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CHAPTER 4
WOMEN’S REPRODUCTIVE HEALTH

Programmes directed at women‘s health have been implemented in India since the
1950s. In the 1950s and 60s contraceptive services were delivered through the Family
Planning programmes. Women‘s maternal health was addressed through the regular primary
health care services. Thus the contraceptive and maternal health services were being provided
through two parallel programmes. From late 1970s to 1990s Government of India changed its
stance and tried to integrate and consolidate the different national programmes to address
women‘s health under one umbrella. The Family welfare programme in 1977 integrated
Family Planning with Maternal and Child Health programme. This was followed by the
World Bank and UNICEF funded Child Survival and Safe Motherhood Programme in 1992-
93, the Reproductive and Child Health programme in 1997-98, the National Rural Health
Mission in 2005 and finally the National Health Mission in 2013. India was one of the first
countries to launch a family planning programme as early as 1950s. The programme was
driven largely by demographic goals rather than women‘s health needs. With each of these
modifications, there was a shift in the way reproductive health concerns and needs,
particularly of women were conceptualized, articulated and addressed. The approach of
Government of India became more comprehensive with reduction in maternal mortality and
morbidity as its goal and client centred, quality oriented services as the cross cutting themes.
The concerted efforts led to improvements on some indicators of women‘s health. Yet, over
the years the improvements on health indicators have been far from the Millennium
Development Goals and the reproductive health of women in India continues to be a cause
for concern and public debate.

This chapter tries to summaries the status of women‘s reproductive health, over time,
in the state of Gujarat and in the districts in which the three PPP models were located. The
country level data is compared with that for neighbouring countries in the sub-continent
which are socio-culturally similar. The state level data on mortality, fertility, reproductive
health, nutritional status and utilization and quality of health services is from the National
Family Health Surveys (NFHS) and the District Level Household Surveys. This data for
Gujarat is compared to the national average, to the Southern State of Kerala as well as with
the western state of Maharashtra to understand where the state features in comparison to the
national average. Kerala and Maharashtra are considered as they represent the best
 79

performing State and the socio-culturally and economically similar neighbouring state
respectively.

The three PPP models belong to three different districts, Bharuch, Sabarkantha and
Surat. The reproductive health data for these three districts available in the public domain
was reviewed to explore the reproductive health status since focussed implementation of the
reproductive and child health programme in the district. This data is sourced mainly from the
State MIS and annual reports. The chapter also touches upon the existing government health
service delivery system and its performance in Gujarat and on the performance of three PPP
models in the context of women‘s reproductive health.

The analysed data is organised around five themes: the vital rates, reproductive health
needs of women, the care they sought and/ or received, the place of their seeking care and the
existing government health service delivery system and its performance.

4.2 Reproductive Health Scenario

Vital rates: Vital rates are critical for public health purposes and reflect the health
profile and adequacy of available health services. The three rates on which data over time
was available in public domain and which reflected the reproductive health of women were
Crude Birth rate (CBR), Total Fertility rate (TFR) and Maternal Mortality Rate (MMR). The
World Bank report in 1993 had claimed that almost a third of disease burden on women in
reproductive age group is related to child birth and reproductive tract infections (World Bank
1993). The gravity of this disease burden is evident in the MMR of that country.

All the three indicators showed improvement in India. Between 2010-2013, the CBR
declined from 21 to 20 per 1000 population, TFR from 2.6 to 2.5 and MMR from 220 to 190
per 1000 live births. This data for the country was compared with that for the four
neighbouring countries, Bangladesh, Bhutan, Pakistan and Sri Lanka which have similar
socio-cultural and demographic profile, to understand where India stands in the sub-continent
on these three indicators. As per the data from World Health Organisation, India along with
Bangladesh and Bhutan, two economically backward countries, showed a decline in CBR
from 21 in 2010 to 20 per 1000 population in 2013. Yet it had high (except Pakistan which
 80

had highest) TFR and despite a decline of 13.6 per cent since 2010, amongst the six countries
it had the highest MMR of 190 per 100,000 live births. (WHO 2013) (see Table 4.1).

Table 4.1: Vital Rates in India and its Neighbouring Countries in the Sub-continent

CBR TFR MMR

Country 2010 2013 2010 2013 2010 2013
Bangladesh 21 20 2.3 2.2 200 170
Bhutan 21 20 2.4 2.2 140 120
India 21 20 2.6 2.5 220 190
Nepal 23 21 2.6 2.3 220 190
Pakistan 27 25 3.4 3.2 190 170
Sri Lanka 18 18 2.3 2.3 32 29
Source: World Health Organisation (2013)

Table 4.2: Vital Rates in the Three States

CBR TFR MMR

India NFHS1 28.9 3.4 SRS 2007-09 212
NFHS2 24.8 2.9 SRS 2010-12 178
NFHS3 23.1 2.7 SRS 2011-13 167
Gujarat NFHS1 27.2 3.0 SRS 2007-09 148
NFHS2 24.3 2.7 SRS 2010-12 122
NFHS3 21.7 2.4 SRS 2011-13 112
Maharashtra NFHS1 26.3 2.9 SRS 2007-09 104
NFHS2 23.0 2.5 SRS 2010-12 87
NFHS3 18.8 2.1 SRS 2011-13 68
Kerala NFHS1 19.6 2.0 SRS 2007-09 81
NFHS2 18.8 2.0 SRS 2010-12 66
NFHS3 16.4 1.9 SRS 2011-13 61
Source:*: NFHS 1 1992-93. IIPS (1995); @: NFHS 2 1998-99. IIPS (2000);
#: NFHS 3 2005-06. IIPS (2007); €: SRS 2007-09. RGI, India (2011)
£: SRS 2010-12. RGI (2013); ¥: SRS 2011-13. RGI (2014)

The Sample Registration System indicated an impressive 45 per cent decline from
212 in 2007-09 to 115 per 100,000 live births in 2011-13, but the MMR remained higher
than the Millennium development Goal identified for the country at 109 per 100,000 live
births by 2015 (RGI 2013).

In Gujarat, Kerala and Maharashtra, the three states under consideration, over time
there was decline on all these three indicators. The decline was sharper in Maharashtra in
comparison to Gujarat and All-India. Gujarat had a CBR of 27.7 per 1000 population, TFR
of 2.4 and MMR of 148 per 1000 live births in 2007. On all three indicators it performed
better than the national average. As compared to Kerala and Maharashtra however, its
performance lagged behind. By 2007 Kerala and Maharashtra had achieved the MDG for
MMR. Despite a decline of 24.3 per cent from 2007 to 2013, Gujarat was still away from
 81

achieving the MDG (see Table 4.2).

Data from Indian sources showed that TFR was higher amongst the women from
―Low‖ Standard of Living Index (SLI) households and from SC/ST families as compared to
those from ―Medium‖ and ―High‘ or OBC and other Caste households. This data
corroborated a decline over years in the three indicators, particularly a larger decline in
MMR, but despite the decline over the years the gap between the different SLI categories
and Castes remained.

The programmatic efforts directed at women‘s health had succeeded in bringing down
the MMR but the profile of maternal deaths did not appear to have changed much. More than
one third (38%) of maternal deaths continued to be due to haemorrhage either in pregnancy
(Ante-partum) or after delivery (Post-partum), puerperal sepsis (11%), unsafe abortion (8%),
obstructed labour (5%) and hypertensive disorders of pregnancy including eclampsia (5%).
Other conditions such as Anaemia contributed to 34 per cent of maternal deaths (RGI 2006).
It is documented that for every maternal death, 16 women suffer from serious morbidities
(Datta et al. 1980). Majority of these deaths and morbidities are preventable with timely and
appropriate antenatal care and emergency obstetric services. The question therefore was
whether maternal health needs in specific and other reproductive health needs of women (Ex.
Contraception, RTIs/STIs, malnutrition and anaemia) were identified and managed in the
country and the three states for which data was analysed.

Reproductive health needs: Reproductive health needs of women are known to vary
during their life cycle and according to their marital and childbearing status. The data was
therefore reviewed for needs in the context of different phases of reproductive life of a
woman.

Early marriage and childbearing: Early marriage and childbearing are known to be
associated with special reproductive health needs. Physically incompletely developed body of
the woman as well as the longer span available for reproduction in a woman who is married
early, have implications for her reproductive health.

At the national level data from three consecutive National Family Health Surveys
(NFHS) (IIPS 1995; IIPS 2000; IIPS 2007) showed that there was a decline in the proportion
 82

of women 20 to 24 years of age getting married before the age of 18 years. Yet, 47.4 per cent
of these women (20-24 years of age) were married before the age of 18 years and 16 per cent
were either pregnant or mothers despite nation-wide focussed efforts to delay age at marriage
and first pregnancy. The median age at first childbirth showed marginal improvement at 19.8
years but remained below the recommended age of 21 years. With early marriage and
pregnancy, it was not surprising that 41 per cent women were multiparous (see Table 4.3). It
is estimated that adolescent girls (15-19 years of age) contribute to 16 per cent of the total
fertility and young women (15-24 years of age) contribute to 45 per cent of total maternal
mortality (IIPS 2010). NFHS data also showed that the situation was worse amongst under-
privileged women. Multi-parity was higher amongst the women from ―Low‖ Standard of
Living Index (SLI) households and from SC/ST families as compared to those from
―Medium‖ and ―High‘ or OBC and other Caste households.

