacy stores without even providing a prescription—an example of how stringent measures under the Indian Pharmacy laws are not implemented. “They are mostly administered by quacks who pose as doctors,”  he explains.

Dismal health services
To make matters worse, adolescents aged 18 or younger are significantly less likely to receive any skilled prenatal or delivery care than older women.

Even the funds disbursed for healthcare services in the district are met with undue interference of politicians, making it extremely difficult to address health needs of a district languishing in despair.

Astonishingly, the Janani Surakasha Yojana (JSY) that promises cash incentives to women having institutional deliveries at public health institutions is not being used, given that the services at public hospitals are depressing.

“Even if all the public institutional deliveries and home deliveries get cash incentives under JSY, about 20 per cent of reported deliveries still miss the payment. This, amid low registration of births,” explains Dr Rachana, a health inspection officer.

According to Mamidi S. Chandra, director, Carped and a member of the Integrated Child Protection Unit, “District health workers, ANMs, ASHA workers are also a cause for the miserable state of medical services.” Of the 3,646 ASHA workers in the district, about 1,000 have stopped working and half of the mid wives who have performed deliveries do not know how to use the delivery kit. “ASHA workers and ANMs do not spread awareness about early pregnancy risks,” he adds.

Interestingly, the low awareness levels are directly proportional to low literacy levels (below 39 per cent according to a district report) and inversely proportional to drop-out rates of kids from schools.

Pawani Kumari, a teacher from Akwaipally village of Mahboobnagar says, “We try to educate as many girls about the risks involved in early marriages. They lack support at home. Most of them oppose, but their resistance doesn’t last long.”

Though there were no child brides in the school during my visit, most of the girls were soon to be brides. “Almost, all our parents want us to get married this year or may be, by next year,” rues Chaitanya, an VIII standard student.

On probing about Sirisha’s wedding, the headmaster of Mudhwyn High School initially admitted that she belonged to the school. Later, he denied that she was ever his student.

Inherent risks of HIV/ STDs
Gopal, a teacher from the school, beams as he states that no child marriage victims belong to his school. In contrast to his statement, Ramya*, Lavanya* and Mahima* were seen with mangalsutras and toe rings (a clear indication of their marriage).

On enquiry, the three 14-year old girls state that they were married off to men between 23 and 28 years of age. Lavanya further reveals that on an average, about 15-20 child marriages take place in this village in a year. Child rights activists, however, say that the number is much higher.

“During the summer vacation, I was married off to my maternal uncle’s son,” quips Ramya, adding that she likes the feeling of being married. On further probing about the nature of her relationship with her husband, Ramya reveals, “He kisses me and we do a lot of things (referring to sex)… I like all of it. I love him and do not oppose to anything he does …both of us enjoy it.”

Unfortunately, Ramya admits she has no idea about using protection while having sex or about the risks of unprotected sex.

The health catastrophes of girls in early matrimony are more than just bruises and breaking bones. Often, they cause  serious emotional harm. “Child marriage is a vicious cycle. Every problem begins with this,”  Mamatha Raghuveer says, adding, “Everything that has beginning has an end.”

World Population Day 2009 - Fight Poverty, Educate Girls

By M H Ahssan

On 11 July 2009, people around the world will be observing the 20th World Population Day in different ways. This year's theme is chance to build awareness of the importance of educating girls to a wide range of development issues, including poverty, human rights and gender equality.

There are many ways to promote this theme:

- Consider inviting local celebrities to help spread the message.
- Organize events to generate widespread attention about the importance of girls' education.
- Spark discussion with seminars, conferences and debates. Host essay and poster contests.
- Work with community groups to create plays and soap operas.

Encourage women and girls to speak or write about the impact of education in their own life. The messages can come to life when different people from different circumstances share their own experiences and knowledge.

Investing in Women is a Smart Choice
No one knows yet what the full scale of this global economic crisis will look like. We do know that women and children in developing countries will bear the brunt of the impact. What started as a financial crisis in rich countries is now deepening into a global economic crisis that is hitting developing countries hard. It is already affecting progress toward reducing poverty.

