UNDERSTANDING THE REPRODUCTIVE HEALTH
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REPRODUCTIVE health
A Resource Pack
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WOMEN HAVE MINDS TOO!
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Exploring The Interface Of Reproductive And Mental Health
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CONTENTS
Introduction
3
Section One- Understanding Mental Health and Mental Illness
4
What are Mental Health and mental Illness
4
Linkages between Reproductive Health and Mental Health
5
Reproductive Symptoms and Psychological Disorder
5
' Childbirth and Mental Health
5
Family Violence and Mental Health
6
Rape and mental health
6
Child Abuse and Mental Health
6
Reproductive Tract Surgery and Mental Health
7
Abortion and Pregnancy loss
- 7
Adolescent and Mental Health
7
PMS, Menopause and Mental Health
8
HIV/AIDS and Women's Mental Health
8
Section Two - Programmes and Policy: Issues and Debates on Women and
Mental Health
.0
The rights of the mental ill, and improvement of mental health care
.0
Hysterectomy of mentally retarded women
.0
Media and mental health
.1
Mental Health Services and Care
.1
Section Three: Women and Mental Health Research: An agenda for the future
.3
Society, Women and Mental Health
.4
Mental Health policy and women
15
Resource Section
:6
Further Reading list
6
Resource Organisations
8
Other Resources
.9
2
INTRODUCTION
The relationship between reproductive and mental health is a topic which at best inspires
cautious scepticism, and at worst, downright dismissal from public health practitioners in
deve oping countnes. Mental health has always been the Cinderella of health concerns in
developing countries, even though health policy and social components nearly 30 years
ago^More recently attempts to place mental health on the public health agenda are
con rented with the senous concerns of old and new infectious scourges ravaging the lowincome world, and the threat of non- communicable disorders such as heart disease and
diabetes becoming a reality where does mental health fir in? Can we really afford to be
mentally well when our bodies are sick and our stomachs empty^ Is it a luxury item on the
health menu derived from Western preoccupations now that they do not have to fret about
resources to mental illness with its vague fuzzy boundaries and connotations of asylums
shock therapy and madness9 Besides, do women who are facing so many pressing
problems in their lives really have time to become mentally ill? Isn't mental illness largely
ue to consumerism and materialism9 These are just some of the cliches and challenges’
one faces in a discourse on mental health.
Reproductive health and Mental Health
How does mental illness relate to reproductive health? As this booklet will demonstrate
there are numerous close linkages between these apparently different health domains. This
arises omt e fact that just like reproductive health, women's mental health can not be
considered in isolation from social, political and.economic issue. When women's position
m society is examined, it is clear that there are sufficient causes in current social
arrangements to account fro an excess of common mental health problems experienced by
women. Gender dynam.es and power relations which lead to an unequal status for women
m a vanety of situations are likely to make their lives more stressful. Indeed, "it is not
surprising that the health of so many women is compromised from time to time Rather
what is more surprising is that stress related health problems do not affect more women"
(see Dennerstein et al, 1993; Reading Material). The area of intersection of reproductive
and mental health though rarely researched so far provides an opportunity to explore
women s mental health from a perspective which is now widely accepted as a fundamental
health pnonty for women. This section of the Reproductive Health Resource Pack briefly
toes to understand Mental Health, its linkages with reproductive health, current issues and
ebates pertaining to programs and policy relevant to women's issues and
recommendations for future research.
3
Section One
Understanding Mental Health And Mental Illness
What are mental health and mental illness
In Indian languages the word 'manasik' is usually translated into English as ‘mental’ It
originates from the word ‘man’ which includes both emotional and intellectiual capacities
However, the English word ‘mental’ attends to the latter and may neglect or occlude the
emotional aspect. This is not just a linguistic issue because the work ‘mental’ is associated
with much stigma m India due to its association with colonial institutions such as mental
asylums and inhumane treatments. Perhaps the first issue that needs clear understanding is
that mental illnesses, like physical disorders, constitute a wide range of specific conditions
and that many of these are closely associated with community health issues. Thus, the very
iverse conditions of infantile autism and hyperactivity, depression and schizophrenia
alcoho and drug abuse, Alzheimer's disease and mental retardation all fall under the broad
umbrella of mental health. Even though mental illnesses are such a vaned group of health
problems disorders, such as schizophrenia. It is this group of disorders which are the
predominant conditions in psychiatric hospitals and clinics in developing countries
However m a community setting, they are rare. When women suffer these disorders they
are likely to suffer far greater discrimination and stigma in areas of life such as mamaae
and employment than men.
~
Depression and anx.ety disorders, on the other hand, are rarely seen in psychiatric clinics
I hey are collectively referred to as "Common Mental Disorders"(CMD) The term
CMD is used as an alternative for depression, both terms are used to refer to those health
S'T ChariaCtensed) by a mixture of medically unexplained physical symptoms such as
tiredness weakness and aches and pains, behavioral symptoms such as sleep and appetite
disturbances and psychological symptoms. Studies from South Asia reveal that up to 40%
o a ult primary care attenders suffer from a Common Mental Disorder Both Community
iff6! Tk'eS and StUd'eS oftreatment seekers indicate that women are disproportionately
free ed by common mental disorders. A recent collation of 5 studies from 4 low and
mic d e income countnes demonstrated the women were 2 to 3 times more likely to suffer
b M rh ” n’e|? (S“ PT' “
l9": Readi"8 M1,enal)- D'Pressl“ has ten Shown to
ronic illness with upto 40% of patients in treatment settings remaining ill for 12
months or more. Patients suffer a higher mortality both as a resuft of suiside i othe’r
pX’io eon?,. qUen',ly hCOnSU'‘ h'al’h
bW
'0 S,,e™ "d »'te fetors.
P eter o consult general physiaans with somatic (or physical) complaints rather than
psychological complaints. Indeed, this is one of the key problems in using terms such
encounter patients who state their complaint as being feeling "depressed". However, even
ie simplest questions about mood and thoughts often reveal the classic "hallmark"
adnZ
depreS;On.' 3h®Sre include: !oss of
daily life and social activities
for CMDW°7ttnd SU'
There 3re effective’ and ^latively cheap, treatments
CMD vet, the vast majority of patients in India do not have access to these and are.