Amongst the married women 20-24 years of age the percentage of those who were
married before the legal age at marriage (18 years) and age at first childbirth was consistently
higher in Maharashtra as compared to Gujarat and Kerala. However, over time there was
decline in this percentage and the decline was faster in Maharashtra. In Kerala the percentage
of women married before 18 years was half of that in Gujarat and Maharashtra. While the age
at first child birth in Kerala was already higher than the recommended age for first childbirth,
Gujarat was close to achieving it. It was therefore not surprising that very few women in
Kerala reported pregnancy or childbirth in adolescence. In both Gujarat and Maharashtra
about 13 per cent women reported pregnancy or childbirth in adolescence. Despite the
curtailed Obstetric span as fewer were getting married early or starting their obstetric career
in adolescence, multiparity was high. In Gujarat 37.9 per cent had 3 or more children as
compared to 26.9 per cent in Maharashtra and 18.7 per cent in Kerala (see Table 4.3).All
these women by virtue of their age at childbirth and parity are high risk, prone to
complications. The incidence of complications during child birth was therefore explored.

Complications associated with childbirth: Complications during postnatal period and

delivery are known to be leading causes of maternal deaths and morbidity. An analysis was
done of the incidence of complications during pregnancy and postnatal period. Over a period
of the three DLHS surveys there was an initial declining trend in both pregnancy and
postnatal complications between the first and second DLHS surveys but by DLHS 3 there
was again an upward trend in reporting of these complications. Contrarily, complications
 83

reported during delivery showed an initial increase and then decline. In DLHS3 more than
half (58.8%) women had reported complications during pregnancy, 61 per cent during
delivery and about 37 per cent had reported complications during the postnatal period (see
Table 4.3).

Amongst the three states, reported pregnancy complications were higher in Kerala
than the other two states and the national average but less than one fourth of the surveyed
women in Kerala reported complications during or after delivery in the postnatal period.
Similarly in Maharashtra, complications during all three phases of child bearing were higher
than national average as well as those reported in Gujarat (see Table 4.3). A study in
Gadchiroli district in Maharashtra supported the DLHS 3 findings related to complications
during postnatal period. Postnatal complications such as postpartum haemorrhage and
infections were reported by 42.9 per cent women (Bang [Link]. 2004).

The percentage of women reporting complications during pregnancy was even higher in
other studies and large surveys. In the UNICEF survey in 2009, 72 per cent of women had
complications during pregnancy. The frequently reported complications were giddiness (37.6%),
oedema over face and feet (29.4%), vomiting (28.1%), fatigue (25.4%), visual problems (12.5%)
and loss of foetal movements (10.8%). The proportion was similar to a study conducted almost a
decade earlier which had reported 25 to 31 per cent women with nausea and vomiting and 21-27
per cent with oedema and anaemia (Das and Shah 2001) during pregnancy. In this study more
than 75 per cent women reported vaginal discharge, bleeding and backache after delivery,
signs and symptoms indicative of infection after delivery. Almost all these complications are
manageable with good quality care during the three phases of child birth.

Unmet need for contraception: Despite near universal awareness about contraceptive
methods, more than a tenth of the women in reproductive age group had unmet need for
contraception. Unmet need for contraception has shown a decline across nation. The unmet
need for contraception showed a decline from 19.5 per cent in 1992-93 to 8.5 per cent in
1998-99 and again rose to 14.1 per cent in 2005-06 (IIPS 1995; IIPS 2000; IIPS 2007). It was
higher amongst the women from ―Low‖ Standard of Living Index (SLI) households and from
SC/ST families as compared to their counterparts and despite decline over the years the gap
between the different SLI categories and Castes was constant.
 84

Unmet need in Gujarat declined from 11.3 per cent to 7.9 per cent and was lower than
both the national average and unmet need reported for Maharashtra (9%). In Maharashtra
unmet need was found to be not only higher but also stagnant. Studies conducted in rural
areas and urban slums in Maharashtra put the unmet need at even higher level. A study in
rural areas of Thane district estimated unmet need for contraception at 44.1 per cent largely
contributed by unmet need for spacing (23.7%) (Solanki et al. 2014).

Reproductive Tract Infections: Early marriage and initiation into sexual activity
without adequate protection and knowledge about preventive measures are known to
contribute to the vulnerability of women to un-intended and unwanted pregnancies and
Reproductive Tract Infections (RTIs). A little less than one third of the women (31.6%)
reported signs and symptoms suggestive of RTIs. The percentage of women reporting signs
and symptoms of RTIs remained more or less same over the 10 year period between DLHS1
(29.7%) in 1998-99 and DLHS3 (31.6%) in 2007-08 (IIPS 2001; IIPS 2006; IIPS 2010).

The reporting of RTIs was found to be highly variable across states as majority of the
data is self-reported. In large studies without adequate rapport building, the data could be
under-reported as the signs and symptoms of these diseases are still associated with stigma
and shrouded in culture of silence. In a study in urban areas of Hubli based on self-reported
symptoms the prevalence of RTIs among women in reproductive age group was found to be
40.4 per cent, based on clinical finding it was 37.4 per cent and based on laboratory test it
was 34.3 per cent (Balmurugan and Bendigiri 2012). In Tamil Nadu more than half the
interviewed women (53%) were symptomatic, 38 per cent had laboratory confirmed RTIs and
14 per cent of these were clinically diagnosed cases of RTIs (Prasad 2005).

In both Gujarat and Maharashtra, after initial increase between DLHS1 and DLHS2,
by DLHS3 there was a decline in women reporting signs and symptoms suggestive of RTIs.
The percentage in Gujarat came down from 37.6 at DLHS2 to 26.4 at DLHS3. However, here
too a number of smaller more focussed studies have reported a much higher prevalence of
RTIs. In 2010 in a study in slums of Rajkot in Gujarat, 57 per cent of women reported
reproductive morbidity including RTIs in 2010 (Bhanderi and Kannan 2010). In
Surendranagar in 2013, 56.5 per cent of women were found to have signs and symptoms
suggestive of reproductive tract infections (Thekdi et al. 2013). In Maharashtra the reporting
was dramatic. Bang [Link] reported 92 per cent prevalence of gynaecological problems in rural
 85

areas of Gadchiroli district in Maharashtra and reproductive tract Infections were reported to
contribute to half of this morbidity.

Malnutrition and Anaemia: India has large number of malnourished people.

According to ―The State of Food Insecurity in the World 2012‖ 217 million people in the
country are malnourished (FAO 2012). The burden of malnutrition in women is likely to be
higher amongst women than men. Malnutrition and anaemia in women are known to pose a
risk to their overall health, particularly during child bearing.

To understand the prevalence of these problems, two aspects of nutritional needs of

women were studied - their Body Mass Index (BMI) and Anaemia status. A BMI below 18.5
is considered to be suggestive of under nutrition, 17.0-18.4 as mild and <17.0 as moderate or
severe undernourishment. As per NFHS 3, 57.4 per cent of the women were anaemic and
40.6 per cent women had BMI below 18.5 suggestive of malnourishment. While the
proportion of women with low BMI remained unchanged, proportion of women with
Anaemia showed an increase in the period between NFHS2 and NFHS3. More than one third
of these women were found to be mildly anaemic (39%), 16 per cent moderately and two per
cent were severely anaemic. Further, the prevalence of anaemia was found to be higher
among rural, illiterate, poor, pregnant and multiparous women (see Table 4.3). More women
from Low‖ SL and SC/ST were found to have BMI less than 18.5 and Anaemia. By NFHS3
there was further overall deterioration in the nutritional status of these women in terms of
BMI below 18.5 and Anaemia prevalence

In Gujarat the percentage of women with low BMI and Anaemia was higher than
national average and Kerala. The proportion of women with low BMI was similar to
Maharashtra, but the proportion women with Anaemia was higher. In Kerala less than one
third of women were reportedly Anaemic and only 12.5 per cent had low BMI indicative of
under-nutrition (see Table 4.3).

Incomplete physical development, short stature, anaemia, early marriage and child
bearing are identifiers of women at risk for difficult delivery and are critical determinants of
maternal mortality. These reflect the inherent reproductive health needs of these women.
Along with unmet need for contraception and the outcome of high risk sex presenting as RTIs
and STIs, they have implications for reproductive health of women and need to be addressed
 86

to focussed reproductive health care. It was therefore important to know how women deal
with these reproductive health needs and where do they go for care.

