Emerging Issues: Ageing, Sex Ratios, Child and Infant Mortality, Reproductive Health

Ageing:

Thanks to development in medical science for the decline in the death rate in India and cure easily available for most of the ailments which has increased human long activity. The number of aged persons in India is increasing. Because of the disintegration of joint-family system and change in the life style of the youth under the influence of modernization and urbanization aged persons are facing many problems. Here, we will consider the nature of problems faced by this section of population in relation to his relations with younger members of the family.

The word ‘Ageing’ has been defined variedly by researchers in different context. Aging in the broadest sense, “as those changes occurring in an individual as a result of the passage of time”. Ageing is a part of living. It begins with conception and terminates with death. Ageing may best be defined as the survival of a growing number of people who have completed the traditional adult roles of making a living and childrearing.

Problems of Aged in India

1. Population ageing is a global issue, which has been recognized to have implications on the health care and social welfare systems. The process whereby the proportion of children in the population decreases and those of old persons increases is known as the “ageing of population”.
2. The global population of elderly has constantly been increasing during the second half of the last century. This has been possible due to easy availability of life saving drugs, control of famines, and various communicable diseases, better awareness and supply of nutrition and health facilities and comparatively better overall standard of living.
3. These achievements have resulted in drastic reduction in mortality rates and substantial increase in the life expectancy at birth and the overall span of people.This phenomenon has been experienced by developed countries in the mid of 20th century. During the last thirty years, this has been emerging as a significant problem in developing countries also.
4. The number of people 60 years and over in the globe is 673 million in 2005 and is expected to increase to 2 billion by 2050, almost a triple increase and the first quarter of 21st century is going to be called as ‘The age of ageing’. More developed regions have almost one-fifth of their population over 60 years but 8 per cent in the less developed regions.And the share of older persons living in these countries is expected to rise from 64 per cent to nearly 80 per cent in 2050.
5. India, like many other developing countries in the world, is presently witnessing rapid ageing of its population. According to Work!Population Prospects, UN Revision, 2006, the population of aged in India is currently the second largest in the world.Even though the proportion of India’s elderly is small compared with that of developed countries, the absolute number of elderly population is on the high.
6. There has been tremendous increase in the number of elderly population since independence in India from 20.19 million in 1951 (5.5 per cent of total population) to 43.17 million in 1981 and 55 million in 1991. According to 2001 census around 77 million population is above 60 years which constitutes 7.5 per cent of the total population of the country.
7. This number is expected to increase to 177.4 million in 2025. (The growth rate of the population (1991-2001) of elderly has been higher (2.89) than overall growth rate (2.02) of the total population. According to World Population Data Sheet- 2002, 4 per cent of the Indian population are in the age group of 65+ which accounts for 41.9 million.This phenomenon of growing population of senior citizens has been the result of recent successes in the achievement of better health standards and a longer span of life for our citizens. Due to this dependency ratio for the old had risen from 10.5 per cent in 1961to 11.8 per cent in 1991; it is projected to be 16.1per cent by 2021.

Defining the Concept

Ageing is a continuous, irreversible, universal process, which starts from conception till the death of an individual However, the age at which one’s productive contribution declines and one tends to be economically dependent can probably be treated as the onset of the aged stage of life. Old age is the last phase of human life cycle, which is again universally true. The use of the words ‘elderly’, ‘older persons’, and ‘senior citizens’, in both popular and scholarly work gives the impression that they are a homogenous group, but in fact there is considerable variation between and among various categories of older people and also between societies. As such it is difficult to provide a clear definition. Different writers have viewed ageing in different contexts as the outcome of biological demographic, sociological psychological or other processes.

The WHO defines those aged 60 -74 years as elderly. In 1980 the UN recommended 60 years as the age of transition for the elderly segment of the population, and has been categorized as follows:

1. Young Old- between the ages of 60-75 years.
2. Old-Old- between the ages of 75-85 years.
3. Very Old- 85 years and above

World Population Data Sheet- 2002 considers aged population as population in the age group of 65+ as old In the Indian context, the age of 60 years has been adopted by the census of India for the purpose of classifying a person as old which coincides with the age of retirement in government sector. The terms Young-Old for 60 to 69, Old-Old for 70 to 79 and Oldest Ok!for 80 to 89 have been used.