4
ms.ead, given sleeping pills and other symptomatic medications and subjected to numerous
■ncestigations and tests. Other mental illnesses wh.ch the community health workers may
encounter are habit problems such as alcohol abuse and drug abuse. At present evidence
suggests that these problems are relatively uncommon in women in India Mental
reu.rdation is a condition which is present from birth or early infancy and is associated
wttn delayed development of the child's intellectual abilities.'
Thus, mental illness is a common and disabling cause of ill-health in developing countries
Die recent Global Burden of Disease (World Bank/WHO., 1996) report listed the most
important causes of disability(as measured by disability Adjusted Life Years, a measure of
te number of years of life lost by disability due to a specific illness). To the surprise of
any public health experts, five of the top 10 causes of disability were mental disorders'
□epression, alcohol abuse, schizophrenia, bipolar disordert also referred to as manicSSS'Va dlS°rder)’ and obsessive compulsive disorder. Depression was the single most
disabling
saoling disorder,
disorder, accounting
accounting for
for more
more than
than one in ten years of life lived with disability.
Linkages between Reproductive Health and Mental Health
One can identify several areas where mental and reproductive health areas intersect, most
notably the following:
Reproductive Symptoms and Psychological Disorder : Weakness and tiredness are
>ome of the most common symptoms reported by women in community and primary
-are populations. Weakness is almost always taken to be caused by anaemia However
weakness >s also a hallmark symptom of depression. A number of recent studies have
demonstrated that many women with complaints such as weakness and white vaginal
discharge do not have reproductive tract infections which can account for these
symptoms. Thus, it is possible that these women are using the reproductive somatic
■d'om to seek help from medical professionals and to escape albeit temporarily from a
stressful situation. In extreme situations, women may adopt the sick as refused of sex
and inability to perform household chores. However, by adopting this idiom, they are
su jtcfe to a series of medical examinations, investigations and treatments which
rare y tackle the key psychosocial issues which underpin their distress.
Childbirth and Mental Health : Women are vulnerable to suffer depression during
lp\i^n0^ ’mme^’ate^ following childbirth. Most research on Post-Natal Depression
(
) is from industrialised countries, this research demonstrates that PND can be
detected in about 10-20% of mothers. The majonty ofPMDs are self-limiting though,
i untreated, this process of resolution may take upto 6 to 12 months. There is a
compelling body of evidence implicating PND in a range of adverse child cognitive and
emotional outcomes. The detection of PND is of great public health interest not only
-ecause ot ns profound impact on maternal and child health but also due to the
abundant evidence that simple inexpensive interventions such as counselling are of
sigmficant benefit in terms of remission of PND and help prevent some of the adverse
outcomes associated with PND The emphasis in postnatal planning ignoring the
5
mother's psychological health: this child-oriented approach renders the mother less
healthwoZs5
d,StreSS SinCe " may be
negatively by her fami>y and
Famdy Violence and mental health: Violence against women is emerging as a
mortalT t8
‘SSUe
C°ntnbutes significantly to preventable morbidifv and
mortality for women across diverse cultures. There is now substantive evidence
emonstratmg that amongst the most disabling and long-lasting health effects of
XiSsXhi'
’ X mentalr disorders
d'!’re!s'“associated
"d with violence are
sorder(PTSD). other recognisedeating disorders, sexual dysfunction and suicidal behavior. The harmful imoact of
sexua vmlence and abuse in childhood has been shown to lead to mental illness in
a ult life. There is evidence that women who have been abused have difficulties in
ormmg trusting, stable relationships and ma land up in more abusive relationships in
the future. Friends and relatives can be very helpful if they susnect an
•
situatiom Support groups and counselling both can help a person in an abusive
needsuch’help60'3 6
pannerships also face abusive relationships and may
Rape and mental health : Rape s one of the most terrifying experiences that anv
uman being can experience. It is not only a violation of a woman's body but of the
Ost sensitive aspect of her being, her sexuality. In many communities ^the woman
suffers the double blow of suffering rape and then being accused or discriminated
nhv<
me™berS Of her immunity: In this sense that rape involves both
physical violence and mental torture, it can be extremely damaging to a woman s
health. Typically, a woman goes througlra sefies of emotional'reactions The woman
emxpyerieentceeTsomekin8XVIth
t0 UnderStand what she has Just
experienced. Some women may appear calm and controlled, this does not mean th-t
emot aVe C°Ped Wel1 W'th tHe rape' In tHe dayS and Weeks after a raPe’ a variety of
emotions re experienced Blaming oneself, fears of being killed or harmed feeling of
unuhation, feeling dirty, repeated thoughts of the rape, nightmares and 1
P °b ems are common. Physical complaints such as aches and pains, loss of appetite
behindh 7
° COmmOn' LatCr °n the WOman may deveioP a fear of people
behind her, fear of situations similar to those in which the rape occurred fears of loss
of interest in Disorder. As s woman recovers her self-esteem, often sadness and tear
remam for a long time. In the end the majority of woman do recover from the trauma
but not without having suffered sever ill-effects for a long time in a few women
though, frank depression can occur and will need treatment.
Child Abuse & Mental Health : Both male and female children can victims of chil-
ci c"hbe eTi(such “
<-oh J "X)"
. Ch]ldren who are abused usually appear the same as those who are not abusec
wever on closer examination they may appear tense and unhappy present with a
vmnZt,On n SCh°01 Perfor“e' and -W complain of a number of physical
y P
S such as stomach aches, headaches, sleeplessness, and eating problems. In
adolescents, antisocial behavior and drug abuse may be signs of abuse. Some may
become troublesome at school or steal. Many children blame themselves for the abuse
that they see in their households. Children n abusive households may have more
trouble dealing with their anger because they may learn that anger means being hit of
being violent towards others.
Reproductive tract Surgery and mental health : Women who undergo reproductive
tract surgery such as tubectomy, mastectomy and hysterectomy may face mental health
related problems. Gynecological surgery poses a unique stress fro women because of
the identification of the reproductive organs both wkh sexuality and with the wider
concept of feminine identity. This stress is particularly apparent when one considers
mastectomy or hysterectomy. Of all cancers, breast cancer is arguably the most
frightening for women. Mastectomy involves emotional trauma of losing a breast, in
addition to numbness of the skin, scarring, and posture problems. Nothing can restore
the sexual and nursing function of the lost breast, even if reconstruction of the breast
for appearance is possible. Counselling may help ensure optimal sexual outcome fcr
women undergoing such surgery. Although Cesarean delivery is now safer than it has
ever been, it remains a major surgical procedure and therefore can never be an entirely
sate alternative in vaginal delivery. A number of negative responses to a caesarian
delivery among women have been reported. These responses include feai,
disappointment, anger and lowered self-esteem, In addition to the stressors that
women have to cope with may have occurred on top of a long and exhaustive labour.