Policy responses that build on women's roles as economic agents can do a lot to mitigate the effects of the crisis on development, especially because women, more than men, invest their earnings in the health and education of their children. Investments in public health, education, child care and other social services help mitigate the impact of the crisis on the entire family and raise productivity for a healthier economy.

Protect the gains achieved
Investments in education and health for women and girls have been linked to increases in productivity, agricultural yields, and national income — all of which contribute to the achievement of the MDGs. Investments by governments worldwide have raised school enrolment rates, narrowed the gender gap in education, brought life-saving drugs to people living with AIDS, expanded HIV prevention, delivered bed nets to prevent malaria, and improved child health through immunization.

Today, as we commemorate World Population Day, the global financial and economic crisis threatens to reverse hard-won gains in education and health in developing countries. Among those hardest hit are women and girls. This is why the theme of this year’s World Population Day focuses on investing in women. Even before the crisis, women and girls represented the majority of the world’s poor. Now they are falling deeper into poverty and face increased health risks, especially if they are pregnant.

Today, complications of pregnancy and childbirth are leading killers of women in the developing world. And maternal mortality represents the largest health inequity in the world. This health gap will only deepen unless we increase social investments, maintain health gains and expand efforts to save more women’s lives.

In countries and communities where women have access to reproductive health services—such as family planning, skilled attendance at birth and emergency obstetric and neonatal care—survival rates are high and maternal and newborn deaths are rare.

Access to reproductive health, in particular family planning and maternal health services, helps women and girls avoid unwanted or early pregnancy, unsafe abortions, as well as pregnancy‐related disabilities. This means that women stay healthier, are more productive, and have more opportunities for education, training and employment, which, in turn, benefits entire families, communities and nations.

And investments in reproductive health are cost-effective. An investment in contraceptive services can be recouped four times over—and sometimes dramatically more over the long-term—by reducing the need for public spending on health, education and other social services.
It is estimated that family planning alone could reduce the number of maternal deaths by as much as 40 per cent.

Our world today is too complex and interconnected to see problems in isolation of each other. When a mother dies, when an orphan child does not get the food or education he needs, when a young girl grows into a life without opportunities, the consequences extend beyond the existence of these individuals. They diminish the society as a whole and lessen chances for peace, prosperity and stability.

UNFPA, the United Nations Population Fund, remains committed to supporting countries to advance women’s empowerment, gender equality and sexual and reproductive health.

Today, on World Population Day, I call on all leaders to make the health and rights of women a political and development priority. Investing in women and girls will set the stage not only for economic recovery, but also for long-term economic growth that reduces inequity and poverty. There is no smarter investment in troubled times.

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

Is Uttar Pradesh (UP), India’s most populous state, better governed than richer and more advanced Maharashtra, Tamil Nadu, Karnataka and Gujarat? If you look at some statistics, the answer is yes.

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.

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."

WORLD HEALTH DAY 2009

By M H Ahssan

World Health Day 2009 focuses on the safety of health facilities and the readiness of health workers who treat those affected by emergencies. Health centres and staff are critical lifelines for vulnerable people in disasters - treating injuries, preventing illnesses and caring for people's health needs.

They are cornerstones for primary health care in communities – meeting everyday needs, such as safe childbirth services, immunizations and chronic disease care that must continue in emergencies. Often, already fragile health systems are unable to keep functioning through a disaster, with immediate and future public health consequences.

This year, WHO and international partners are underscoring the importance of investing in health infrastructure that can withstand hazards and serve people in immediate need. They are also urging health facilities to implement systems to respond to internal emergencies, such as fires, and ensure the continuity of care.

Emergencies: global and local impact
Wars, cyclones, earthquakes, tsunamis, disease outbreaks, famine, radiological incidents and chemical spills – all are emergencies that, invariably, impact heavily on public health. Internal emergencies in health facilities – such as fires and loss of power or water – can damage buildings and equipment and affect staff and patients. In conflicts, reasons for hospital breakdowns include staff being forced to leave due to insecurity and the looting of equipment and drugs.