Changing Social Structure and Institutions

1. Indian society is undergoing rapid transformation under the impact of industrialization, urbanization, technical and technological change, education and globalization. Consequently, the traditional values and institutions are in the process of erosion and adaptation, resulting in the weakening of intergenerational ties that were the hallmark of the traditional family.
2. Industrialization has replaced the simple family production units by the mass production and the factory. Economic transactions are now between individuals. Individual jobs and earnings give rise to income differentials within the family. Push factors such as population pressure and pull factors such as wider economic opportunities and modern communication cause young people to migrate especially from rural to urban areas.
3. With the rapidly increasing number of aged, compounded by disintegration of joint families and ever increasing influence of modernization and new life styles, the care of elderly has emerged as an important issue in India.
4. Providing care for the aged has never been a problem in India where a value based joint family system was dominant. However, with a growing trend towards nuclear family set-up, and increasing education, urbanization and industrialization, the vulnerability of elderly is rapidly increasing.The coping capacities of the younger and elder family members are now being challenged under various circumstances resulting in neglect and abuse of elderly in many ways, both within the family and outside.
5. Sociologically, ageing marks a form of transition from one set of social roles to another, and such roles are difficult. Among all role transformation in the course of ageing, the shift into the new role of the ‘old’ is one of the most complex and complicated In an agriculture based traditional society, where children followed their parent’s occupation, it was natural that the expertise and knowledge of each generation were passed on to the next, thus affording older persons a useful role in society.
6. However, this is no longer true in modern society, in which improved education, rapid technical change and new forms of organization have often rendered obsolete the knowledge, experience and wisdom of older persons. Once they retire, elderly people find that their children are not seeking advice from them anymore, and society has not much use for them.
7. This realization often results in feeling of loss of status, worthlessness and loneliness. The growth of nuclear families has also meant a need for changes in role relations. Neither having authority in the family, nor being needed, they feel frustrated and depressed If the older person is economically dependent on the children, the problem is likely to become even worse.
8. Nuclear households, characterized by individuality, independence, and desire for privacy are gradually replacing the joint family, which emphasizes the family as a unit and demands deference to age and authority. Children who migrate often find it difficult to cope with city life and elect to leave their old parents in the village, causing problems of loneliness and lack of care givers for old parents. Parents in this circumstance cannot always count on financial support from their children and may have to take care of themselves. They continue to work, although at a reduced pace.
9. Another development impacting negatively on the status of older people is the increasing occurrence of dual career families. Female participation in economic activity either as workers or as entrepreneurs has increased considerably in the recent past in the urban informal sector, and the middle class formal sector, as well as in the rural areas.
10. In the rural informal sectors, increased expenditure on education, health and better food require high incomes. This development has implications for elderly care. On the one hand, working couples find the presence of old parents emotionally bonding and of great help in the caring for their own children. On the other hand high costs of housing and health care are making it harder for children to have parents live with them. This is true both in rural and urban areas.
11. Hence the changing factors in the family in its structure and function are undermining the capacity of the family to provide support to elderly and the weakening of the traditional norms underlying such support’, leading to neglect and abuse of older people in family.

Disabilities in old age :

The disabilities that a person experiences in the course of ageing are multiple in nature. For some, ageing enhances status and enriches life satisfaction, but for many others, it may be difficult and problematic. On one hand getting old provides opportunity to relax, enjoy and do things they always wanted to do, but never had the time for when they were young. On the other hand old age also implies increasing physical mental and psychological disabilities. Such disabilities are the result of many factors. With the increasing age and decreasing health, the older person begins to depend unknowingly physically and psychologically on either the kinship group or the existing social support network.

Economic Problems :

Economic factors definitely play a major role in generating care for elderly people. The economic status, of the family, as well as that of the care-receiver, the functional ability status of the care receiver and care giver is an additional factor that appears to contribute to the burden. Economic dependence is one of the major factors that very often affects the well being of older persons. Economic dependence is manifested in two ways. First, the status of economic dependence may be caused by retirement for a person employed in the formal sector. Secondly, for a person in the rural or urban informal sectors, it may result from their declining ability to work because of decreased physical and mental abilities. Sometimes older persons are also faced with economic dependence when management responsibilities for matters relating to finances, property or business are shifted to children, pushing the older person into a new status of economic dependence.

Psychological Problems :

The common psychological problems that most of the older persons experienceare : feeling of powerlessness, feeling of inferiority, depression, uselessness, isolation and reduced competence. These problems along with social disabilities like widowhood societal prejudice and segregation aggravate the frustration of elderly people. Studies report that conditions of poverty, childlessness, disability, in-law conflicts and changing values were some of the major causes for elder abuse.