" Abortion and pregnancy loss : Although grief has'been understood and documented
for many decades, only recently have the fully impact and consequences of pregnancy
loss Been appreciated. Unique aspects of pregnancy losses surrounding miscarriage
and ectopic pregnancy, stillbirth of neonatal 'death include: real (actual) loss of a
person; and symbolic loss (of the future) in addition there is a loss of self-esteem
resulting from the woman's inability to rely on her body and give birth. Emotional
shock, feelings of loss, sadness, emptiness, anger, inadequacy, blame and jealousy are
common feelings experienced after post-nonatal loss. Each pregnancy loss may mean
tat there is no recognisable body to visualise, and this further complicated the
mourning process. Symptoms suffered by women in case of stillbirth and neonatal
death include depression sleep disturbance, social withdrawal, anger, guilt and marital
disturbance.
Adolescent Sexuality & Mental Health : The sexual health of adolescents is rapidly
becoming the newest "buzz" word in reproductive health research. However , there is
a risk that the agendas and priorities of reproductive health workers may miss out on
the other real concerns of adolescents and their families, viz., stress arising from
conflict within families and from pressures in the educational system and rising
unemployment. There is now substantial evidence pointing to the rising rates of
depression ad suicide amongst young people. Suicide has become of the commonest
causes of death and hospitalization in adolescents in many societies. Pressures of
academic performance can lead to considerable psychological stress and symptoms of
7
weakness, lack of concentrations, headaches and
and <o on Peer Dress.,rp ie ,
factor that ,„llue„ees the M., health of adoleace^ P^X^e “
adolescent to expen.nenl with sexual behavior in order to be accepted in the peer
group. Peer pressure can also force an adolescents dealing with thetr homosexuahtv
can be especially vulnerable to mental health problems as they have to cope with their
sexuality and other related issues with little support or approval Anxiety around
pubertal changes may also cause mild to severe mental health problems n the
adolescents. They often worry about matters such as menstruation masturbation
delay in the onset of puberty, size of breast, perns and so on. Young men sometimes
believe that semen is a source of physical strength and vitality. They become very
concerned when they notice that they are "losing" semen by pasIg it in the^
un erwear during the night, or when passing urine or stool. They may become very
anxious about their desire to masturbate , and, if they do masturbate suffer guilt and
tension because ot this. Many men will go on to complain of tiredness aches and
pains, impotence and suicidal feelings. Typically, they will blame these complaints on
the passmg of semen( Also called "dhat" in North India) in their urine The health
worker must spend time explaining male sexuality. ,An example which helps is that of a
glass of m k to which more milk sexuality. An example which helps is th t o a X
of milk wHl begin to dnbble out of the glass; this is the same that happens with semen
PMS, Menopause, and Mental Health : The combination of emotional behavioral
gmtive and physical changes occurring pre-menstrually have been designated as a
syndrome- the premenstrual tension syndrome(PMS). Typical symptom^ of PMs
include irritability, mood swings, poor concentration depression and tiredness The
symptoms complained of by women in the menopause
headaches weepmess Ind
depression irritability ; anxirty, insomnia , fatigue, lack of sexual felling are
conditions which are just as real and which'can be even more worrying than Mother
ajor symptoms attributed to menoapuse such as hot flushes , vaginal dryness and
s oporosis ( porous and fragile bones). Hormaonal replacement therapy helps reduce
Mems bul drs "o'
m"ci',o wp refae
^hppX“
arToften At h h t0Pra.USe' 15 WOrt nOting that 01der WOmen’ Past the menopause
often at high risk of depression due to an number of reasons such as loneliness.
HIV/AIDS and Women’s Mental Health : Il
HIV/AIDS produces mental health
problems in those who suffer from the disorder fo
.nd ai„,m,„a,|0„
agnosis to long-term survival, the impact of discovering an illness whilh may have
already infected loved ones in the family, and the direct and indirect effects of the HIV
terminCr S'7 neOplaStlCuand ,nfectious diseases on ^e brain. The effect of caring fcr
e mmal y dl persons on the mental health of carers is now recognized as an importart
e o depression. There are growing reports that women, who are often carers fcr
persons wth HIV/AIDS, suffer considerable mental and physical health problems as a
su o care giving and that depression, in particular, is common.
3
I
Section Two
Programs & Policy: Issues and debates on Women & Mental Health
The rights of the mental ill, and the improvement of mental health care
On December 1991, a set of principles for the protection of persons with Mental illness
and for the improvement of Mental Health Care was approved by the United Nations
general Assembly. The principles provide comprehensive protection for a particularly
vu nerable group that is readily susceptible to discrimination. Persons in this group are
vu nerable groups that is readily susceptible to discrimination. Persons in this group are
vulnerable because of their disturbed mental state, which prevents them from making
■ easonable judgments about their own needs. As a result, mentally ill persons are often
given east prionty in terms of access to care and services. It is true that mentally ill people
can sometimes be dangerous to themselves or to others, although this hazard is often
greatly exaggerated.. The principles attempt to set forth safeguards against such hazards
without ignoring the fact that such provisions are particularly liable to be abused by family
members, other members of the community or state authorities. If a national jurisdiction
■o ows this balanced set of principles in drafting domestic law and in instituting
procedural modalities, both the rights of the mentally ill and improvement in mental health
vare can be accomplished. However, as with many other grand and well-meaning
COuntry’ there 1S a vast gap between ideology and practice. As recently
, a National Human Rights Commission inquiry on the condition of mental
hospitals reported horrifying abuses of mentally ill women in some large asylums These
included the inappropriate use of ECT (shock therapy). Sexual abuse of patients and gross
neg ect ot medical care. It is important to keep vigilant of whether the recommendations
ot the commission are implemented in the years ahead. Some other important legislative
changes in recent years include the revision of the Disability Act to include mental
disorders, and the rewriting of the old Indian Mental Health Act to be more Sensitive to
ine needs of mentally ill people.
