A trend in women ’ s health in India – what has been achieved and what can be done

The health of Indian women is intrinsically linked to their status in society. Research into Indian women’s status has found that their family contributions are often overlooked and they are likely to be regarded as an economic burden, especially in rural areas. This attitude has a negative impact on their health status. Poor health has repercussions not only for women, but also for their children and other family members. This commentary focuses on the trend in five key women’s issues in India: maternal and child health; violence against women; nutritional status; unequal treatment of girls and boys; and care quality. The discussion is based on data extracted from Indian National Family Health Surveys (NFHS-1, NFHS-2 NFHS-3) spanning the period 1993-2006, and data from the Indian Sample Registration System and National Crime Research Bureau.


Introduction
You can tell the condition of a nation by looking at the status of its women. Jawaharlal Nehru India has 16% of the world's population but only 2.4% of its landmass, resulting in great pressures for resources. It is a country where 70% of the population resides in a rural area and males significantly outnumber females, an imbalance that has increased over time. The typical female advantage in life expectancy is not seen in India and this suggests there are systematic problems in women's health care.
Indian women have high mortality rates, particularly during childhood and in their reproductive years. India's maternal mortality rates in rural areas are among the world's highest.
From a global perspective, India accounts for 19% of all live births and 27% of all maternal deaths. The health of Indian women is intrinsically linked to their status in society, especially for those living in a rural area.
Research into women's status in society has found that the contributions Indian women make to families are often overlooked. Instead they are often regarded as economic burdens and this view is common in rural areas of the northern belt. There is a strong preference for sons in India because they are expected to care for ageing parents. This son preference and high dowry costs for daughters results in the mistreatment of daughters. Indeed, Indian women have low levels of both education and formal labor-force participation. They typically have little autonomy, living first under the control of their fathers, then their husbands, and finally their sons [1][2][3][4] .
These factors have a negative impact on the health status of Indian women. Poor health has repercussions not only for women, but also their families. Women in poor health are more likely to give birth to low weight infants. They are less likely to be able to provide food and adequate care for their children. Finally, a woman's health affects the household's economic wellbeing because a woman in poor health will be less productive in the labor force (Table 1). In rural areas where women are less educated and economically deprived, their health condition is worse. In the context of health as defined by WHO -'…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' 5 -one must ask how can this be achieved for Indian women.

Objective
This article focuses on the trend in five key women's health issues: maternal and child health; violence against women; nutritional status; unequal treatment of girls and boys; and quality care. Data was extracted from the three Indian National Family Health Surveys (NFHS-1 1992-1993, NFHS-2 1998-1999and NFHS-3 2005-2006 [7][8][9] . Sample Registration System (SRS) and National Crime Research (NCR) Bureau data was also used in an attempt to discover the extent of improvement or deterioration in these indicators. Some practical recommendations are made.

Trends in Indian maternal and child health
Many of the health problems of Indian women are related to or exacerbated by high levels of fertility. Overall, fertility has been declining in India; the total fertility rate was 3.4, 2.9 and 2.7 in NFHS-1, NFHS-2 and NFHS-3, respectively 9 .
However, there are large differences in fertility levels by state, education, religion, caste and place of residence; for instance, the interstate total fertility rate was more than 5 children/woman in Utter Pradesh and less than 2 in Kerala. High levels of infant mortality combined with the strong son preference motivates women to bear high numbers of children in an attempt to have sons surviving into adulthood, especially in the Hindi speaking belt.
Research has shown that numerous pregnancies and closely spaced births erode a mother's nutritional status, which can negatively affect pregnancy outcome (eg premature births, low birth-weight babies) and also increase the health risks for mothers 10 . Although the incidence of low birth weight babies is gradually declining in India (51.5%, 47% and 45.9% in NFHS-1, NFHS-2 and NFHS-3, respectively; Table 2), unwanted pregnancies terminated by unsafe abortion have negative consequences for women's health. Therefore, reducing fertility is an important element in improving the overall health of Indian women. Increasing contraceptive use is one way to reduce fertility.
Knowledge of family planning is almost universal in India, but its implementation was only 36%, 43% and 49% in NFHS-1, NFHS-2 and NFHS-3, respectively. Female sterilization is the main form of contraception with over twothirds of married women using contraception being sterilized.
Place of residence, education and religion are strongly related to both fertility and contraceptive use. The ruralurban differential in contraceptive use was 14 percentage points in NFHS-1, tapering to 11 percentage points in NFHS-3 (Table 2). More than half married women with a high school or above education use contraceptives, compared with only one-third of illiterate women. Not surprisingly, the total fertility rates for these two groups are significantly different: 4 children for illiterate women compared with 2.2 children for women with a high school or above education. Differentials among the religious groups are also pronounced, for example Muslims had the highest total fertility rate and the lowest contraceptive use in NFHS-1 and NFHS-2.
Although there is a marginal increase in the number of women using contraceptives and limiting their fertility, there is still unmet need for contraceptives in India. Almost 20% of married women either want to delay their next birth or have no more children but this tapered by 6 percentage points in subsequent surveys. Most of the unmet need among younger women relates to spacing births, rather than limiting them. This suggests that methods other than female sterilization should be strongly promoted by India's family planning program. having ratios over 500. This is most likely related to differences in the socioeconomic status of women and access to healthcare services among the states. The high levels of maternal mortality are especially distressing because most of these deaths could be have been prevented if women had adequate health services (either effective pre-natal care or referral to appropriate healthcare facilities) 10 . In fact, the leading contributor to the high MMR in India is lack of access to health care 4 .