Health Problems :

1. Health problems are supposed to be the major concern of a society as older people are more prone to suffer from ill health than younger age groups. It is often claimed that ageing is accompanied by multiple illness and physical ailments. Besides physical illness, the aged are more likely to be victims of poor mental health, which arises from senility, neurosis and extent of life satisfaction.
2. Thus, health status of aged should occupy a central place in any study of the elderly population. In most of the primary surveys, the Indian elderly in general and the rural aged in particular are assumed to have some health problems like cough, poor eyesight, anemia and dental problems.The proportion of the sick and bed ridden among the elderly is found to be increasing with advancing age, the major physical disabilities being blindness and deafness.
3. Besides physical ailments, psychiatric morbidity is also prevalent among large proportion of elderly. Given the prevalence of ill health and disability among the elderly, there is also lack of the provision of medical aid, and proper familial care, in addition, while public health services are insufficient to meet the health needs of the elderly.
4. Since a large majority of older Indians live in rural areas, discussion of ageing in India is essentially a discussion of ageing in rural areas.Almost eight out of ten older people in India live in rural areas. According to 2001 census, 78 per cent of elderly people in India resided in rural areas. Women comprise a slightly higher proportion than men, basically due to higher female expectancy at birth. Pervasive poverty and inequalities of income, coupled with a very inadequate safety net, has meant that majority of older persons become marginalized or even destitute. The poor among elderly people have been losing out even as economic development is taking place in the country as a whole.
5. Ageing is predominantly a women’s problem. Not only do women live longer but most of them are widows. They face serious discrimination with respect to their rights and are over burdened with familial responsibilities. This adversely affects their health, nutrition and mental well being. Irrespective of economic, marital or educational status, elderly women face an emotional void in their life. A women explanation for distress among elderly female is the ’empty nest syndrome’.The empty nest’ period may indeed bring in depression in the course of their diminishing role in the family. Extra provisions of care and support are required to redeem them from their miserable plight.
6. Added to this is the problem of widows in our society today. Approximately 99 per cent of India’s elderly population lives below the poverty line and 50 per cent of them are widows. They are especially vulnerable to poverty, inadequate care and neglect in ok!age. The tradition of women marrying men older than them by several years, the increasing life expectancy of women, social disapproval of widow remarriage, patrilineal inheritance, and problems of finding employment all render widows more vulnerable than most other groups in society. Their situation become worse when they own very little or no assets of their own and do not have an independent source of income.Single persons, particularly women are more vulnerable in old age as few people are willing to take care of non-lineal relatives.

Government’s Role in the Rehabilitation of Aged :

Since independence the Indian government has been committed to supporting the old people in our society with certain interventionist welfare methods. The year 1999 was declared by the UN as the International Year of Older Persons followed on 13th Jan 1999, by the Government of India approving the National Policy for Older Persons for accelerating welfare measures and empowering the elderly in ways beneficial to them. Maintenance and Welfare of Parents and Senior Citizens Act, 2007 provides legal sanctions to the rights of the elderly. In addition constitutional provisions for old age security, old age pension, establishing ok!age homes, expanding geriatric services, liberalizing housing policy for elders have also been undertaken.

Social security benefits :

In the context of changing intergenerational relationships, economic dependence on children is a major factor determining the quality of life of elderly. As such, social security by the state assumes great importance. Unfortunately, at present, there is very little in terms of social security from the state in India. Only those who work in the public sector or for large private companies have benefits such as pensions and provident funds. However, for the most of the 90 per cent of elderly persons who work in the informal sector, there are scarcely any benefits. The only available benefits for the poor are:

• The National Old age Pension of 75 rupees per month, which is universal but available only to destitute people over the age of 65 years.
• Various state schemes, with benefits ranging between Rs.60 to Rs. 250 per month, meant generally for people aged 65+ and below the poverty line, and
• Benefits for widows, with benefits below Rs. 150 per month.

With the constantly increasing cost of health care and housing, these benefits fall far short of supporting even minimal basic needs.The right of parents without any means of their own to be supported by their children has been recognized by section 125(1) (d) of the Code of Criminal Procedure 1973, and section 20 (3) of the Hindu Adoption and Maintenance Act, 1956. More recently, in 1996, the Government of the state of Himachal Pradesh passed the Parents’ Maintenance Bill requiring children to take care of parents with no means and to provide assistance to those neglected by their children.The Governments of Maharashtra, Goa and others are in the process of passing similar bills.

Government of India has passed the maintenance and welfare of parents and senior citizens bill 2007 this bill seeks to make it legal obligation for children and heirs to provide maintenance to senior citizen. It confreres right to senior citizen to apply to a maintenance tribunal if they are unable to maintain themselves.