Hysterectomy of mentally retarded women
When the media reported that a State run institution in India has conducted hysterectomy
on eleven mentally retarded women, it sparked off an explosive public debate Issue such
as human rights, medical ethics, the right to survival and reproduction, dignity and
aecency, responsibility of the family and the State were all placed under the spotlight. The
primary argument of the proponents was that it was essential to conduct hysterectomy to
maintain menstrual hygiene of the mentally retarded women. Avoiding unwanted
pregnancies and sexual abuse have been used only as secondary arguments The key
question for human rights and health activists is whether this is the best that science today
-an o er to this normal aspect of human functioning. Since hysterectomy is an irreversible
process, should we resort to it as a matter of routine and worse as a matter of policy. If
we accept this practice for the mentally retarded women, then will other vulnerable and or
unwante women' like women who beg, HIV positive women and orphan girls be the next
9
group to be considered eligible for such involuntary operations'’
u
society develop a code of medical ethics nnH
iryfpera‘I0ns; Should not an enlightened
possible abuse9 These are issues and debates h^5
Safeguardin8 the wards form
Professionals and women's activists in collahorat'W ,ch ™ust involve b°th mental health
« front the .edtcaiised
h a! h pm
™
" 'T^ * ""
model of community care However, in practice it lakes Zm l b P'' “
perception and management of mental disorders Indeed the NMhZ
Tl"
unknown ou,si(le psychial„c
rema,ns largey,
rectified so that its goals and methods are altered n-c 7 furP°se- 1 he NMPH needs to be
model. fr„m , psychiatr,c oriented
commu„hy“a'hh oTZedm’ .ST^T"
making a purely clinical commitment or making a social Zml™
"■ "‘l lrOm
■ha, this discrimination towards women’s mental \ealth aZs many' ”
researchers and donor agencies too! Thus in India w omen's m mal healZZ “ a*Jh
only a fraction of renroductive heaifh
,
mental health is addressed by
dismiss mental healtZ. Zaudssue Z™Zk
health discourse is in itself an attemnt t rT
■
ome even argue that the mental
son of argumen ,
sel 7
fr°” g“der
This
distraction from the ' e ■ n ob em i th
a"’8 ’
fraC,Ured “> '* >
being severely beaten by her husbZ OearH b'm • P°'V'r ’""S
led “ h"
health problem need action. As this article has shown' ZeT.Zd' "r '"f
degme of acknow.edgmen. of.be imponance ofmemai heabh Z X* XfZ
Media and mental health
insane woman or the wick-pd mnth^r • i
Media coverage must shift from k^inr,
link,
■ rr- >•
■ •
i
•
>•
YP $• 1 ne portrayal of the
cental illness in woman.
“X ,npis™ z±;"dpersons
mfor",i"8 the ™ mental
health issues can eo a lone wav m hS
f°le stereotypes
® ’
8ene"“e
“vera«' “t1 Courage negative
Mental Health Services and Care
India, the involvement of the famil
facilities,
care in f
doubtfulI or even hatmfr! funbermore. there is also thlneed for pZ^Zl c"
13
™ny types of mental illnesses. In addition, just because families caring for the mentally ill
also need guidance and support. Thus, there is a need for systematic organisation of
essential services for mentally ill women especially those living in rural, tribal and urban
slum areas. Requirements of working women and girls on the street represent another
group who require innovative approaches to meet their mental health needs. There is a
need for innovative, cost effective services which are in'harmony with existing socicpohtical and cultural norms. This is more likely to be achieved by thinking in terms of
•ocal initiatives, appreciating the power of micro-planning at the villages/grass root level,
gather than orienting towards centralised plans, programs and projects. During the last two
• ecades, a number of innovative approaches have been developed to meet the deferent
needs of people with illnesses, to prevent mental disorders and to promote mental health.
Some of these innovations are described in detail in a forthcoming book (Patel & Thara.
Reading List). The overall picture is one of tremendous scope, positive initial experience
and the need to enlarge and over larger groups of population all parts of the country. The
^ey to sensitive mental health care delivery for women lies in two major programme areas;
rirst, the inclusion of mental health as a priority in existing community and women’s health
programmes and second, the sensitisation of health workers to the unique mental health
needs of women and the need for a revision of the NMHP to accommodate these needs.
11
Section Three
Women and Mental Health Research: An agenda for the future
h^7the TTCh mUSt rplore and determine the l,nkases between mental a"d reproductive
alth. A key area for any research investigation'in mental health is examining its
re at.onship w.th cultural factors. Concepts such as depression, can be elicited in different
cultures, but may mean something quite different; for example, it may reflect the patients
assessment of their socio-economic and spiritual state. As a result, persons with
epression rarely consult mental health professionals and tend to use somatic idioms such
as vague aches and pains. Therefore, it is essential to generate a local language of
depressions and to explore its contextual significance and the explanatory models of the
epressed individual; what the person believes is causing her distress, her understanding of
the changes that are affecting her and how the distress has affected her daily life
XtZSsf rTch in itse,f has severe limitations in accurateIy descnbinS
s
tT n O 1Y r ,aS P0Sttraumatlc stress disorder
major depression that are linked
to socio-political and economic realities. Feminist perspectives on women's health
underscore the-importance of "treating survey methods for their gender bias" and using
more innovative instalments to collect accurate quantitative data on women’s mental
distress. In this respect, ethnographic research may also be valuable in exploring reasons
why women are more vulnerable to suffer from Common Mental Disorders ad the
mechanisms by which these disorders lead to disability. Several themes and hypotheses for
research are considered below.
uypotneses tor
How common is postnatal depression’’ Which women
are more vulnerable to suffer
PND’’ What is the impact of postnatal depression on
infant and maternal health? What
is the role of fathers in this context?
s?xZhiat a?ne fe?rS and deSireS that W°men have regarding their own bodies and
- a lives. How do researchers and programmers incorporate emotional aspects of
sexuality into the reproductive health parading?