Reproductive health seeking: Do women receive the needed care was the next issue
looked at. The services women received for each of the identified health issue were explored.
Data from DLHS, State MIS and independent studies was used for the purpose.

Antenatal care: Data on routine care during pregnancy, delivery and postnatal period
showed that though antenatal registration was high, quality and continuum of care was poor.
About 75 per cent of the pregnant women had registered for antenatal care and of that 45 per
cent of these pregnant women had registered in the first trimester itself. Majority (73.4%)
women had received TT injections, 49.7 per cent had three or more check-ups and 46.9 per
cent had received Iron Folic Acid (IFA) tablets during pregnancy. Despite this, less than one
fifth (18.8%) of these women had received the recommended ―Full‖ antenatal care 4. There
was some improvement in quality of care over years. Percentage of women who reported
early registration in first trimester and receipt of recommended Iron Folic Acid tablets
showed an increase in the five year period between DLHS2 and DLHS3, yet ―Full‖ antenatal
care remained more or less similar as the receipt of TT injections had decreased (see Table
4.4). Fewer women from ―Low‖ SLI and SC/ST households reported antenatal care
registration as compared to their comparative counterparts from other SLI categories and
castes. The gap between SLI categories and castes for health seeking during antenatal period
continued.

A survey by UNICEF in 2009 again underlined the poor quality of antenatal care. It
showed that a vast majority of (90.4%) pregnant women had received some antenatal care, 81
per cent had received IFA tablets, 31 per cent had consumed these but only 26.5 per cent had
received the recommended ―Full‖ antenatal care (Urban: 36.1%, Rural: 22.8%)

4
―Full‖ antenatal care: 3 Antenatal check-ups, 2 TT injections and 100 IFA tablets
 87

Table 4.3: Women’s Health Care Needs (In %)

India Gujarat Maharashtra Kerala

NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3#
92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06
High risk mothers
<18 (in 20-24 yrs) 54.2 50.0 47.4 33.4 40.7 38.7 53.9 47.7 39.4 19.3 17.0 15.4
[Link] 1st birthin yrs 19.4 19.3 19.8 20.2 20.1 20.6 19 19 19.9 21.6 21.9 22.7
Childbirth 15-19yrs NA NA 16.0 NA NA 12.7 NA NA 13.8 NA NA 5.8
Birth order of >=3 49.6 45.2 41.1 41.8 40.9 37.9 42.7 39.1 26.9 25.8 21.0 18.7
DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3&
98-99 02-04 07-08 98-99 02-04 07-08 98-99 02-04 07-08 98-99 02-04 07-08
Complications associated with childbirth
Pregnancy 63.6 34.2 58.8 66.5 35.2 47.9 69.1 46.8 58.2 80.4 47.5 63.6
Delivery 37.0 40.0 61.2 76.0 43.3 47.3 56.0 74.1 65.0 28.8 30.2 24.0
Postnatal period 44.4 31.4 36.8 49.7 25.5 25.6 54.6 35.4 38.7 28.2 18.3 21.5
NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3#
92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06
Nutritional Status of Women
BMI <18.5 NA 36.2 33.0 NA 47.7 45.5 NA 49.3 45.6 NA 18.7 12.5
Anaemia NA 51.8 56.2 NA 51.3 58.7 NA 51.2 50.6 NA 22.7 32.7
Source: *: NFHS I 1992-93. IIPS (1995); @: NFHS II 1998-99. IIPS (2000); #: NFHS III 2005-06. IIPS (2007)
$: DLHS I 1998-99. IIPS (2001); ^: DLHS II 2002-04. IIPS (2006); &: DLHS III 2007-08. IIPS (IIPS 2010)
 88

Table 4.4: Women’s Maternal Care Seeking (In %)

India Gujarat Maharashtra Kerala

DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3&
98-99 02-04 07-08 98-99 02-04 07-08 98-99 02-04 07-08 98-99 02-04 07-08
Antenatal care
ANC reg. 65.3 73.4 75.2 79.1 87.6 71.5 87.6 92.9 91.8 99.3 99.7 99.8
Early reg. 29.7 40.2 45.0 36.5 47.1 52.3 41.0 51.7 61.6 83.2 89.3 95.6
>=3 ANC 44.2 50.0 49.7 55.0 61.4 54.8 65.8 72.0 74.4 98.3 96.8 95.2
2 TT inj 74.7 80.1 73.4 77.9 85.9 68.4 89.5 90.9 89.5 95.7 95.4 98.5
IFA tablets 48.7 20.4 46.9 68.1 30.2 50.7 76.8 28.1 45.7 90.0 73.6 73.3
‗Full‘ ANC 31.8 16.4 18.8 42.7 25.8 19.9 54.8 23.0 33.9 86.1 69.3 72.2
Institutional delivery
Inst. Delivery 34.0 41.0 47.0 46.1 52.5 56.4 57.1 58.3 63.5 97.0 97.8 99.4
Del @ Gvt fac 51.2 46.3 NA 31.0 24.4 NA 47.1 41.7 NA 39.3 34.8 NA
Del @ Pvt fac 48.8 53.7 NA 69.0 75.6 NA 52.9 58.3 NA 60.7 65.2 NA
Postnatal care
PNC@<=6 wks NA 40.8 15.6 NA 39.5 20.0 NA 33.8 22.4 NA NA 99.5
Source:$: DLHS I 1998-99. IIPS (2001); ^: DLHS II 2002-04. IIPS (2006); &: DLHS III 2007-08. IIPS (IIPS 2010)

Table 4.5: Contraceptive Acceptance (In %)

India Gujarat Maharashtra Kerala

NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3#
92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06
Modern methods 36.5 42.8 48.5 45.7 62.1 55.5 53.8 53.3 65.8 54.4 56.1 57.9
Tubectomy 27.4 34.1 37.3 37.5 43.0 42.9 40.0 48.5 51.1 41.8 48.5 48.7
Vasectomy 3.5 1.9 1.0 3.5 2.3 0.6 6.2 3.7 2.1 6.5 2.5 1.0
IUD 1.9 1.6 1.7 3.0 3.1 4.4 2.5 1.9 3.0 2.7 1.6 2.3
Condom 2.4 3.1 5.2 1.8 3.5 5.8 2.5 4.0 6.2 2.9 3.1 5.5
Oral Pills 1.2 2.1 3.1 1.0 1.5 2.6 1.4 1.7 2.4 0.5 0.4 0.4
Source: *: NFHS I 1992-93. IIPS (1995); @: NFHS II 1998-99. IIPS (2000); #: NFHS III 2005-06. IIPS (2007)
 89

Amongst the three states, in Kerala close to three fourth of the women in DLHS3
survey reported receipt of ―Full‖ antenatal care. Neither Gujarat nor Maharashtra were
anywhere close achieving that level of antenatal care seeking. The percentage of women
registered for antenatal care in Gujarat showed an improvement in 2002-04 but declined in
2007-08 to a level below the national average. Gujarat‘s performance on all indicators of
antenatal care barring receipt of IFA tablets was lower than Maharashtra and significantly
lower than Kerala (see Table 4.4).

The findings related to poor antenatal care in Gujarat were confirmed by small,
independent studies. A study in Santrampur and Adesar block in 2013 showed that less than
50 per cent of the pregnant women had received antenatal care and only 16 per cent had
received the recommended three antenatal check-ups (JSA. 2014). NGO members of Jan
Swaasthya Abhiyan (JSA) in Gujarat claimed that in their work areas they found that
disadvantaged women i.e. from rural and urban slum areas, SC/ST community, ―Low‖ SLI
households, and illiterate women were five times less likely to have received recommended
antenatal care (JSA. 2014). Moreover assessment of antenatal care coverage on the basis of
―Full‖ care masked the actual quality of care received by women. Most women were not
physically examined, given any health education, counselled about high risk conditions or
provided with any birth plan during these antenatal contacts.

Delivery care: The proportion of deliveries taking place in institutions showed a

slow and steady increase since 1998. It increased from 34 per cent to 47 per cent. The
trajectory of improvement in institutional deliveries was confirmed by the UNICEF survey
in 2009 (UNICEF 2010). The survey reported a significantly high 72.9 per cent deliveries
taking place at institutions. Fewer women from ―Low‖ SLI and SC/ST households had
institutional delivery as compared to those from ―High‖ SLI categories and ―Other‖ castes.
As in case of other health seeking, the gap continued despite improvement in institutional
deliveries as a whole.

In Kerala institutional delivery was almost universal. Institutional delivery showed

a slow and steady increase in Maharashtra and in Gujarat (see Table 4.4). Smaller studies
in Gujarat in the recent past have reported about majority of deliveries taking place in
institutions. In Santrampur and Adesar blocks in Gujarat (JSA 2014) 81.4 per cent of
deliveries were reported to have taken place in institutions.
 90

Last 10 year data from the Gujarat state MIS for institutional delivery highlights the
steady increase in the proportion of deliveries taking place at institutions (see Graph 4.1)
(Appendix 4.1).