In 2008, 321 natural disasters killed 235 816 people – a death toll that was almost four times higher than the average annual total for the seven previous years. This increase was due to just two events. Cyclone Nargis left 138 366 people dead or missing in Myanmar, and a major earthquake in south-western China's Sichuan province killed 87 476 people, according to the United Nations’ International Strategy for Disaster Reduction (UNISDR). Asia, the worst-affected continent, was home to nine of the world’s top 10 countries for disaster-related deaths. Along with other weather-related events, floods remained one of the most frequent disasters last year, according to UNISDR. Conflicts around the globe have also led to great human suffering and have stretched health care services to the extreme.

Disasters also exact a devastating economic toll. In 2008, disasters cost an estimated US$ 181 billion – more than twice the US$ 81 billion annual average for 2000–2007. The Sichuan earthquake was estimated to cost some US$ 85 billion in damages, and Hurricane Ike in the United States cost some US$ 30 billion.

"The dramatic increase in human and economic losses from disasters in 2008 is alarming. Sadly, these losses could have been substantially reduced if buildings in China, particularly schools and hospitals, had been built to be more earthquake-resilient. An effective early warning system with good community preparedness could have also saved many lives in Myanmar if it had been implemented before Cyclone Nargis," said Salvano Briceno, the director of UNISDR.

Although only 11% of the people exposed to natural hazards live in developing countries, they account for more than 53% of global deaths due to natural disasters. The differences in impact suggest there is great potential to reduce the human death toll caused by natural disasters in developing countries – and that the key ingredient in these tragedies is human inaction.

This is only one part of the picture. There are many smaller-scale events that inflict an even greater toll in terms of human suffering, such as in the case of vehicle accidents and fires. Road traffic crashes kill 1.2 million people annually, or more than 3200 people a day, while a further 20–50 million people are injured or disabled every year. At least 90% of road and fire fatalities occur in low- and middle-income countries. There are also 300 000 deaths each year from fires alone.

Outbreaks of communicable diseases can spark emergencies that cause widespread death and suffering. In the 12 months up to 31 May 2008, WHO verified 162 outbreaks of infectious disease in 75 countries worldwide. More than a third of the outbreaks occurred in Africa. They included cholera, other diarrhoeal diseases, measles, haemorrhagic fevers and other severe emerging diseases.

"The risk for outbreaks is often presumed to be very high in the chaos that follows natural disasters, a fear likely derived from a perceived association between dead bodies and epidemics. However, the risk factors for outbreaks after disasters are associated primarily with population displacement (commonly linked to conflict)." Even a few cases of a given disease can give rise to the perception that the public faces a grave health risk, which can lead to major political, social and economic consequences.

Infectious diseases are major causes of death and illness in children in conflict settings, especially among refugees and the internally displaced.

How emergencies threaten health facilities and delivery of care?
Apart from their effects on people, emergencies can pose huge threats to hospitals, clinics and other health facilities. Structural and infrastructural damage may be devastating exactly at the time when health facilities are most needed. Health workers have been killed in collapsing hospitals. The number of other deaths and injuries is compounded when a hospital is destroyed or can function only partially. Health facilities should be the focus for assistance when disaster strikes but, if they are damaged or put out of action, the sick and injured have nowhere to get help.

The 2003 Algerian earthquake rendered 50% of health facilities in the affected region non-functional due to damage. In Pakistan's most-affected areas during the 2005 earthquake, 49% of health facilities were completely destroyed, from sophisticated hospitals to rural clinics and drug dispensaries. The December 2004 Indian Ocean tsunami affected national and local health systems that provided health services for millions of people. In Indonesia's northern Aceh province 61% of health facilities were damaged.

Despite international laws, health facilities continue to be targeted or used for military operations in conflicts. Health facilities in Bosnia and Herzegovina, Somalia, the Central African Republic and the Gaza Strip are among those that have been caught in the line of fire.

An emergency may be limited to the health facility infrastructure – for example, fire damage, power cut or loss of water supply. Chemical and radiological emergencies in or near a health facility can also disrupt the delivery of care. In addition, emergencies threaten health staff – the doctors, nurses, ambulance drivers and other staff working to save lives. When a hospital collapses, or an artillery shell destroys a ward or an ambulance, health staff are killed or injured. When staff are incapacitated and cannot do their work, health care is further interrupted.