W hat the health priorities and concerns for adolescents’’ What
is the relationship
hX"H8owed„dAPPi"gr0l“ Ofed“a,i0"- stress
l» education and menial
adotacema”
SeXMl “d
health in
A
15 jhe reIatl0nshiP between the common complaints of white vaginal
tresTl/
,WeakneSS kWlth mental health?
^ese idioms for psychosocial
symptoms? S0,
mental health lnterventmns for these
What are the mental health consequences of domestic violence? Can family
or
marital therapy interventions help in these situations?
What is the relationship between infertility and mental health? Can counselling
interventions help couples with infertility problems9
" What is the mental health impact of AIDS for women, both when thev are
women, both when they
with foe^isOrS"8 fr°m tHe dlS°rder aS We“ aS tHe ‘mpaCt °fbeing Carers Natives
12
VV hat is the impact that community based interventions for either reproductive cr
mental health issues have on both health outcomes/
hat is the impact of reproductive tract surgery and abortions on women's mental
health7 Can counselling help reduce this impact?
Society, women and mental health
studies in the area of physical health show how the organisation of health care in the
county has been designed to privilege a certain class at the expense of others depending
upon the socio-economic status and the function of individual is a society. It is welldocumented that women in particular, have been the enduring victims of this political
organisation of health care. Statistics on the prevalence of mental illness in the community
show that women are more frequently ill than men. In general, the utility of mental heat
services is not commensurate with the prevalence between prevalence and utility (see
Bhargavi Davar, 1999, Reading List). In India the proportion of women attending the
.acilities is very low, as compared to men. This low attendance is partly explained by the
oon-availability of resources for women. The traditional mental health services appear to
primarily cater to the needs of male patients. Research indicates that mental hospitals show
gender -discrimination in terms of availability of beds. In short, even though women are
more frequently ill in the community, their utilisation of mental health services is lower
’■han men. This discrimination is also visible in the access to mental health care of mentally
handicapped children. Besides this, parents of handicapped young girls are less motivated
’.0 send them to these institutions for rehabilitation. There are no economic gains in doing
•his, as there might be in the case of boys who can still be trained for some usefi.il
employment. The mentally handicapped girl also helps out with the household chores. As
she is unlikely to get marned, parents would think if a waste to expend resources, material
or psychological, on her.
Mentally ill people, in general, are forced to suffer a stigma in addition to their
psychological suffering. Social attitudes towards and understanding of mental illnesses in
women are much more pernicious than that towards men. A mentally ill man is an
economic burden, but a mentally ill woman is an economic as well as a moral burden.
Mentally ill women may be severely condemned for any behavior that could be perceived
as a violation of feminine nature and modesty, such as tearing off clothes, violence
■o wards others, lack of attention towards the preparation or consumption of food, neglect
of children, etc. Mental illness in women is seen as a moral disgrace to the family and thus
-ensure, neglect, rejection and isolation are commonly associated with mental health. In
-he case of men it is a cause for sorrow, not disgrace. Many mentally ill women receive no
social support, either from their family not into the family into which they get married.
Marned and mentally ill women are more likely to be sent back to their natal homes,
abandoned, deserted or divorced. Our social way of life, its hierarchies, gender relations
-nd social structure, other than out perception of mental illness, all contribute towards the
■ arge scale neglect of mental illness in women. A concerted advocacy campaign could be
one major way of changing such negative and regressive attitudes.
13
Mental Health Policy and women
Our current National Mental Health Programme also reflects this culturally pervasive
insensitivity towards the mental health needs of women. This policy prioritises the severe
mental disorders like epilepsy and psychosis, whereas it is the common mental disorders
that are frequently found among the women in particular and the community in general.
Our national policy reflects the priorities of the priorities of the WHO, which is informed
by cost-effectiveness of implementation of policy rather than community need. While
severe mental disorders are more easily managed through the mental health and primary
health care infrastructure already available, common mental disorders require insight into
the social reality of the patient. Pharmacological interventions cannot be used in isolation,
and often, counselling and family therapy, may be required. All this needs long term social
planning and considerable shift in the current training and curricula for health workers of
all grades. Our current women’s health needs should not be compartmentalized into
‘reproduction”, “mental”, “physical” and so on. They key to a realistic understanding of
health needs is accepting that such categories are artificial. Indeed, it can be argued that
categories are created more to satisfy the needs of researchers and activists whose
experiences and training have been compartmentalized, than to cater to the real needs of
ordinary people. Thus, reproductive health research and programming will need to
incorporate mental health and mental health research and programming will nee'd to
incorporate reproductive health. The many potential themes of intersection of these two
crucial health domains described earlier provides an avenue for exploring these issues
using already existing networks and resources and without risking the stigmatization of
women who would, otherwise, not wish to be associated with a “mental illness”. While it
maybe premature to suggest interventions that address mental issues, reproductive health
researchers should take the .initiative to provide sufficient evidence to policy makers and
health programmers that Women Have minds too.
14
RESOURCE SECTION
Further Reading list (books/joumals in alphabetical order of first author)
c" L°V‘Ch' R" Mcmvel1'1 ^^apiro, K. (1997) Where women have no doctor—
a health guide for women The Hesperian Foundation, Berkeley USA
‘he third book in the senes "Where there is No Doctor” and by far, one of the most
oTZoe rfh'lT “T1? ' toVe
‘ F“" Of <ir’™8S a"‘l
advice
on a range of health issues including mental health and violence.
Davar, B. (1999) Mental Health of Indian women : a feminist agenda. Sage
Publications. New Delhi.
A book which reviews the literature on women and illness and explores a range of themes
Softiew
and hea'th SerV'Ce reSP°nSeS’ Written aS the title suggests from a feminist
Dennerstein, L„ Asthury, J., Morse, C.
ana tvtemat rtealtn Aspects
(1993) Psychosocial and Mental Health A.<
of Women \s Health WHO, Geneva.
P
dUiculZrWH°men? T?1 heaIth iSSU6S Published by the WH0 as a Report. It will be
ult to find m a bookshop but can be obtained from the WHO SEARO in New Delhi
Fischbach PL, Herbert B. (1997) Domestic Violence and Mental Health : correlates and
conundrums wthtn and across cultures. Social Science & Medicine; 45 ■ 1161-1170
A revmw art.cle presenting the evidence on the fe‘lati6nshiP between domestic violence
and its impact on mental health.