Graphs 4.1: Institutional Deliveries 2000-13, Gujarat (In %)

92
84 86
80
71 73

59
52 53 53

36 37 37 37

Source: State MIS Data. Government of Gujarat

Place of care: The contribution of private facilities showed a steady increase over
time and was highest in Gujarat. By 2002-04 three fourths of the institutional deliveries
were taking place at private facilities, much higher than Kerala (65.2%) and Maharashtra
(58.3%) (see Table 4.4). Studies in Gujarat confirmed the preference for private facilities.
A study by six NGO partners in JSA confirmed fewer deliveries at government facilities.
It reported that only 24 per cent of the deliveries took place in government institutions.
Rest of the deliveries took place in private and Chiranjeevi facilities (JSA 2014). An
evaluation of the 2013-2014 Project Implementation Plan for Sabarkantha district reported
96 per cent of the deliveries in the district taking place in institutions and of these a large
number had taken place in private facilities (Gujarat: 56.5%, Sabarkantha: 71.6%) (Desai
et al. 2013).

The state MIS provided a different picture. It reported that of the institutional
deliveries, the increase has been slow and consistent in government facilities. Improvement in
deliveries at the private facilities surged after 2007 but thereafter remained stagnant at around
43-44 per cent and in 2013 the proportion of deliveries taking place at government facilities
surpassed those taking place at private facilities (see Graph 4.2). This coincided with the
 91

recommendation of the Common Review Mission (CRM 2011) of the National Rural Health
Mission (Now known as National Health Mission or NHM) to use the government facilities
for the purpose as most of these were found to be adequately equipped to conduct deliveries
(De Costa 2014). However, the deliveries at Chiranjeevi facilities could be accounted for
under government institutions.

Graph 4.2: Deliveries at Government and Private Institutions, Gujarat (In %)

Government facility Private facility

55

43 44 45
40 40 41 41
37 37
33
29 29 30 30 29 31
23 23 24

Source: State MIS Data. Government of Gujarat

Postnatal care: Though the deliveries taking place in institutions showed

improvement, there was no commensurate improvement in postnatal care. Rather, as
compared to DLHS 2, DLHS 3 figures for the country showed a sharp decline in receipt of
postnatal care within six weeks of delivery (see Table 4.4). The UNICEF coverage
evaluation survey differed in its findings. It showed that postnatal care within 10 days of
delivery was received by as many as 60 per cent of the women (UNICEF 2010). Postnatal
care amongst underprivileged women from ―Low‘ SLI families and SC/ST households
showed improvement.

Similar to the institutional delivery, postnatal care within 6 weeks of delivery was
near universal in Kerala. Both in Maharashtra and Gujarat about one fifth or a little more
women reported receipt of postnatal care though more than half the women had institutional
delivery. In Gujarat, the studies done by NGO members of JSA confirmed poor postnatal care
of women. The JSA members claimed that in their areas postnatal care was almost non-
existent. The data for the period 2006-09 from MNGO scheme implementation in select
 92

districts of Gujarat also supported the poor postnatal care in the state. It found that less than
one third of the women received postnatal care within six weeks of delivery.

Achievement of targets: (see Appendix 4.2) Though there are no explicit maternal
health and contraceptive targets for achievement, Gujarat State health system does expect a
certain level of performance based on the estimated population needs for specific health care.
Performance of the programmes is assessed on select indicators against these targets. Data for
last 15 years showed that despite all these infrastructural shortcomings and perceptions, on
most indicators related to antenatal care and postnatal care, programme has consistently
achieved more than 80 per cent of the target. Institutional deliveries showed a steady
improvement in target achievement over the last decade and a half in the State. The data also
showed that on antenatal registration and postnatal care, the performance has shown an
increase since 2012). Receipt of TT injections and early registration have shown some
decline in the same period. This performance is consistent with the reported early
registration for antenatal care and receipt of two TT injections in the DLHS surveys (see
Graph 4.3).
Graph 4.3: Maternal Care Achievement, Gujarat (In %)

100
95
90
Percentage achievement

85
ANC registration
80
Early registration
75
Receipt of TT
70
Institutional delivery
65
Postnatal care
60
55
50
2001

2014
2000

2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013

Source: State MIS data. Government of Gujarat

 93

Contraceptive acceptance: As far as seeking contraceptive service are concerned,

even after six decades of family planning programme and interventions, 48.5 per cent of
women in the reproductive age group reported acceptance of modern contraceptives. Of the
modern methods of contraception, acceptance of female sterilisation showed an increase.
There was also a marginal increase in acceptance of spacing methods particularly condoms
but the overall acceptance was still around 10 per cent and acceptance of male methods was
negligible (6.2%) (see Table 4.5). Contraceptive acceptance amongst under-privileged
women remained low and stagnant between the two national surveys.

In all three states there was in increasing trend in modern contraceptive method
acceptance in the period between DLHS1 and DLHS2 and after that there was either
stagnation or marginal decline in acceptance. The acceptance of modern methods was highest
in Maharashtra and lowest in Gujarat and was largely contributed by female sterilisation. In
Maharashtra the percentage of condom use and vasectomy and in Gujarat use of oral pills as
proportion of use of modern method was higher than the national average (see Table 4.5).

Gujarat State MIS data for last 15 years showed different figures. There was a
marginal decline in contraceptive acceptance. The data however confirmed that sterilisation
was the major contributor to contraceptive prevalence and its acceptance along with that of
IUDs had remained more or less steady. Acceptance of condoms and oral pills however
showed either stagnation or some decline, particularly since 2011 (see Graph 4.4).

Graph 4.4: Family Planning Use, Gujarat (In %)

60
55
50
Percent accepators

45
40 CPR
35 Sterilisation
30
25 IUD
20
15 Condom
10 Oral pills
5
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013

Source: State MIS Data. Government of Gujarat

 94

The achievement of contraceptive targets mirrored the picture of stagnant or marginal

increase in acceptance of contraceptives as reported in national surveys. There was some
improvement in achievement of targets for condoms and oral pills but the targets themselves
were set at a very low level thus making it easier to achieve those (see Graph 4.5).

Graph 4.5: Family Planning Achievement, Gujarat (In %)

110
105
Percenatge Achievement

100
95
90
85 Sterilisation
80
75 IUD
70
65 Condom
60
55 Oral pills
50
45
40
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Source: State MIS data. Government of Gujarat

Curative care: Curative care was assessed on two parameters, care for maternal
complications and infections in women. Data showed that seeking of care for complications
during pregnancy and complications after delivery had increased over the time period of the
three DLHS surveys. More than half of those who had complications during pregnancy and in
the postnatal period actively sought treatment for these.

The seeking of care for pregnancy and postnatal complications was highest in Kerala
followed by Maharashtra and then Gujarat. In all three states seeking of care for these was
notably higher than national average and showed an increase over the period of the three
DLHS surveys. Of the women who had reported signs and symptoms suggestive of
Reproductive Tract Infections, 40.7 per cent had sought treatment. The percentage of those
seeking care showed an increase between DLHS2 and DLHS3 (see Table 4.7).

The trend in seeking treatment for RTIs and STIs was slightly different. More than
half the women in Kerala and Maharashtra and about one third sought treatment for these in
Gujarat. In Gujarat the percentage of women with RTIs seeking treatment showed a decline
in DLHS3 (see Table 4.6). A study in urban slums in Gujarat reported similar findings. The
study reported that one third of the women who had these problems had sought treatment for
 95

these (Bhanderi and Kannan. 2010). Thus, the data indicated that women had started to pro-
actively seek care for their varying health needs. The next question was which health
facilities did they opt for the purpose and why?

Place of health seeking: While seeking of care definitely improved over time, the
facility where women sought care differed according to the reproductive health needs they
sought the care for. Almost two thirds of the women in the country sought care at private
facilities in case of general ailments. For RTIs, though only one fourth of the women reported
seeking care at private facilities, this percentage was higher than those seeking treatment at
government facilities and the trend was consistent across surveys. At the national level
women seemed to prefer government facilities for antenatal care and contraceptive services.
More than three fourths of the women, across the three NFHS surveys were found to opt for
contraceptive services at government facilities (see Table 4.7). Though the percentage
showing preference for seeking care at private facilities was lower amongst ―Low‘ SLI and
SC/ST families as compared to those from other castes and SLI categories, women showed
clear preference for private facilities for both antenatal care and institutional delivery in the
DLHS2 data. The difference was more marked for institutional delivery.

In all three states similar trend was visible for preferred place for reproductive care
seeking. In Gujarat and Maharashtra women preferred private facilities for treatment of
general ailments and RTIs and STIs. The preference for government facility for contraceptive
supplies and services was evident even at state level. For antenatal care the preference for
both private and government was similar in Gujarat and Maharashtra but in Kerala there was
a clear preference for private facilities even for antenatal care (see Table 4.7).