Even if health facilities themselves are not affected during disease outbreaks and epidemics, their services and provision of safe care may be. Increased demands for services and a decreased workforce can impact on health care by disrupting communications, supplies and transport. Continuity of care is then in turn disrupted, including for chronic diseases like HIV and tuberculosis.

If measures to prevent and control infection are not effective, health-care facilities may act as "amplifiers" of outbreaks, generating cases of the disease among other patients or health-care workers and further decreasing the capacity to provide services.

Power cuts linked to disasters may disrupt water treatment and supply plants, thereby increasing the risk of waterborne diseases and affecting proper hospital functioning, including preserving the vaccine cold chain. A massive power outage in New York in 2003 was followed by an increase in diarrhoeal illness.

Why keep health facilities safe?
Safe health facilities in emergencies are a collective responsibility
Hospitals are more than just buildings. They are a vital asset at the heart of a community, the place where often life starts and ends. Due to the central role played by hospitals in our communities, we all share the responsibility of making sure they are resilient in the face of emergencies. Below are three reasons as to why we must make hospitals safe in emergencies.

1. Save lives, protect health
As they are occupied 24 hours a day, hospitals cannot be evacuated easily. They must remain working if their occupants – especially the most vulnerable such as newborn babies and patients in intensive care – are to survive. When the work of hospitals and other health facilities is disrupted or their buildings are damaged, both urgent and routine health care is interrupted and may be halted altogether – leaving the sick and injured without the care that they need.

Health "systems" rely on a range of public, private and nongovernmental facilities to work together to serve the community. In times of emergency, this is even more important. Hospitals, primary health care centres, laboratories, pharmacies and blood banks work with other non-health sectors, including energy, roads and transport, and the police to ensure the continuity of health services.

Health facilities are safe havens for people during an emergency. Hospitals and their staff must be regarded by all parties – particularly combatants during conflicts – as neutral and must not be subjected to any form of violence. Sadly, the provisions of international humanitarian law in this regard are often not respected. During emergencies, health facilities play a vital role. They:

provide emergency care to the injured (e.g. surgery and blood transfusions) and to the critically ill – as in outbreaks of communicable disease;
- collect and analyse data on illness and deaths in order to detect and prevent potential communicable disease outbreaks;
- deliver longer-term health care before and after an emergency. People need long-term nursing and medical care, maternal and child health services, rehabilitation of injuries, management of chronic diseases, and psychosocial support long after the emergency is over;
- provide immunization services to prevent outbreaks of communicable diseases such as measles that lead to the needless deaths of more children; and
provide other critical services – including laboratories, blood banks, ambulances, rehabilitation facilities, aged care facilities, and pharmacies.

2. Protect investment
The most costly health facility is the one that fails. Hospitals and health facilities are enormous investments for any country and their destruction or damage imposes major economic burdens. In some countries, up to 80% of the health budget is spent on hospitals and other health facilities. Rebuilding a hospital that has been destroyed virtually doubles the initial cost of the facility.

3. Safeguard social stability
Public morale can falter and political discord be ignited if health and emergency services fail during emergencies. Conversely, an effective emergency response and functional health service can reinforce social stability and cohesion. Hospitals are a haven for the public during conflicts and other emergencies due to their neutrality, impartiality and ability to protect a community's social and health capital.

Global efforts to make hospitals safe from disasters
Much has been done to ensure that health facilities can better cope with emergencies and to increase awareness of the vital role that health facilities play in emergencies. “Hospitals Safe from Disasters” is the theme of the 2008–2009 World Disaster Reduction Campaign, which focuses on natural disasters and the damage they can cause to hospitals in particular. The United Nations International Strategy for Disaster Reduction (ISDR), the World Bank and WHO are jointly involved in this campaign. WHO’s regional and country offices have been instrumental not only in helping to share best practices in health facility preparedness for emergencies but also in implementing such guidance and making hospitals and clinics more resilient and functional.

While much work has been done to raise the issue of emergency preparedness for health facilities and to build a "community" of people and parties dedicated to the cause, efforts remain sporadic and are neither sufficiently integrated into government development and emergency response plans nor properly harmonized with other sectors.