'
violence
v.ta^
Hance of Madness. Kangra: Alma Swasthya Kendra
‘hls bool< brings out vei7 clearly the fact that the context of women's health in India can
sexualitt
d°eS
Pr°be
‘he faCt°rS which COntro1 her labonr
sexuality, emotion, fertility, intellect- in short her whole being.
Kleinman, A. d- Good,
~
B. (1985) Culture & Depression: studies in the anthropology and
cross-cultural psychiatry
of affect
and
-------------- disorder.
University of California Press.
Berkeley.
tOgether " Wide ran8e °f PersPectives from linguistics and
Clin'Cal PSyCHiatry t0 eXpl°re the relatlonsh'P ^ween
K- (,9^1
Health in India: Issues & Concerns. Tata
Institute of Social Sciences. Mumbai
XXr™8 3 ra?8e °f iSSU6S re‘ating t0 mental health including its relationship with
aw, and policy, social support, NGO responses etc.
15
Murthy, P„ Chandra, P., Bharath, S. et al (1998) Manual of Mental Health Care for
Women in C ustody, NIMHANS, Bangalore.
An excellent practically oriented handbook aimed ai the mental health needs of women
prisoners. Available from NIMHANS.
Patel. K Where There is No Psychiatrist. A mental health care handbook for the
community health worker (Gaskell, London) in Press
This handbook, modelled along the “Where There is No Doctor” lines, is due for release
m 2000. It offers a novel approach a mental illnesses by focusing on problems faced in the
health care setting rather than psychiatric diagnoses. It also covers many gender-related '
mental health issues including postnatal depression, rape and sexual abuse. Contact the
author of this article for more details.
I atel, L, Araya, R., Lima, M., Ludermir, A. Todd, C. Women, poverty and common
mental disorders in four restructuring societies. Social Science & Medicine, in press.
A research paper which brings together epidemiological datasets from 4 developing
countries and demonstrates the consistent association between low income, low education
and female gender with common mental disorders.
/ atel, I. de Thara, R. Meeting the Mental Health needs in developing countries: NGO
Innovations in India
This forthcoming multi-author book described a dozen innovative NGO programs across
India covering a.variety of mental health issues. It aims to demonstrate how mental health
, care can be delivered in different community-oriented formats. The books is likely to be
published by Sage (India) in 2000. Contact the author of this article for publishing details.
Raghavan, K, Srinivasa Murthy, R. & Lakshminarayana, R. (1995) Women and Mental
Health-NIMHA NS, Bangalore.
This is the report arising from a conference held on this topic in NIMHANS. You can set
copies from the NIMHANS Publications Department.
SCAIU- (1998) A Study of Mentally Disabled Women. SCARF, Chennai (sponsored by
the National Commission for Women)
A monograph describing a research study on the impact of chronic severe mental disorders
on women and the attitudes of caregivers. Copies available from SCARF.
Some other books:
Davar, B .V. 1999. Dilemmas of Advocacy in Mental Health : Making Policy
Recommendations for Women. New Delhi: VHAI.
Govt, of India. 1981. National Mental Health Programme for India. New Delhi: AIIMS
nXiHANS
Mental Health Care by Primary Care Doctors. Bangalore:
Murthy, R.S. and B.J. Burns. 1992. Community Mental Health. Bangalore: NIMHANS
16
National Addiction Research Centre. 1994. Hysterectomy and the Mentally Retailed
Women: Issues and Debate. Bombay: National Addiction Research Centre.
NIMHANS. 1990. Training ofPHC Personnel in Mental Health Care. Bangalore:
NIMHANS.
Sriram, T G. et.al. 1990. Manual of Psychotherapy for Medical Officers. Bangalore:
NIMHANS.
VHAI. 1995. National Level Workshop on Alternatives in Women and mental Health
New Delhi: VHAI.
Resource Organisations working on mental health (in alphabetical order)
The following organisations are a selections of groups who have been working in the area
of mental health and women/reproductive health.
Anveshi
This NGO is based in Hyderabad and has been active in the field of women’s mental
health policy and theoretical research. On of its founders, Bhargavi Davar, has written a
book on the mental health of women in India. It is currently proposing to develop
materials for community based interventions for common mental health problems in
women.
For more information for common mental health problems in women. For more
information, contact Bhargavi at:davar@pn2.vsnl.net.in or write to: Rekha Pappu,
Anveshi Research Centre for Women’s Studies, OUB-1 Osmania University. Campus,
Hyderabad, 500007.
IFSHA
Interventions for Support Healing & Awarness is an NGO, based in new Delhi, which
works in the area of the mental health impact of violence and sexual abuse. It has recently
published a report on research it conducted on the experience of violence in women who
were admitted to psychiatric hospitals. It runs a counselling centre in New Delhi.
For more inforamtion contact Jasjit Purewal or Maya Ganesh
mailto:seher@del3.vsnl.net.in or by mail to: J39, 1st floor, South Extension 1 New Delhi
1100049.
NIMHANS:
The National Institute of Mental Health & Neurosciences is an autonormous University in
Bangalore which is the leading academic institution working in varied fields allied to
psychiarty, psychology and neurology. It is essentially a training institution for doctors
and mental health professionals but does host a variety of programs and workshops.
Many of its staff work closely with NGOs and in community mental health programs.
Persons you can contact who have an interest in reproductive health are Dr Pratima
17
Murthy, Dr Prabha Chandra, Dr Santosh Chaturvedi and Prof Mohan Isaac in the
Department of Psychiarty, NIMH ANS, Post Bag 2900, Bangalore 560029.
Sangath Society :
This NGO is based in Goa and its main activities are focused on behavioural,
developmental and emotional problems facing children and families. The author of this
article is a founder-member of Sangath. Sangath’s main activities are in the fields of Child
Development & Learning Disability Adolescent Sexuality, Family violence, Depression
and other mental health problems affecting families. Ongoing research projects include
studies on postnatal depression, the use of counselling for the treatment of common
mental disorders, the impact of violence on the mental health of women and children and
adolescent mental health. The Society has a multidisciplinary approach to behavioural
problems and its staff include doctors, social workers, psychologists and teachers. For
more information, contact Vikram mailto:vpatel@vsnl.com (address:Sangath Centre.
Porvorim, Goa 403521).