What made women opt for different facilities for different reproductive health needs,
that was the next aspect of reproductive health seeking which was explored.
 96

Table 4.6: Curative Care for Reproductive Health Problems (In %)

India Gujarat Maharashtra Kerala
DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3&
98-99 02-04 07-08 98-99 02-04 07-08 98-99 02-04 07-08 98-99 02-04 07-08
Complications associated with childbirth
Pregnancy 46.7 50.6 55.3 59.8 54.3 61.5 71.1 73.2 76.6 86.3 76.7 85.7
Postnatal 46.6 50.2 57.7 51.2 55.3 59.7 64.9 64.4 71.9 80.8 72.0 83.2
Reproductive Tract Infections
Tt. sought 37.6 32.4 40.7 36.1 25.1 33.5 47.9 39.2 50.7 50.8 41.4 52.6
Source:$: DLHS I 1998-99. IIPS (2001); ^: DLHS II 2002-04. IIPS (2006); &: DLHS III 2007-08. IIPS (IIPS 2010)

Table 4.7: Preferred Place of Care (In %)

India Gujarat Maharashtra Kerala

NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3#
92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06
General ailments
Govt fac NA NA 34.4 NA NA 35.2 NA NA 36.8 NA NA 52.0
Pvt fac NA NA 65.5 NA NA 64.8 NA NA 63.2 NA NA 48.0
DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3& DLHS1$ DLHS2^ DLHS3&
98-99 02-04 07-08 98-99 02-04 07-08 98-99 02-04 07-08 98-99 02-04 07-08
Antenatal care
Govt fac 31.6 32.6 54.4 23.9 22.9 38.7 41.2 40.1 43.8 35.8 34.0 39.3
Pvt fac 26.2 34.4 36.4 37.9 50.3 48.3 37.9 49.7 46.1 65.6 66.7 67.7
Delivery care
Govt fac 17.3 30.2 NA 14.2 12.7 NA 26.9 24.1 NA 38.0 NA NA
Pvt fac 16.6 40.8 NA 31.8 39.5 NA 30.1 33.8 NA 58.9 NA NA
NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3# NFHS1* NFHS2@ NFHS3#
92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06 92-93 98-99 05-06
Contraceptive services
Govt fac 87.0 83.2 78.2 82.2 85.5 83.8 87.8 86.7 83.5 76.0 66.4 62.0
Pvt fac 13.0 17.8 21.8 17.7 14.5 16.2 12.2 13.3 16.5 24.0 33.6 38.0
Treatment for RTIs
Govt fac NA 10.0 NA NA 9.8 NA NA 11.1 NA NA 13.6 NA
Pvt fac NA 24.1 NA NA 19.3 NA NA 32.7 NA NA 31.6 NA
Source:*: NFHS I 1992-93. IIPS (1995); @: NFHS II 1998-99. IIPS (2000); #: NFHS III 2005-06. IIPS (2007); $: DLHS I 1998-99. IIPS (2001); ^: DLHS II 2002-04. IIPS
(2006); &: DLHS III 2007-08. IIPS (IIPS 2010)
 97

Reason for preference for place of care: Almost two thirds of the women in the
NFHS3 survey mentioned that government facilities are not their first choice for routine care.
The two predominant reasons listed were perceived poor quality of care at the government
facilities and their distance from women‘s home. One third of the women complained about
hygienic standards at the government facilities, 27.1 per cent about staff behaviour, 24.8 per
cent about long wait and 21.6 per cent about lack of respect for their privacy. All these
factors deterred these women from seeking care at government facilities. (see Table 4.8)

In Gujarat and Maharashtra more than 70 per cent women said that in general they did
not use government facilities. A comparison with Maharashtra showed that fewer women in
Gujarat blamed poor behaviour of staff and lack of hygiene and cleanliness at government
facilities for avoiding them as places of care. Two main reasons in Gujarat were distance of
facilities (45%) and poor quality of services at government facilities (42.6%). More women
in the state as compared to national average talked about long wait and inconvenient timings
(see Table 4.8).

Table 4.8: Reasons for Not Seeking Care at Government Facilities (In %)

India Gujarat Maharashtra Kerala

Do not use government facility# 65.5 72.5 70.3 50.0
Poor quality of care# 57.7 42.6 56.4 34.0
Not close by# 46.8 45.0 37.5 48.0
Long waiting time# 24.8 31.6 30.1 26.0
Timings not convenient# 13.1 16.0 16.1 21.0
Health staff not available# 9.2 6.9 5.3 6.0
Facility lacks cleanliness@ 32.9 10.0 16.8 12.0
Staff behaviour not nice@ 27.1 6.8 15.4 4.8
Privacy is not respected@ 21.6 8.1 5.8 3.5
Do not receive the services@ 5.1 1.9 2.3 0.3
Source:@: NFHS II 1998-99. IIPS (2000); #: NFHS III 2005-06. IIPS (2007)

The MNGO study in Gujarat confirmed distance of government facilities being a

deterrent. Women complained about the distance to the health facility. They also faced
problems in securing transport to go to the place of care. In some villages women had
reservations about calling 108 for transport to health facility for delivery. The 108s usually
come with blaring sirens. Women did not like this public announcement of their being in
labour. They were unhappy about this lack of sensitivity in the government managed
services. Smaller studies highlighted additional reasons for avoidance of government services
in Gujarat. In the experiences narrated by NGO partners of JSA, women had serious
grievances about government facilities. They claimed that 108 drivers charged them and that
 98

is why only 18.7 per cent use this facility. They also said that facility staff did not release
their government scheme payments without bribes being paid to the staff and the staff often
appropriated the Take Home Ration meant for the women.

To understand women‘s preferences and grievances in their context, the status of

government health care delivery system was studied.

Government health facilities: Government facilities offer care through a three

tier structure of Subcentres, Primary Health Centres and Community Health Centres.
Data from DLHS3 facility survey was analysed to understand the facility availability,
accessibility and preparedness to address women‘s health needs.

Subcentres: At the most peripheral level are the Subcentres. Each Subcentre is
expected to serve a population of 5000 in the plains and 3000 in tribal and hilly areas. As
per Indian Public Health Standards, 2012, each Subcentre is to be manned by two ANMs
and one Male Health Worker and has to provide services related to maternal and child
care, immunization, family planning, national programmes and other primary health
care.

Data showed that Subcentres in these three states served population much in
excess of their mandate. Most Subcentres across the three states had more than 60 per
cent of the recommended equipment and almost two thirds of them had requisite
essential drugs and functional labour rooms. Though majority (96.7%) of these
Subcentres had ANMs in position, only 57.9 per cent of the ANMs stay at headquarters.

The population served by Subcentres in Maharashtra was four times the

recommended population under jurisdiction of each Subcentre. Interestingly, though the
population under their jurisdiction was significantly more in Maharashtra, accessibility
of Subcentres in villages, availability of ANMs and functional labour rooms at the
Subcentres was higher. Majority of the Subcentres in Gujarat had the requisite
infrastructure in terms of equipment and manpower. As compared to national average
and Maharashtra, Gujarat fared poor on two indicators, ANM staying at headquarters and
availability of functional labour room. On the other hand, in Kerala more villages
reported availability of Subcentres and more Subcentres reported ANM at headquarters
 99

but fewer had needed equipment and none reported functional labour room (see Table
4.9).

Primary Health Centres: The Primary Health Centre (PHC) is meant to serve a
population of 30000 in plains and 20000 in tribal and hilly areas. It is the referral unit for
6 Sub-Centres. Its staff includes one MBBS and one AYUSH medical officer, staff
nurses, health assistant (female and male), female health workers, health educator,
laboratory technician, pharmacist, data entry operator and a class IV staff. It is expected
to have 6 beds for indoor care and facilities to take care of a caseload of 40 patients per
day. It has to provide OPD, IPD and emergency reproductive and child health services
and services related to national programmes.

Data shows that the PHCs also served more population than what they are
expected to serve. Three fourths had Medical Officer in position but only one fourth had
Lady Medical Officer in position. Two thirds had the necessary drugs and equipment
and more than half (52.7%) of them were designated 24X7 PHCs. Though almost all had
functional labour room and 61 per cent had functional operation theatre, only half the
centres reported conducting 10 or more deliveries a month.

Maharashtra appeared to be best equipped to serve people with mandated

facilities and services. More than three fourths of the PHCs in Maharashtra were 24X7,
had MOs in positions and necessary infrastructure. Comparatively Gujarat had
significantly fewer 24X7 PHCs, MOs in position and functional operation theatres. A
little more than one fourth (29.3%) conducted deliveries. The PHC infrastructure in
Kerala barring MOs in position was worst of the three states. Not a single PHC reported
deliveries being conducted at the facility (see Table 4.9).