WHO's partners, including WHO's regional and country offices and ministries of health, are also leading the way in advocating how best to safeguard health facilities and their personnel and patients. The International Committee of the Red Cross, which advocates for the protection of health personnel and services in conflict settings, and its sister organization, the International Federation of the Red Cross and Red Crescent Societies, which works with communities on emergency preparedness at community level in natural disasters, play critical roles in making hospitals safe from disasters. Donors and financial institutions – including the World Bank, USAID and DIPECHO – have answered the call by offering funding to make health facilities safer.

WHO is devoting World Health Day 2009 to the theme of health facilities in emergencies – “Save lives. Make hospitals safe in emergencies” – to further strengthen the imperative that health facilities must be prepared to withstand emergencies so that they can treat patients both during crises and afterwards. The World Health Day campaign builds on the "Hospitals Safe from Disasters" campaign and calls for hospitals to be safer in all types of emergencies, including natural disasters, conflicts and outbreaks of communicable diseases.

World Health Day is more than just a one-day event. WHO, from its country and regional offices and headquarters, is continuously working with international and national partners to assist countries in preparing their health facilities and staff for emergencies. What 7 April 2009 marks is the launch of the next step of a campaign to build resilience into our health systems so that hospitals, clinics and staff can withstand the next crisis, whatever it may be, and provide the health care that their communities need in times of emergency.

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. 

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.

Row Over Death After Abortion In Hyderabad

Victim Was Forced By In-Laws To Abort Female Foetus. When India was busy celebrating International Women’s Day, a group of women activists were protesting the death of a woman who was forced by her family to undergo an abortion to get rid of her five-month-old female foetus, which eventually led to her death. The activists, armed with a fact finding report, revealed the gory details of how 28-year-old M Vijayalakshmi died after a botched-up abortion which was carried out in a private nursing home in Nalgonda. 
    
Vijayalakshmi’s death has once again put the spotlight on thriving sex selective abortions and the grim girl child sex ratio in the state, they said. Nalgonda in fact has the third lowest girl child sex ratio in AP with 921 girls per 1,000 boys, with high preferences for boys. 
    
Vijayalakshmi died in Hyderabad on February 28, a day after she was admitted to a city hospital in a critical condition. 
    
Living with her in-laws in Burugadda in Huzurnagar mandal of Nalgonda, Vijaylakshmi was forced to go to a nursing home in Kodad for a sex determination test. When the in-laws found that it is a girl child, the pregnancy was terminated. Activists said that due to the incomplete abortion, Vijayalakshmi started bleeding excessively and developed sepsis. As her condition continued to deteriorate, she was rushed to a private hospital in Hyderabad, five days after the abortion. 
    
“She had three daughters and had delivered twin girls in her second pregnancy. Her third pregnancy was aborted and when she conceived for the fourth time, the family did not want another girl child and pushed her to abort after determining the sex of the foetus,” said D Kalpana Kumari, programme officer, Actionaid. 
    
Activists said that the nursing home in Kodad, a small town, was famous for sex selective abortions and the 28-yearold woman was allegedly not the first to die. “Locals told us that Lakshmi is probably the fifth one to die after a botched up abortion,” Suma Latha, an activist with Gramya Resource Centre for Women, said.
    
While the scanning centre at the nursing home is registered under PCPNDT Act, the facility is not registered under the Medical Termination of Pregnancy (MTP) Act, they said. 
    
Indian Council of Medical Research (ICMR) data suggests that more than 65% abortions are done by quacks and almost 15% of maternal deaths were due to septic abortions, which killed Vijayalakshmi. 
    
When contacted, Nalgonda district collector N Mukteswara Rao said he was yet to read the fact-finding report. “Whether a sex selective abortion has happened or not, we don’t know. In-laws are denying the information and the doctor said the woman was bleeding and he therefore carried out the abortion,” Rao said. “We have seized the scanning machine in nursing home,” he added. The activists submitted a memorandum to the district collector on Thursday seeking action against those involved.

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.

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. 

What’s Turning Women In Labour Away From Hospitals?

Institutionalised delivery is encouraged as a means of reducing maternal or infant mortality, but the misbehaviour meted to pregnant women in government hospitals deters them, and others who hear of their experiences, from seeking such care. 

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.

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). 

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.’

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.