SCARF:
The Schizophrenia Research Foundation in Chennai is India’s leading NGO workingexclusively in the field of mental health. It is a recognized WHO Collaborating Centre and
has pioneered a comprehensive range of services for persons with severe mental disorders.
It has an active research program dealing mainly with schizophrenia and has published
many articles on its effect on women. The Director, Dr R Thara can be emailed on :
scarf@md2.vsnl.net.in or by mail to Schizophrenia Research Foundation (SCARF), R/7 A,
North Main Road, West Anna Nagar Extn, Chennai 600101
TISS : The Tata Institute of Social Sciences (Mumbai) is a leading autonomous institution
m the field of the social sciences in India. It has a department of Medical and Psychiatric
Social work which has been conducting programs and research in various aspects of
mental health. Key contact persons are: Dr Surinder Jaswal, Dr Pumima Mane or Kety
Gandevia, at TISS, Sion-Trombay Road, Deonar, Mumbai 400088, Dr Jaswal can be
reached on :surija@tiss.edu
Other Resources
You may also find resources in local medical schools or psychiatric hospitals in many parts
of India. Some other contact addresses and resources in the non-govemmmental sector
are:
1 Alzheimer Diseases & Related Disorders Society of India (ADRDSI): Dr Jacob
Roy, Villa Tropicana, XV/496 Thrissur Road, Kunnamkulam, Kerala 680502 Works
in the field of family support and care for patients with .Alzheimer’s Disease.
2. Antarnad : Dr Apoorva Shah, 402 Shikhar, nr. Mithakali Six Roads, Navrangpura,
Ahmedabad : Works in the field of psychotherapy and child mental health
18
J
4.
Forum for Mental Health Movem
ent: Ms Ratnaboli Ray, 93/2 Kankulia Road,
Benuban#A302, Calcutta 700029:
A collective of NGOs working in mental health anc
allied fields
Medico-Pastoral Association
: Lata Jacob, 47 Pottery Road, Fraser Town,
Bangalore : 560005: Provides resident?!
illness
------------- J Care and rehabil'tation for severe mental
5.
sb
6.
Richmond Fellowship Society; S Kalyanasundaram, Asha 501 47th cross 9th M '
7
Samadhan: Pramila Balasundaram, Day Care Centre, Block F
. •, .- ,,
- • Main Park, Sector V,
Uakshinpun, New Delhi 62: u,orks
•. •in
the field of mental retardation
8 fSn|?ar Df Lakshmi V'jakumar, 4 Lloyds Lane, Royapetta
. .
im, Chennai 14. Works in ths
neld of suicide prevention.
9 TT Ranganathan Foundation
Dr Anita Rao, 17 IV Main Road, Indira Nagar
Chennai 600020. Works in the field of alcohol abuse.
Booklet prepared by:
Text: Alok Srivastava, Jashodhara Dasgiipta
Additional text, and review : Vikram Patel
19
\
U.
i I r ■
UNDERSTANDING
REPRODUCTIVE HEALTH
A Resource Pack
.A
•HA.
’
’•
Booklet - Eleven
•v .
SEX AND SEXUALITY
J. ,>>
'v-L.- -Z'/
Acknowledging Ourselves
'■
f; .':Vj v
SAHAYOG
A'-’p
-'V.' ?<
- Kt.'C.f!.' ^.A‘l
5
>•■
r'v.
CONTENTS
INTRODUCTION
Section One : Understanding Sex and Sexuality
Sexuality
Sexual Health
Sexual Anatomy
Puberty
Social Construction of Sexuality
Sexuality and Reproductive Health
Common Sexual Problems: Sexual disorders and dysfunctions
1. Sexual dysfunctions in men
2. Sexual dysfunctions in women
Preventive and curative aspects of sexual health
Different forms of sexuality and gender
A. Heterosexuality, homosexuality and bisexuality
B. Transvestitism, cross-dressing and Transexualism
C. Hijras
D. Paraphilias
Section Two: Issues and Debates in India
Human Rights and sexuality
Indian history and sexuality
Sexuality and sexual behaviour in India
Heterosexuality the only acceptable form of sexuality
Homosexuality
Male Homosexuality
♦
Female Homosexuality
Crime and sexuality
Child Sexual Abuse
Rape
Eve Teasing and Sexual Harassment
Section Three: Working on Sexual Health Issues
Research
Education
Services
Media
Law and Policy
Organisations working on Sexual Health and Sexualirv
Resource Section
Further Reading
Other Resources
Resource Organisations
4
4
4
5
. 5
6
7
7
7
8
8
9
9
10
10
11
11
11
11
13
14
15
15
15
15
16
17
17
17
17
18
18
18
21
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22
23
2
INTRODUCTION
The most pressing of human biological needs after hunger is probably sexuality. This is
also probably the least talked about subject and the one which carries the biggest taboo.
Religions, philosophies and legal systems - all concerned with shaping human behaviour,
have typically tried to establish sexual values and taboos. It is still a subject about which'
not enough is known, and myths and misconceptions abound.
As talking about sex and sexuality in polite circles has been a taboo for a long time our
language for talking about these is also very limited. It is especially difficult to talk about
sex in Indian vernacular languages because most of the words available to talk about sex
and sexuality are also abusive words. There is a schism between public discomfort and
private obsessions about sexual issues. Being open about sexuality threatens people who
can get away with sexual abuse and exploitation, including perpetrators of rape and incest.
These people, among others, take advantage of the strict silence maintained on these
issues.
However, things are changing now, and suddenly people are talking about sexuality
everywhere The most important reasons are the onset of AIDS and globalisation. Also,
the International Conference on Population and Development (Cairo 1994) has introduced
sexuality as an issue, to the development agenda. Consequently a lot of the taboo around
the subject is also disappearing and new sexual mores are forming.
Unfortunately, there is still very little being done on the issue of sexuality. There is a
serious dearth of available data on the various issues involved. The government is still
hesitant to address sexuality, even though reproductive health has been the focus of
government attention for the last 50 years.