Role of Old Age Homes as care givers

1. The concept of the old age home, though not very common in India, is not unknown. The first old age home was established in Bangalore in 1983 by the Bangalore Friends-in Need society and was called the ‘(Old Home)’. According to Help Age India estimates, there are 728 institutions at present, perhaps a majority of them in urban areas. Kerala has the largest number of old age homes. More than 60 per cent of the old age homes in India are of the charitable type, meant for destitute or very poor persons.
2. About 20 per cent of them are of the ‘pay and stay’ type and another 20 per cent are mixed. About15 per cent of the homes were for women exclusively. In recent years, there has been rapid increase in the number of old age homes and they are gradually gaining acceptance, especially by those who see these institutions as a better alternative than living in a son’s home where you are not wanted.
3. There is a debate going on in India at present among seniors’ organizations, non-governmental organizations and others about whether this growth should be allowed supported or curbed There is a strong feeling that proliferation of old-age homes would make it easier for children to shirk their responsibility for taking care of their aging parents by placing them in institutions. Increasing institutionalization of elderly people would lead to erosion of the desirable traditional family values and may even lead to the breakup of the institution of family itself.
4. While this is the possibility in view of decline in traditional filial obligations among children and lack of an adequate social security safety net, there is also need for various types of institutions to accommodate the increasing number of elderly parents whose children are unable or unwilling to care for their parents.
5. In spite of the government’s and NGO’s efforts in rehabilitating the aged in India they are still the most vulnerable group facing multiple problems and hence require proper care and attention. Ageing is a natural process. ‘Old age is an incurable disease’. But more recently J.S. Ross commented “You do need old age, you protect it, you promote it, and you extend it”. A man is as old as he feels and woman as old as she looks. Hence there is need for proper care and protection for the elderly in the changing scenario. Following suggestions may go a long way in changing the life of elderly in India:
   • Efforts should be made to strengthen the family care, because the preferred source of support for the aged is still the family – informal system where the notion of care is embedded within a tradition of social obligations that are understood and reciprocated The reciprocal care and support within multi-generational families of parents, grandparents and children should be encouraged Traditional values of filial obligations can also be reinforced in school curricula and through the media.
   • The Institutional care must be able to enhance relationships within families that incorporate both young and old persons. There is a need for effective legislation for parents’ right to be cared for by the children.
   • The existing health care systems are not sufficient to meet the physical and health needs of the ageing population such as old age security establishing old age homes, expanding geriatric services and liberalizing the welfare policy for older persons. It is necessary to increase public awareness of the need for protection of this sub group.There is a great need to protect the target group i.e. rural old and ok!women, and widows.
   • There is also need for the elderly to remain active, to know that they still have a part to play in the family or community to which they belong and can make a useful co contribution to nation and society as a whole.

There are four types of programmes which are needed in the country for the older persons :

1. Day-care Centers or Older Persons Club for those who leave their families.
2. Institutions for unattached dependent and friendless persons.
3. Counseling for incurable and chronically ill and
4. Financial assistance to those who can live in their families but do not have sufficient means to maintain themselves.

United Nations has suggested following principles and recommendations for the aged:

1. National machinery should he established or strengthened to ensure that the humanitarian needs and development potential of the aged are appropriately addressed;
2. The expansion of research focusing on the demographic, epidemiological biological social and economic aspects of ageing, particularly in developing countries, should be supported
3. The establishment or expansion of community based or institutional care systems that provide the necessary health and social services for the frail elderly who have limited or no family support should be encouraged;
4. Organizations and associations of the elderly, which ensure their active involvement in policy, and programme development, should be encouraged and promoted Training in Gerontology and Geriatrics should be promoted to ensure that policy makers researchers and practitioners have an adequate knowledge of issue related to ageing.
5. The Ministry of Social Justice and Employment has been implementing has Central Scheme of assistance for establishing and maintaining the day- care centers, old age homes, mobile Medicare units as well as for supporting and strengthening non-institutional services for the aged This revised scheme is called as ‘An Integrated Programme for older persons’.

Sex ratio in India

1. The sex ratio is an important indicator of gender balance in the population.As mentioned in the section on concepts earlier, historically, the sex ratio has been slightly in favour of females, that is, the number of females per 1000 males has generally been somewhat higher than 1000. However, India has had a declining sex-ratio for more than a century.
2. From 972 females per 1000 males at the turn of the twentieth century, the sex ratio has declined to 933 at the turn of the twenty-first century. The trends of the last four decades have been particularly worrying- from 941 in 1961the sex ratio had fallen to an all time low of 927 in 1991 before posting a modest increase in 2001.
3. But that has really alarmed demographers, policy makers, social activists and concerned citizens is the drastic fall in the child sex ratio. Age specific sex ratio began to be computed in 1961.The sex ratio for the 0-6 years age group (known as the juvenile or child sex ratio) has generally been substantially higher than the overall sex ratio for all age groups, but it has been falling very sharply .In fact the decade 1991-2001 represents an anomaly in that the overall sex ratio has posted its highest ever increase of 6 points from the all time low of 927 to 933, but the child sex ratio has dropped from 945 to 927,a plunge of 18 points taking it below the overall sex ratio for the first time.
4. The state-level child sex ratios offer even greater cause for worry. As many as six states and union territories have a child sex ratio of under 900 females per 1000 males. Punjab is the worst off with an incredibly low child sex ratio of 793 (the only state below800), followed by Haryana, Chandigarh, Delhi, Gujarat and Himachal Pradesh. Uttaranchal Rajasthan, Uttar Pradesh and Maharashtra are all under 925, while Madhya Pradesh, Goa, Jammu and Kashmir, Bihar, Tamil Nadu, Karnataka and Orissa are above the national average of 927 but below the 950 mark. Even Kerala, the state with the best overall sex ratio does not do too well at 963, while the highest child sex ratio of 986 is found in Sikkim.