Community Health Centre: A Community Health Centre (CHC/Rural Hospital) for a

population of one lakh. With 30 indoor beds, operation theatre, labour room, x -ray, ECG and
laboratory facility it is expected to provide emergency services and general outpatients (OPD)
and inpatients (IPD) services for surgery, obstetrics & gynaecology, paediatrics, dental and
AYUSH patients. To provide the routine, specialist and public health services, it is expected
to have a staff that includes a Block Medical Officer, a public health specialist, a public
health nurse, a general surgeon, a physician, an obstetrician, a paediatrician, an anaesthetist, a
 100

dental surgeon, two general duty and an AYUSH medical officer. The nursing staff has to
have 10 staff nurses, two pharmacists (1 AYUSH), two lab technicians, one radiographer ,
one dietician, one ophthalmic, dental and cold chain and vaccine logistic assistant each, one
Operation Theatre (OT) technician and one counsellor , supported by an administrative staff
of 13 people.

The CHCs too were found to serve larger population. Almost two thirds had
functional operation theatre but one fourth or less had the requisite staff (Obstetricians and
Anaesthetists) to utilise these facilities to provide surgical services. Two thirds or more of the
CHCs in the sample had functional operation theatres and were designated FRUs but only 10
per cent had the required specialists in position to make use of the facilities and infrastructure
available. CHCs in Gujarat served the number of people they were expected to. Situation in
Kerala was worst(see Table 4.9).

The data from DLHS 3 indicated the gaps in infrastructure and service delivery in
Gujarat at the time of the survey, 15 years data from the State MIS was analysed to see if
there were any changes since then. Annual data from the Government of Gujarat confirmed
that the Subcentres, PHCs and CHCs were in reality serving a much larger population than
that specified under the IPHS. Data for the last 15 years showed that the Subcentres on an
average served a population of more than 7000, the PHCs served a population of more than
40,000 and the CHCs a population of more than 1.6 lakhs.
 101

Table 4.9: Subcentres, PHCs and CHCs

India Gujarat Maharashtra Kerala

Subcentres
Average population served 8372 7234 20182 5994
Villages with Subcentres 41.0 39.2 37.5 99.6
ANMs posted 90.7 94.7 93.0 97.6
ANM at headquarters 57.9 37.8 71.5 53.3
Functional labour room 63.0 29.4 74.7 0.0
Adequate equipment (60%) 83.5 98.0 92.6 77.6
Essential drugs (60%) 65.3 94.1 86.8 96.4
Primary Health Centre
Average population served 49193 38171 45267 29683
24X7 PHCs 52.7 46.9 78.1 10.3
MO posted 75.8 62.2 90.8 85.0
Lady Medical Officer posted 24.4 11.6 30.8 6.1
Functional OT 61.3 74.1 81.5 1.4
Essential drugs (60%) 69.6 87.4 85.7 74.0
Conducts >=10 deliveries 49.9 29.3 46.8 0.0
Community Health Centre
Average population served 128356 90765 123096 118654
Designated FRU 52.0 74.1 58.7 18.0
Functional OT 65.2 65.6 84.6 26.3
Obstetrician posted 25.2 11.3 40.3 14.3
Anaesthetist posted 17.1 9.4 27.0 2.3
Source: DLHS III 2007-08. IIPS (IIPS 2010)

Gujarat state MIS data was also analysed to see how the ever increasing population
under their jurisdiction affected the caseload at government centres (see Appendix 4.3). Data
showed a shift of cases from primary to secondary level of health services. Caseload at the
PHCs Out-Patient‘s Department (OPD) showed a decline and at In-Patient‘s Department
(IPD) was more or less stable at 7 patients on any given day till 2012, thereafter it showed a
decline (see Graph 4.6).

Graph 4.6: Average Daily OPD/IPD at PHCs, Gujarat

60
50
Number of patients

40
30 PHC OPD
20 PHC IPD
10
0
2014
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013

Source: State MIS data. Government of Gujarat

 102

Caseload at the CHC OPD and IPD, however showed an increase. While the increase
of caseload at CHC IPD was slow and steady, that at the OPD declined from 2010 to 2012
and then a rose again (see Graph 4.7).

Graph 4.7: Average Daily OPD/IPD at CHCs, Gujarat

140
120
Number of patients

100
80
CHC OPD
60
CHC IPD
40
20
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Source: State MIS data. Government of Gujarat

Thus, at the national level women had a range of reproductive health needs arising out
of early marriage and child bearing, multiparity, unmet need for contraception, RTIs,
Anaemia and malnutrition. The concerted efforts to meet to improve maternal and
contraceptive services to women through the government health services had shown some
results, yet these were still far from MDGs or State‘s targets for achievement. Women
preferred government facilities predominantly for contraceptive services and to some extent
antenatal care and private for meeting all other reproductive health needs. The government
facilities were serving population much in excess of the norm. The non-availability of staff at
facility headquarters, the intermittent shortage of drugs, lack of functional infrastructure and
shortage of lady medical officers and specialists in the system ailed the government health
system and affected its service delivery. Infrastructural deficiencies and perceptions of
women affected their utilisation of services at government facilities. To summarise, in
Gujarat reproductive health achievements were found to be lower than the neighbouring state
of Maharashtra as well as those reported for the country. Health infrastructure particularly in
terms of manpower was significantly poorer than the neighbouring state and the preference
for private was more marked.
 103

4.3 Reproductive Health Scenario in Select Districts

This section includes review of reproductive health scenario in the three districts
where the selected PPPs are located. The review is based on DLHS and State MIS data. The
data was analysed for three themes reproductive health seeking; places where care is sought
and government facilities available in the three districts

Reproductive health seeking: Data on health seeking was analysed for maternal care,
nutrition, contraception and RTI/STI management.

Antenatal care: DLHS data showed that over time in Surat and Bharuch there was
some improvement in early registration for pregnancy. But, in all the three districts similar to
the state there was decline in antenatal registration, receipt of TT injection and ―Full‖
antenatal care. In Bharuch and Sabarkantha districts the decline in ‗Full‘ antenatal care was
contributed to by fall in receipt of TT injections and three antenatal check-ups (see Table
4.10).

Contrarily, as compared to DLHS3, data for last six years from the State MIS showed
a much higher receipt of three antenatal check-ups and TT injections by women. More than
three fourths of the pregnant women were found to have received three antenatal check-ups
and TT injections. This proportion had still not attained the stated goal of 100 per cent
coverage by antenatal services in the State as the coverage by three antenatal check-ups and
TT injections, particularly in Sabarkantha and Surat had either stagnated or in some years had
actually declined (see Table 4.11).

Delivery care: According to the DLHS data, over time institutional delivery
percentage showed improvement especially in Bharuch and Surat districts (see Table 4.10).

Data for last six years for institutional deliveries at the three PPP model districts from
state MIS showed variations across the districts and over years. In all the three districts,
despite the Common Review Mission‘s (CRM) recommendation to encourage institutional
deliveries at government facilities, deliveries at government facilities remained below 48 per
cent. The proportion of institutional deliveries in government facilities was especially low in
 104

Sabarkantha, the tribal district. Deliveries at private institutions in Surat showed an increase,
while in Sabarkantha the increase was evident till 2012. Thereafter there has been a decline in
institutional deliveries at private facilities (see Table 4.11).

Last 10 years State MIS data on deliveries taking place under Chiranjeevi Yojana in
the State, particularly in Surat district showed a rise in the number of complicated deliveries
and deliveries by Caesarean section (LSCS) in Surat district under the Chiranjeevi Yojana
since 2012. It also showed a significant decline in the number of empanelled doctors under
Chiranjeevi Yojana in the state and more so in Surat district.

Postnatal care: Though trend of postnatal coverage over time was not available (both
from DLHS and State MIS sources), according to DLHS2 overall coverage was poor with
about a fourth or less of women reporting having received postnatal care within 6 weeks of
delivery (see Table 4.10)

Curative care for maternal complications: Reporting of complications during

childbirth and RTIs and seeking of curative care for these varied across the districts. As
compared to previous years, in all the three districts more women reported complications
during pregnancy and in Sabarkantha more women also reported complications during the
postnatal period. Seeking of care for complications during both the phases of childbirth
showed an increase except in Sabarkantha. About one fourth or more of the women with
complications did not seek care in all the three districts (see Table 4.13).

Care for RTIs and STIs: Reporting of signs and symptoms of reproductive tract
infections decreased in Sabarkantha and Surat and so did the seeking of care for these in
Surat. Overall, less than 37.5 per cent sought treatment for these. Almost two thirds of the
women did not seek care for reproductive tract infections even in 2008 in these three districts
(see Table 4.13).