Utilization of antenatal and post-natal care
The data from NFHS-1, 2 and 3 seem to depict an encouraging trend in the utilization of antenatal care (ANC) ( Table 3). The proportion of women receiving 'no care' varied greatly by educational level and place of residence. Almost two-thirds (70%) of all illiterate women received no care compared with 15% of literate women. Women in rural areas were much less likely to receive ANC than women in urban areas (43% and 74%, respectively).
Most women who did not receive health care during pregnancy said this was because they thought it was unnecessary 8 . It is currently estimated that 16% of the rural population lives more than 10 km from any medical facility 11 . This may be another factor of non-utilization of health care. Thus, there is a need to educate women about the importance of health care for healthy pregnancies and safe childbirth. Another reason for the low level of prenatal care is a lack of adequate healthcare centers, especially in rural areas.
Place of birth and type of assistance during birth have an impact on maternal health and mortality. Births that take place in unhygienic conditions or births that are not attended by trained medical personnel are more likely to have negative outcomes for both the mother and the child. Both NFHS-1 and NFHS-2 surveys found that nearly threequarters of all births took place at home and that almost twothirds of all births were not attended by trained medical personnel in rural India 7,8 . Health care during delivery is a factor influencing maternal mortality and health. Research also shows that an early age at first birth and a high number of total pregnancies negatively impact women's health.
Although fertility has been declining in India, in many areas of the country it remains high. In general, high MMR is related to high fertility and the type of antenatal, natal and postnatal care for pregnant women.
One in five maternal deaths are related to an easily treated problem However much a mother may love her children, it is all but impossible for her to provide high-quality child care if she herself is poor and oppressed, illiterate and uninformed, anaemic and unhealthy, has five or six other children, lives in a slum or shanty, has neither clean water nor safe sanitation, and if she is without the necessary support either from health services, or from her society, or from the father of her children 12 .
Anaemia, which can be treated relatively simply and inexpensively with iron tablets, is another factor in maternal health and mortality. Studies have found that between 50 and 60% of all pregnant women in India suffer from anaemia.
Severe anaemia accounts for 20% of all maternal deaths in Indian states. The survey shows that anaemia prevalence among women is double that of men with almost half experiencing moderate to severe anaemia. The prevalence of anaemia is marginally higher in rural than urban areas but anaemia is a common problem in both. More than 50% of women in urban areas are anaemic with almost one-third suffering moderate to severe anaemia 13 .

Every three minutes a case of violence against woman is registered in India
The great tragic irony of the Indian woman is that within the four walls of the temple she is symbolized as the goddess but

More than half of all Indian children are underweight and malnourished
Numerous studies indicate that malnutrition is another serious health problem for Indian women 1,2,4 . It threatens their survival as well as that of their children. The negative effects of malnutrition in women are compounded by heavy work demands, poverty, childbearing and rearing, and the special nutritional needs of women, resulting in increased susceptibility to illness and consequent higher mortality.
While malnutrition in India is prevalent among all segments of the population, poor nutrition among women begins in infancy and continues throughout their lifetimes 1,2 . Women and girls are typically the last to eat in a family; thus, if there is not enough food they are the ones who suffer most 3 .
An unhealthy mother gives birth to an unhealthy child.
According to the NFHS, Indian children have among the highest incidence of malnourishment in the world (Table 5).
More than half (53%) of all girls and boys under 4 years were malnourished, and a similar proportion (52%) was stunted (too short for their age). Other studies show that many women never achieve full physical development 4 . This incomplete physical development poses the considerable risk for women of obstructed obstetric deliveries. underweight decreased from 18% to 16%. Stunting decreased by a larger margin, from 51% to 45%. Severe stunting also decreased from 28% to 22%. The decrease of stunting over time was greater in rural than urban areas but the prevalence of children who were underweight decreased slight more in urban areas than rural areas.

Indian women's health in summary
• It is of concern that the sex ratio in India has been declining consistently over the century • It is estimated that 16% of the population in rural areas lives more than 10 km from any medical facility 11 .
• Women in rural areas were much less likely to receive prenatal care than women in urban areas.
Most women who did not receive health care during pregnancy said this is because they thought it was unnecessary 9 .
• Every second woman in India suffers from some degree of anaemia; 2% are severely anaemic, while 35% and 15% have mild and moderate anaemia levels, respectively. Inter-state differences are pronounced 24 .
• Lack of adequate resources prevents women from poorer households using health services. Undernourished, ill-fed and overworked, most women from such households are extremely vulnerable to ailments and disease, which may not be properly diagnosed and treated. Poor sanitation, unhygienic surroundings and difficulty in procuring safe drinking water are some additional factors that affect the general health of women 24 .

Conclusion
Indian women, especially those in rural areas, need to be empowered to receive greater education and training. If this is utilised properly a woman will earn more money. As women earn more money they spend it to further the education and health of their children. As women rise in economic status, they will gain greater social standing in the household and the village, and will have a greater voice. As women gain influence and consciousness, they will make stronger claims to their entitlements. As women's economic power grows, it will be easier to overcome the tradition of 'son preference' and thus put an end to the dowry system. As son preference declines and acceptance of violence declines, the age of marriage will rise. As women are better nourished and marry later, they will be healthier, more productive, and will give birth to healthier babies.
Bishakha Dutta has said that women's health policy and programs need to work with potential allies such as women's groups, development groups, health workers' association and the media. Without a strong focus on the links between women's empowerment and women's health policy, programs may become like 'grass without roots' 27 . It is only through action to remedy discrimination against women that the vision of India's independence -an India where all people have the chance to live healthy and productive lives -can be realized.