Demographers and sociologists have offered several reasons for the decline in the sex ratio

1. The health factor that affects women differently from men is childbearing. It is relevant to ask if the fall in the sex ratio may be partly due to the increased risk of death in child birth that only women face. However, maternal mortality is supposed to decline with development, as levels of nutrition, general education and awareness as well as the availability of medical and communication facilities improves. Indeed maternal mortality rates have been coming down in India even though they remain high by international standards. So it is difficult to see how maternal mortality could have been responsible for the worsening of the sex ratio over time.
2. Combined with the fact that the decline in the child sex ratios has been much steeper than the overall figure, social scientists believe that the cause has to be sought in the differential treatment of girl babies. Several other factors may be held responsible for the decline in the child sex ratio including.
3. Severe neglect of girl babies in infancy leading to higher death rates,
4. Sex specific abortions that prevent girl babies from being born, and
5. Female infanticide (or the killing of girl babies due to religious or cultural beliefs).

Each of these reasons point to a serious social problem, and there is some evidence that all of these have been at work in India. Practices of female infanticide have been known to exist in many regions, while increasing importance is being attached to modern medical techniques by which the sex of the baby can be determined in the very early stages of pregnancy. The availability of the sonogram, originally developed to identify genetic or other disorders in the foetus, may be used to identify selectively abort female fet uses.

The regional pattern of low child sex ratios seems to support this argument So the problem of selective abortions is not due to poverty or ignorance or lack of resources only. For example, if practices like dowry payments is there for marriage of their daughters, then prosperous parents would be the ones most able to afford this. However, we find that sex ratios are lowest in the most prosperous regions.

It is also possible (though this issue is still being researched) that as economically prosperous families decide to have fewer children- often only one or two now-they may also wish to choose the sex of their child. This becomes possible with the availability of ultrasound technology, although the government has passed strict laws banning this practice and imposing heavy fines and imprisonment as punishment Known as the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, this law has been in force since 1996, and has been further strengthened in 2003. However, in the long run the solution to problems like the bias against girl children depends more on how social attitudes evolve even though laws and rules can also help.

Reproductive Health

Deaths due to pregnancy and child birth are potential threats to women in the reproductive age groups.The toll that unsafe motherhood takes on the lives and health of women, and hence, on their families and communities, becomes really tragic as it is mostly preventable. Reduction of mortality of women has thus been an area of major concern and governments across the globe have set time bound targets to achieve it Maternal death is an important indicator of the reach of effective clinical health services to the poor, and is in turn act as one of the composite measure to assess the country’s progress.