Contraceptive services: There was a modest increase in acceptance of modern

methods of contraception by 2008 in Bharuch and Surat. In Sabarkantha it showed a marginal
decline. Interestingly, despite this increase in contraceptive acceptance the same two districts
of Bharuch and Surat showed an increase in unmet need for contraception (see Table 4.14).
 105

Table 4.10: Maternal Care Indicators for Bharuch, Sabarkantha and Surat (In %)

Bharuch Sabarkantha Surat

DLHS2^ DLHS3& DLHS2^ DLHS3& DLHS2^ DLHS3&
02-04 07-08 02-04 07-08 02-04 07-08
Antenatal care
ANC registration 94.2 80.3 84.8 68.5 93.7 87.4
Early registration 47.9 62.9 48.9 44.6 57.5 76.1
>=3 Antenatal check-ups 70.5 64.6 63.5 49.7 71.6 78.4
2 TT Injections 87.9 78.1 85.0 65.4 92.9 85.6
IFA Tablets 36.6 44.4 28.5 42.1 33.1 39.7
―Full‖ ANC 31.9 22.7 23.0 7.4 39.4 25.1
Institutional delivery
Institutional delivery 38.7 47.9 62.6 61.4 56.5 72.3
Postnatal care
Within 6 weeks 26.1 NA 18.9 NA 15.0 NA
Source:^: DLHS II 2002-04. IIPS (2006), &: DLHS III 2007-08. IIPS (IIPS 2010)

Table 4.11: Antenatal Care Over Years in Bharuch, Sabarkantha and Surat (In %)

Years
2009 2010 2011 2012 2013 2014
>=3 Antenatal check-ups
Bharuch 73.7 82.3 86.3 79.5 78.1 78.9
Sabarkantha 79.1 77.5 82.3 76.7 75.7 78.7
Surat 73.9 71.1 78.1 75.9 74.2 75.9
Receipt of TT injections
Bharuch 91.6 91.1 89.9 89.8 84.2 84.5
Sabarkantha 91.4 95.1 95.8 97.2 96.5 95.7
Surat 90.8 80.6 90.1 92.6 91.7 85.4
Source: State MIS data. Government of Gujarat

Table 4.12: Place of Delivery in Over Years in Bharuch, Sabarkantha and Surat (In %)

Years
2009 2010 2011 2012 2013 2014
Deliveries at government institutions
Bharuch 27.5 31.5 28.0 29.7 25.3 48.2
Sabarkantha 11.1 13.0 11.0 11.3 18.0 27.4
Surat 20.8 25.3 32.6 30 42.2 38.9
Deliveries at private institutions
Bharuch 45.6 41.4 57.1 59.1 69.8 48.3
Sabarkantha 72.6 76.7 83.5 84.3 77.5 69.5
Surat 51.4 53.3 54.9 60.5 21.0 57.2
Source: State MIS data. Government of Gujarat
 106

Places where care was sought: Private facilities were the preferred place for routine
as well as antenatal care except in Bharuch. In Bharuch for antenatal care women preferred
government facilities. The data also showed that since DLHS 2, the percentage of women
opting for care at government facilities had also increased, more so in Sabarkantha (see Table
4.15).

Table 4.13: Curative Care Sought in Bharuch, Sabarkantha and Surat (In %)

Bharuch Sabarkantha Surat

DLHS2^ DLHS3& DLHS2^ DLHS3& DLHS2^ DLHS3&
02-04 07-08 02-04 07-08 02-04 07-08
Complications and RTIs reported
Pregnancy 45.5 50.8 29.1 56.9 32.7 45.7
Delivery 65.5 53.4 43.8 43.0 39.8 27.6
Postnatal period 39.8 24.3 19.5 40.0 15.5 15.5
RTIs 25.3 31.8 44.2 30.5 45.5 18.5
Curative care sought
Pregnancy 56.9 63.1 52.5 61.8 58.9 71.2
Postnatal period 56.5 63.2 52.3 48.9 53.8 77.0
RTIs 31.9 27.4 29.7 37.6 47.2 33.7
Source: ^: DLHS II 2002-04. IIPS (2006), &: DLHS III 2007-08. IIPS (IIPS 2010)

Table 4.14: Contraceptive Acceptance in Bharuch, Sabarkantha and Surat (In %)

Bharuch Sabarkantha Surat

DLHS2^ DLHS3& DLHS2^ DLHS3& DLHS2^ DLHS3&
02-04 07-08 02-04 07-08 02-04 07-08
Use of modern methods 58.4 65.0 51.1 50.0 60.3 65.9
Unmet need 12.4 12.7 19.7 18.9 10.5 15.3
Source: ^: DLHS II 2002-04. IIPS (2006), &: DLHS III 2007-08. IIPS (IIPS 2010)

Table 4.15: Preferred Place of Care in Bharuch, Sabarkantha and Surat (In %)

Bharuch Sabarkantha Surat

DLHS2^ DLHS3& DLHS2^ DLHS3& DLHS2^ DLHS3&
02-04 07-08 02-04 07-08 02-04 07-08
Routine care
Government 22.4 NA 20.8 NA 13.0 NA
Private 73.4 NA 77.4 NA 83.5 NA
Antenatal care
Government 35.8 46.2 16.6 40.5 21.2 37.5
Private 45.4 40.7 51.3 60.2 60.8 55.3
Source:^: DLHS II 2002-04. IIPS (2006), &: DLHS III 2007-08. IIPS (IIPS 2010)
 107

Government facilities available in the three districts: DLHS3 data on assessment of

facilities in selected Primary Sampling Units (PSUs) in these three districts was done.

Subcentres: Data showed that except Surat population served by Subcentres though
much lower than the average for the State but marginally higher than that specified under the
IPHS norms. More than half the villages (55%) in Surat and 39 per cent in other two districts
had Subcentre in the village itself. Majority of the Subcentres (>93%) had equipment,
essential drugs and the ANM in position. Though posted only half the Subcentres in Surat, 43
per cent in Sabarkantha and 28 per cent in Bharuch did the ANM live at the headquarters.
Similarly though most Subcentres had equipment and drugs, only 36.8 per cent in
Sabarkantha and 25 per cent in Bharuch and 10 per cent in Surat had functional labour rooms
(see Table 4.16).

Primary Health Centres: As compared to state average the percentage of PHCs

designated as 24X7 PHCs was higher in Sabarkantha (53.6%) and significantly lower in Surat
(30.3%). Most PHCs have the requisite essential drugs. Most PHCs in Bharuch, about 71 per
cent in Sabarkantha and 53.8 per cent in Surat had functional operation theatres. More than
two thirds of these PHCs had a Medical Officer (MO) in position but 15 per cent or less had a
Lady Medical Officer. Ten deliveries a month were reported by less than one third of the
PHCs in Bharuch and Sabarkantha and less than 10 per cent (7.7%) in Surat (see Table 4.16).

Community Health Centres: In the three districts, more than two thirds of the CHCs
were designated First Referral Units. The proportion was higher than the state average in
Bharuch and Surat and a similar proportion had functional OT. However, Surat did not have
Anaesthetist posted in any of the CHCs and Bharuch had neither an Obstetrician nor an
Anaesthetist posted in any of the CHCs. (see Table 4.16).
 108

Table 4.16: Subcentres, PHCs and CHCs in Bharuch, Sabarkantha and Surat

Bharuch Sabarkantha Surat

Subcentres
Average population served 5813 5131 3232
Villages with Subcentres 35.1 33.3 55.0
ANMs posted 96.7 100.0 93.0
ANM available 27.8 42.9 50.0
Functional labour room 25.0 36.8 10.0
Adequate equipment (60%) 96.6 100.0 100.0
Essential drugs (60%) 93.3 96.4 100.0
Primary Health Centres
Average population served 30565 36513 26282
24X7 PHCs 42.8 53.6 30.3
MO posted 80.9 75.0 69.2
Lady Medical Officer posted 9.5 10.7 15.4
Functional OT 90.5 71.4 53.8
Essential drugs (60%) 80.9 85.7 100.0
Conducts >=10 deliveries 33.3 25.0 7.7
Community Health Centres
Average population served 45671 78108 126344
Designated FRU 85.7 69.2 83.3
Functional OT 85.7 69.2 83.3
Obstetrician posted 0.0 7.7 33.3
Anaesthetist posted 0.0 15.4 0.0
Source: DLHS III 2007-08. IIPS (IIPS 2010)

To summarise, the three districts mirrored the state as far as maternal care was
concerned. There was decline in components of antenatal care, improvement in institutional
delivery but not concomitant increase in postnatal care. The antenatal coverage had either
stagnated or even declined in Sabarkantha and Surat. Even institutional deliveries showed a
decline in Bharuch and Sabarkantha. Though there was an increase in institutional delivery in
Surat, with the drop out of private obstetricians from the Chiranjeevi Yojana, many of the
deliveries were taking place in private clinics not empanelled under the Yojana and where
women had to pay from their pockets for services. Over years reporting of obstetric and
gynaecological problems had improved and so had the seeking of curative care for these.
Both contraceptive prevalence as well as unmet need showed marginal increase, particularly
in Bharuch and Surat. Private facilities continued to be the preferred place for routine as well
as antenatal care in two of the three districts. The infrastructural gaps and challenges found at
the state level were echoed at the district level. Manpower availability continued to be the
major challenge in all the three districts, particularly so in Surat.
 109

4.4 Summary and Discussion

Data was analysed to assess the changes in women‘s reproductive health over time.
Data from national surveys, State MIS and small studies was analysed or reviewed on select
indicators for women‘s reproductive health. In addition to assessing the status of women‘s
reproductive health for the country as whole, since the study was conducted in the State of
Gujarat, the State‘s data was compared to the neighbouring socio-culturally and economically
similar state of Maharashtra and the best performing state of Kerala. Data was also compared
with the national average to understand where the State stood vis-à-vis the country as a
whole. An attempt was also made to explore the reproductive health situation of women in
the three districts from where the PPP models were selected for study. The themes for study
spanned across the reproductive health needs of women, the services they received, the places
they chose for these services and the condition of available government services and services
under the three PPP models.