Maternal Mortality Ratio

1. The Maternal Mortality Ratio (MMR) is the number of women who die from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy irrespective of the duration and site of the pregnancy per 100,000 live births.
2. The problem in estimating MMR is due to the comparative rarity of the event, necessitating a large sample size. However, even with this constraint.Sample Registration System (SRS) data indicates India has recorded a deep decline of 45.6% in MMR from 327 in 1999-2001 to 178 in 2010-12 and a fall of about 30% happened during 2006 -12. The decline in MMR from 1990 to 2012 is 59%. This can be attributed to the increase in awareness and the intensive efforts being taken throughout the country in improving healthcare especially that of pregnant women and mothers.
3. From an estimated MMR level of 437 per 100,000 live births in 1990, India is required to reduce the MMR to 109 per 100,000 live births by 2015.At the historical pace of decrease, India tends to reach MMR of 140 per 100,000 live births by 2015, falling short by 31points. However, the bright line in the trend is the sharper decline i.e.16% during 2009-12, 17% during 2006-09 and 16% during 2004-06 compared to 8% decline during 2001- 2003.
4. As per SRS 2010-12, among the major States, Maternal Mortality Ratio is lowest in Kerala (66) and highest in Assam (328). During 2010-12, the Maternal Mortality Ratio is higher than the national level estimate in the States of Bihar/ Jharkhand Madhya Pradesh/ Chattisgarh, Odisha, Rajasthan, Uttar Pradesh/Uttarakhand and Assam.
5. The present status of MMR along with the extent of progress achieved in the last one decade, give a better picture of the performance of the States in reducing maternal mortality ratio. The States which showed highest points of decline during 1999-2012 are Uttar Pradesh/ Uttarakhand (declined by 247 points), Rajasthan (declined by 246 points), Odisha (declined by 189 points), Bihar/Jharkhand (declined by 181 points), Madhya Pradesh/ Chhattisgarh (declined by177 points) where as at all India level the decline was 149 points.Thus, most of the States with highest level of MMR in 2010 – 12, have shown maximum points of decline.
6. It is worrying that more young mothers in the age group 20-29 years die due to maternal causes and the proportion increased in 2010-12 from that of 2007-09. The proportion of maternal deaths in the age group 20-29 years stood at 67% in 2010-12, whereas the corresponding figure in 2007 -09 is 63%. Further, the age group, 20-24 yrs are more susceptible to maternal death as deaths due to maternity causes are highest in this group. During 2010-12, the maternal deaths are highest in the age group 20-24 years (39%) followed by 25-29 years (28%), whereas the corresponding figures for 2007-09 were 36% and 27% respectively.
7. In addition to Maternal Mortality Ratio (MMR), the Maternal Mortality Rate (MMRate – Number of maternal deaths in a given period per 100000 women of reproductive age during the same time period) and Adult lifetime risk of maternal death (The probability that a 15-year-old women will die eventually from a maternal cause) are important statistical measures of maternal mortality.
8. The maternal mortality rate at all India level has come down from 20.7 in 2004-05 to 12.4 in 2010-12. All the major States have also shown a decline in MMR during this period. The MMRate is lowest in Kerala (3.3) and highest in Uttarpradesh/ Uttarakhand (28.7) in 2010-12.
9. At all India level lifetime risk declined from 0.7% in 2004-06 to 0.4% 2010-12 and all the major States have shown decline during this period In 2010-12, lifetime risk was lowest in Kerala 0.1% and highest in Uttar Pradesh/ Uttarakhand (1%).
10. Gaps still persisting in ensuring safe delivery and Proportion of births attended by skilled health personnel.
11. Safe motherhood depends mainly on delivery by trained / professional personnel particularly through institutional facilities. Among other things, ensuring ante-natal care of prospective mothers at health centres and recommended doses of IFT are important factors that help improve maternal health and reduce life risk during pregnancy.
12. The National Family Health Survey (NFHS-2005-06) and District Household Survey (DLHS- 2007-08) revealed the trend in institutional deliveries and safe deliveries and pointed towards the need for more focused and accelerated initiatives to improve the situation. The institutional deliveries in India increased from 40.9% in 2002-04(District level Household Survey) to 72.9% in 2009 (Coverage Evaluation Survey).
13. As per Coverage Evaluation Survey (CES), 2009, delivery attended by skilled personnel is 76.2% which was 47.6% as per District level Household Survey (DLHS-2002 -04). With the existing rate of increase in deliveries by skilled personnel, the likely achievement for 2015 is only to 77.29%, which is far short of the targeted universal coverage. As per CES 2009, the percentage of deliveries attended by skilled health personnel ranges from 43.8% (Nagaland) to 100% (Kerala).
14. Going by the historic rate of coverage increase in deliveries assisted by trained/ professional persons, 7 States namely, Andhra Pradesh, Goa, Jammu &Kashmir, Kerala, Madhya Pradesh, Orissa, Rajasthan, Sikkim and Tamil Nadu are likely to reach universal coverage or close to it (achievement of 90%& above) by the year 2015.For the other States, shortfall from universal coverage tends to vary from 11 to 61 percentage points.
15. The maternal health care services for antenatal care includes at least three antenatal care visits, iron prophylaxis for pregnant and lactating women, at least one dose of tetanus toxoid vaccine, detection and treatment of anemia in mothers, and management and referral of high-risk pregnancies and natal care.

Status of some major indicators related to maternal health

Indicators	DLHS-2 (2002-04)	DLHS-3 (2007-08)	CES (2009)
Mothers who had received any ANC (%) Mothers who had 3 or more ANC (%) Mothers who had full ANC check up (%) Institutional Delivery (%) Safe Delivery (%) IFA tablets consumed for 100 days Mothers who received PNC within 2 weeks of delivery (%)	73.6 50.4 16.5 40.9 48.0 20.5	75.2 49.8 18.8 47.0 52.7 46.6 49.7	89.6 68.7 26.5 72.9 76.2 60.1

Addressing issues related to Reproductive Health

Interventions & Strategies under NRHM :

The National Rural Health Mission (NRHM) was launched on 12th April 2005 throughout the country with special focus on 18 states, including eight Empowered Action Group (EAG) States, the North-Eastern States, Jammu & Kashmir and Himachal Pradesh. The NRHM seeks to provide accessible, affordable and quality health care to the rural population, especially the vulnerable sections. During the 12th Plan, one of the goals of NRHM is to reduce MMR to less than 100 per 1,00,000 live births. Under National Rural Health Mission (NRHM) and within its umbrella, the Reproductive and Child Health Programme. Phase II, the Government of India has taken a number of steps to accelerate the pace of reduction in maternal mortality. These strategies and interventions are:

1. Janani Suraksha Yojana (JSY) :
   • Janani SurakshaYojana, a demand promotion scheme for reduction of MMR and IMR has led to steep increase in Institutional Delivery in government health facilities. Cash benefits are provided under the scheme to SC/ST /BPL women to promote institutional delivery.
2. Quality Antenatal, Intranatal and Postnatal care :
   • Quality ANC includes minimum of at least 4 ANCs including early registration and 1st ANC in first trimester along with physical and abdominal examination, Hb estimation and urine investigation, 2 doses of T.T Immunization and consumption of IFA tablets for 100 days.
   • Iron and Folic Acid supplementation to pregnant & lactating women for prevention and treatment of anaemia.
   • Health and nutrition education to promote dietary diversification, inclusion of iron and folate rich food as well as food items that promote iron absorption.
3. Operationalisation of the health facilities for provision of Basic Emergency Obstetric Care (BeMOC) and Comprehensive Emergency Obstetric Care (CEmOC) services :
   • Sub-Centres, Primary Health Centres, Community Health Centres and District Hospitals are being operationalized for providing 24×7 basic and comprehensive obstetric and newborn care services.
4. Delivery Points :
   • Govt of India is facilitating the States in identifying the “delivery points” for providing comprehensive and quality Reproductive Maternal Newborn and Child Health (RMNCH) Services at these health facilities which are performing deliveries/ C- sections above a certain benchmark.
5. Capacity building of health care providers :
   • To Operationalise PHCs, CHCs, DH and other health facilities, the health providers working at these facilities are being trained and oriented for improving their knowledge and skills in providing quality obstetric care services.
6. Referral Services at both Community and Institutional level :
   • Under NRHM, states are provided financial assistance for establishing the emergency response services and patient transport ambulances. Government of India has a thrust on establishing a network of Basic patient care transportation ambulances with the aim to reach the beneficiaries in rural areas within 30 minutes of the call for quick service delivery.The states have been given flexibility to use different models of emergency referral transport for establishing the necessary linkages between home and health facility and between different levels of health facilities and for drop back home for pregnant women and post delivered women and sick neonates for whom it is to be provided free of cost.
7. Comprehensive Abortion Care services :
   • To reduce maternal mortality and morbidity due to unsafe abortion, consistent efforts have been made to expand safe abortion services in peripheral health care facilities in rural areas.These include provision of drugs and equipment for Manual Vacuum Aspiration (EVA), Manual Vacuum Aspiration (MVA), Medical Methods of Abortion (MMA) at PHCs, CHCs, DHs with focus on the delivery points, encouraging private and NGO sectors to provide quality MTP services, certification and regulation of private sector facilities through District Level Committees (DLCs) within the framework of the MTP Act 1971and development of appropriate IEC /BCC messages to create awareness in the community on MTP.
8. Services for Reproductive & Tract Infections (RTI /STI) :
   • Services for RTI /STI are provided at all health facilities from PHC upwards including CHCs, other sub district hospitals and district hospitals with a focus on Delivery Point in convergence with the NACP. These include Syndromic management of RTIs/STIs, provision of colour coded kits, RPR testing kits and Whole Blood Finger Prick Testing at the delivery points.
   • Prevention of Parent to Child Transmission (PPTCT) Services to enhance coverage of PPTCT services, HIV screening of all pregnant women is being offered during routine Ante natal care visits on a voluntary basis. NACO has launched new Guidelines for PPTCT under the NACP.
9. Outreach activities :
   • Village Health and Nutrition Day (VHNDs) at Anganwadi centre at least once every month and to provide ante natal/ post partum care for pregnant women, promote institutional delivery, immunization. Family Planning & nutrition are the part of various services being provided during VHNDs.
10. Engagement of Accredited Social Health Activists (ASHAs) to generate demand and facilitate accessing of health care services by the community.
    • The ASHAs have been engaged to perform various key activities e.g. regular visit to pregnant women, prepare micro-birth plans, counsel for institutional delivery, escort the pregnant woman to the nearest public health facility at the time of delivery, facilitate arrangement for referral transport, assist ANM in providing care to the mother during the postnatal period through home visits and to facilitate the pregnant women in getting the benefits under the JSY scheme etc.
    • Performance Based Incentives: States are incentivizing the ASHA for her key activities as per GOI & State Guidelines.