The data differed in terms of extent or range of findings according to the source but
the essential messages emerging out of the data remained same. The data showed that on vital
indicators the efforts to address the poor performance have met with limited success. Data
from showed that the TFR remained higher than desired and MMR was still far from the
goal. Perhaps the inter-state variations in physical infrastructure, manpower, resources at the
systemic level and the socio-cultural background at individual and community level were
largely responsible for these variations. A large proportion of women continued to have early
marriage and childbearing. Women‘s reproductive health needs spanned the entire spectrum
from nutritional needs, maternal health, contraception to reproductive tract infections and
anaemia. The data from national surveys showed that though Gujarat was critically placed as
per the need for these services as compared to the country and its needs were more
pronounced than Maharashtra and Kerala on many of the indicators.

These needs were met to a variable extent. The overall receipt of maternal care,
barring institutional delivery was low and of poor quality and lacked continuity. The poor
coverage with postnatal services indicated the lack of continuum of care received by women.
The data was not analysed to understand if this was a result of systemic failure to ensure
continuum of care or women‘s reluctance to take care unless faced with high risk conditions.
 110

The data suggested that latter did play some role as it showed that identification and seeking
of care for complications associated with childbirth had definitely increased. In case of
contraception, the classical conundrum played out through the data. High unmet need for
contraception co-existed with low and stagnant contraceptive acceptance, often of permanent
methods after bearing more than desired number of children. This perhaps was suggestive of
poor acceptability of existing methods. Women were found to seek care with greater alacrity
for reproductive tract infections. While the aforementioned variability in data because of the
sources continued for this theme also, the clear message was that health care seeking was far
from desirable with a few exceptions, especially in Gujarat.

Women were found to seek the care and treatment for their reproductive health needs
from various sources. The overall trend was to seek preventive and promotive health care
services from the government and curative from private facilities. Government facilities were
preferred mainly for contraceptive supplies and sterilisation operations. Women had serious
grievances against the distances, behaviour, corruption and quality of care at the government
facilities. The private was perceived to be better on some of these indicators and therefore
preferred.

Women‘s perceptions about government health facilities were not entirely misplaced.
These facilities in Gujarat were found to serve population much in excess of the norm and the
ability of their infrastructure to deliver. The non-availability of health staff, lady medical
officers, specialists and requisite medicines had implications for the ability to attract patients
and deliver services. It was therefore not surprising that despite the State government‘s claim
in Gujarat; even the State MIS data showed that the caseload at government facilities had
remained unchanged over last decade or more.
 111

Appendix 4.1: Trend of Institutional Deliveries in Gujarat (%)

Year Total Government Private

Institutional facilities* facilities
2000-01 36.3 NA NA
2001-02 36.6 NA NA
2002-03 36.6 NA NA
2003-04 36.7 NA NA
2004-05 51.7 28.7 23.0
2005-06 52.5 29.2 23.3
2006-07 53.2 29.5 23.7
2007-08 59.1 29.8 29.3
2008-09 71.3 31.0 40.3
2009-10 73.2 32.5 40.0
2010-11 79.8 36.9 42.9
2011-12 84.4 40.5 43.9
2012-13 86.1 41.2 44.9
2013-14 92.0 54.9 37.1
Note: Could include Deliveries at Chiranjeevi Facility
Source: State MIS, Government of Gujarat

Appendix 4.2: Trend of Contraceptive Acceptance in Gujarat (%)

Use of Modern Contraceptive Methods

Year Overall Sterilisation IUCD Condom Oral Pills
2000-01 56.6 36.9 12.1 5.4 2.2
2001-02 54.2 35.3 11.5 5.3 2.1
2002-03 52.8 34.4 11.1 5.1 2.2
2003-04 52.6 33.6 11.0 7.0 4.0
2004-05 52.5 33.0 10.8 6.2 2.5
2005-06 51.9 32. 10.7 6.3 2.3
2006-07 48.3 30.5 10.3 5.1 2.5
2007-08 47.6 29.8 10.2 5.3 2.3
2008-09 48.7 29.6 10.3 5.9 2.9
2009-10 49.4 29.6 11.2 5.7 2.6
2010-11 49.8 31.6 2.4 3.6 2.2
2011-12 49.4 29.6 11.2 5.7 2.6
2012-13 47.9 29.9 11.4 4.2 2.4
2013-14 47.9 31.4 12.7 2.5 1.5
Source: State MIS, Government of Gujarat
 112

Appendix 4.3: Trend of Maternal Care Programme Achievements in Gujarat (%)

Maternal Health
Year ANC Early TT Institutional delivery PNC
registration registration injections against targets
1999-2000 NA NA 96.6 NA NA
2000-01 NA NA 93.7 NA NA
2001-02 92.3 94.2 94.2 51.4 75.9
2002-03 97.4 NA 94.3 NA 81.4
2003-04 95.9 NA 93.3 NA 84.1
2004-05 93.1 NA 89.5 NA 84.8
2005-06 93.9 89.5 89.5 63.2 86.6
2006-07 92.8 88.8 NA 67.6 65.2
2007-08 91.3 84.2 NA 77.8 76.4
2008-09 87.9 80.7 NA 82.0 80.3
2009-10 97. 58.0 80.9 89.4 80.0
2010-11 93.1 66.2 83.3 91.8 75.0
2011-12 93.1 70.8 85.7 93.7 81.1
2012-13 96.3 73.0 87.2 95.0 84.7
2013-14 101.4 70.9 85.1 96.3 88.6
Source: State MIS, Government of Gujarat

Table 4.4: Trend of Family Planning Programme Achievements in Gujarat

Use of Modern Contraceptive Methods

Year Sterilisation IUCD Condom Oral Pills
1999-2000 96.4 90.1 88.3 88.6
2000-01 90.9 94.6 96.1 87.9
2001-02 91.7 92.3 90.9 88.3
2002-03 97.1 93.8 102.5 94.8
2003-04 92. 91.7 109.3 99.5
2004-05 91.3 88.3 99.8 88.9
2005-06 85.7 94.4 85.6 96.7
2006-07 78.5 82.1 93.4 86.6
2007-08 87.4 83.4 98.4 102.8
2008-09 92.1 96.7 98.4 95.6
2009-10 93.8 94.7 73.8 87.9
2010-11 85.7 88.8 55.3 73.0
2011-12 85.6 90.9 44.7 63.8
2012-13 83.8 89.9 39.8 53.6
2013-14 81.3 90.3 66.1 68.5
Source: State MIS, Government of Gujarat
 113

Appendix 4.5: Facilities and Population Served in Gujarat

Subcentres PHCs CHCs

Year Number Population served Number Population served Number Population served
1999-2000 7274 5679 984 41981 224 184419
2000-01 7274 6966 1001 50620 233 217472
2001-02 7274 6966 1044 48535 253 200280
2002-03 7274 6966 1051 48543 259 195671
2003-04 7274 6966 1067 47496 271 187007
2004-05 7274 6966 1070 47363 272 186319
2005-06 7274 6966 1072 47275 273 185637
2006-07 7274 6966 1073 47231 273 185637
2007-08 7274 6966 1084 46751 283 179077
2008-09 7274 6966 1096 46239 290 174755
2009-10 7274 6966 1114 45492 305 166160
2010-11 7274 8301 1158 52144 318 189883
2011-12 7274 8301 1158 52144 318 189883
2012-13 7274 8301 1158 52144 318 189883
2013-14 7274 8315 1158 52192 300 201463
Source: DoHFW, Government of Gujarat

Table 4.6: Average Caseload at Facilities in Gujarat

PHCs CHCs
Year OPD IPD OPD IPD
1999-2000 NA NA 75 6
2000-01 NA NA 71 6
2001-02 NA NA 93 5
2002-03 52 7 110 8
2003-04 34 6 125 9
2004-05 35 7 117 9
2005-06 36 7 118 10
2006-07 45 7 126 12
2007-08 40 7 120 12
2008-09 35 7 122 13
2009-10 37 7 124 14
2010-11 37 7 116 13
2011-12 37 7 105 12
2012-13 35 1 106 13
2013-14 29 0 120 14
Source: State MIS, Government of Gujarat