New initiatives :

11. Mother Child TrackingSystem (MCTS): Name Based web enabled tracking of pregnant women and children:
    • An online Mother Child Tracking System (MCTS) has been made operational for all the States and UTs. After entering the data, work plan is being generated for the ANMs and ASHAs to deliver the health services during any point of time. MCTS call centre has been setup to call the beneficiaries and validate their data.
12. Janani Shishu Suraksha Karyakaram (JSSK)
    • Government of India has launched Janani Shishu Suraksha Karyakaram (JSSK) on 1st June,2011 The initiative entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery, including caesarean section. The entitlements include free drugs and consumables, free diet up to 3 days during normal delivery and up to 7 days for C section, free diagnostics, and free blood wherever required This initiative also provides for free transport from home to institution, between facilities in case of a referral and drop back home.Similar entitlements have been put in place for all sick newborns accessing public health institutions for treatment till 30 days after birth. All the States and UTs have initiated this programme.
13. Maternal Death Review (MDR) :
    • Maternal Death Review (MDR) is one of the important interventions under the RCH Programme to accelerate the pace of decline of MMR in the country.
    • The MDR process has been institutionalised across the country to serve as a tool for improving the quality of obstetric care and reducing maternal mortality and morbidity. Under the process, reporting and analysis of the maternal deaths provides an opportunity to identify the delays that contribute to maternal deaths at various levels and use the information to take corrective actions to overcome the systemic and programmatic gaps in service provision.
    • The MDR Guidelines and monitoring tools have been disseminated to the states and UTs for guiding states in rolling out and monitoring the MDR Process. All the States & UTs are currently reporting on the MDR process through monthly reports to MOHFW. Tamil Nadu and Kerala have well established processes to conduct MDR for a number of years. Other States like Maharashtra, Odisha, Punjab, Madhya Pradesh and Assam have shown considerable progress in reporting and analysis of maternal deaths.
14. Maternal and Child Health Wings:
    • JSY has led to steep increase in Institutional Delivery in government health facilities. ASHAs are also generating demand and facilitating access of women and children to public health institutions. As a result, these hospitals are overstretched in order to ensure quality of care.

Indira Gandhi Matritva Sahyog Yojana (IGMSY)

1. A Conditional Cash Transfer Schemes for pregnant and lactating women was introduced in October, 2010 to contribute to better enabling environment by providing cash incentives for improved health and nutrition to pregnant and nursing mothers by the Ministry of Women and Child Development.
2. The scheme envisages providing cash to Pregnant & Lactating (P&L) women during pregnancy and lactation in response to individual fulfilling specific conditions. It addresses short term income support objectives with long term objective of behavioural and attitudinal changes.
3. The scheme attempts to partly compensate for wage loss to Pregnant & Lactating women both prior to and after delivery of child Being implemented on pilot basis in 53 selected districts using the platform of ICDS, 12.5 lakh P&L women are expected to be covered every year under IGMSY. The beneficiaries are paid Rs. 4000/- in three instalments per Pregnant and lactating women between the second trimester and till the child attains the age of 6 months on fulfilling specific conditions related to maternal and child health. Pregnant women of 19 years of age and above for first two live births are eligible under the scheme.
4. All Government / Public Sector Undertakings (Central and State) employees are excluded from the Scheme as they are entitled for paid maternity leave. The wives of such employees are also excluded from the scheme. The scheme is now covered under Direct Benefit Transfer (DBT) programme and under which nine districts have been included under first phase of the implementation. For phase-II, which starts from 01/07/2013, seven districts namely Palakad (Kerala), Yanam (Puducherry), West Delhi (Delhi), Nalgonda (Andhra Pradesh), Hamirpur (Himachal Pradesh), Lakshadweep (Lakshadweep) &Dhamtari (Chhatisgarh) have been identified.
5. Under the “The National Food Security Act”, every pregnant women and lactating mother will become entitled to maternity benefit ofRs. 6000/ -. The Ministry will have to revise the guideline of the IGMSY to bring it in conformity with the provisions of the Act. The significant changes will include universalisation of IGMSY from 53 districts to whole of the country, increasing the number of beneficiaries manyfold and increase in amount to be transferred per beneficiary from present Rs. 4000/- to Rs. 6000/- in 53 districts across the country is being issued.
6. In addition to the above mentioned major initiatives by Central ministries, the State Governments also implement similar programmes to improve maternal health, and to reduce maternal mortality. The programmes are to focus on all concerned fronts including awareness generation, better accessible heath care facilities, financial benefits etc which in turn ensure safe motherhood.

The available facts pertaining to reproductive health in India point out that:

1. Of the total conceptions that take place annually, about 78 per cent are unplanned and about 25 per cent are definitely unwanted About 30 million women in India desire better family planning services since they are not satisfied with the available facilities/programmes.
2. Out of about 11 million abortions every year, 69 per cent are induced and 31 per cent are spontaneous.
3. Over one lakh women die every year during pregnancy and child birth.
4. About three-fourth babies are delivered at home and only one-third deliveries are assisted by a doctor, nurse or a midwife.
5. One in every13 children dies within the first year of life and one in every nine dies before reaching the age of five. Infant mortality is as high as 52 per cent in rural areas.

In recent years government has started many programmes to improve reproductive health of women. Janani Suraksha Yojana, National Rural Health Mission, ASHA volunteers etc., are all dedicated to this cause. Reproductive health of the women has become prime concern of policy makers. High infant mortality rate, maternal mortality rate are contributed to weak reproductive health.