In this booklet we shall look at some of the terms used and issues involved vis-a-vis
sexuality, besides examining current debates surrounding the topic
Section One
UNDERSTANDING SEX AND SEXUALITY
Sexuality
The word sexuality has not been defined very clearly. The word ‘sex’ is generally used to
mean male or female (biological gender) or to rerer to physical activity involving the
genitals (having sex). The word “sexuality” has a broader meaning since it refers to all
aspects of being sexual. Every person has sexual feelings, attitudes and beliefs yet each
individual's experience of sexuality is unique, because it is processed through a uniquely
personal perspective. Sexuality is a complex phenomena, and has several aspects It
includes the various ways of expressing sexuality and the various sexual preferences or
dislikes that people have. Hence, sexuality has biological, psychosocial, behavioral clinical
ana cultural dimensions.
Sexuality includes how one regards one’s body and self-image and the manner in which
societal norms affect the construction of the same, the way we communicate our sexual
ee ings and needs, what stands we take on matters relating to sex, the ethics and values
that we uphold on sexual matters and so on. All these affect the way we see ourselves and
others as sexual beings and how we express our sexuality.
Sexuality therefore has two dimensions —
— outward
outward and
and inward.
The outward
outward includes
includes
inward. The
perceptions of one’s sexual needs and their expression of this. Inward sexuality includes
one sown perception of sexual pleasure (or lack of it), sensuality, and the kinds of
. meanings we ascribe to our sensory perceptions.^
Sexual Health
Sexual Health refers not only to the condition where there is an absence of sexual
problems and dysfunctions, but also to the enhancement of the quality of sexual
rImZ?5 a^.PerS°nal life fexuai health is not limited by the mere understanding of
reproduct.ve abilities but goes further to include the ability to experience a pleasurable and
seZClnZ3?7 SefrXUa'hea‘th !S Wf°men and men’s abilitV t0 enjoy and express their
sexuality, and to do so free from nsk of sexually transmitted diseases, unwanted
pregnancy coercion, violence and discrimination. Sexual health means being able to have
an informed, enjoyable and safe sex life, based
rel/ti1^65?6"1’ .
aPPrOach t0 human sexuality’ and mutual r«pect in sexual
relations. Sexual health enhances life, personal relations and the expression of one’s sexual
' en iy. It is positive, enriching, includes pleasure, and enhances self-determination
communication and relationships.
™nauon.
Sexual health is fundamental to the development of one’s foil human potential to the
enjoyment of human rights and to an overall sense of well-being. By endorsing sexual
4
health for all - legal, health and education sysxems build a strong foundation for preventing
and treating the consequences of sexual violence, coercion, and discrimination.'
Sexual Anatomy
Sexual anatomy is usually thought of as including the various reproductive organs like the
vagina, clitoris, breasts and anus in women, and the penis, testicles and anus in men.
However, in reality, the entire human body is capable of receiving and giving sexual
sensations. This includes our hands, hair, eyes, skin, mouth and every other part of the
human body.
Puberty
Puberty is the phase ot adolescence in which boys and girls begin to develop the sexual
and physical charactenstics of adults. Puberty can start as early as 8 years in girls and 10
years m boys. In boys these changes are triggered by increased production of the male sex
hormone called testosterone. In girls these changes are triggered by the production of the
female sex hormone known as estrogen. Every young person’s biological timetable is
different, and wide variations regarding the beginning and end of puberty are quite normal,
While infants and children also have sexual feelings, these are not developed and
conscious. Puberty is the time when boys and girls begin to take a definite interest in
sexual relations and start experimenting with some form of sexual behaviour.
Social construction of sexuality
The social constmction of sexuality refers to the process by which sexual thoughts,
behaviours, and conditions are interpreted and ascribed cultural meaning. This^hird
element incorporates collective and individual beliefs about the nature of the body, about
what is considered erotic or offensive, and about w'hat and with whom it is appropriate or
inappropriate for men and women to do or talk about sexuality. In some cultures,
ideologies of sexuality stress female resistance, male aggression, and mutual antagonism in
the sex act; in others they stress reciprocity and mutual pleasure.
The social construction of sexuality is inevitably linked with cultural concepts of
masculinity and femininity. Ideas about what constitutes the essence of “maleness” and
"femaleness” are expressed in sexual norms and ideologies. Cross-cultural studies reveal
that, the imagery of manhood in most societies is a “culturally imposed ideal to which men
must conform (often at great cost to themselves and to to others) whether or not they find
it psychologically congenial”. This is also true for females as they must conform to ideas
of "womanhood” within a particular culture. In our own culture, a familiar script that has
been constructed to guide female sexual behaviour places emphasis on virginity and
chastity for the woman. This construction in rum impacts the self image and behaviour
patterns of many women.
5
The contradictions of male power and sexuality are expressed in men's efforts to dominate
women, which derive from male physical, material, and ideological advantage and in their
anxieties about failure and loss of face. Sexual potency is equated with men’s authority
over women, thus, attacks on potency threaten male power, and vice versa
Sexuality and Reproductive Health
Women’s reproductive health as we know it today is based on the principle that every
woman has a right to reproductive health, that is, not only the right to regulate her fertilitv
safely, remain free of disease and bear healthy children, but also to understand her
sexuality. It further recognizes that rights to sexual as well as reproductive health are vital
elements of physical and emotional well being.
A woman’s ability to negotiate during sexual intercourse affects safeguarding of
Reproductive Health in many ways. This negotiating power depend on a lot of factors
including her self-esteem, social construct of sexuality and empowerment of the woman
Women in India, largely, lack all of these factors ,making them highly vulnerable to
unwanted pregnancy, STDs, AIDS and other infections.
The fact is that women are not allowed to be sexual in mainstream Indian society. They
are brought up to feel ashamed of their own bodies, which only results in low self-esteem
The social constructs that determine the scope of female sexuality, force women to repress
their sexuality until they get married. Then suddenly one day the woman is expected to
surrender completely to a husband - who is in effect a stranger, who will from now on
control her sexuality. In this situation, she is unable to negotiate during sexual intercourse
thus leaving her vulnerable to unwanted pregnancy,'infections and forced sex.
C<T?tlOnS surroundin8 sexual initiation have particular importance in shaping attitudes
and behaviours, including long-term reproductive and health outcomes. According to
research, girls who have experienced sexual abuse as children are more likely than°others
to have early first intercourse and more sexual partners as adolescent and young girls
ey are also more likely to have unintended pregnancies and STDs including HIV
K e 3 W°man’S
'S mcumbent on marriage and facilitated
OrJu
husband’ mafginafrsed women like Commercial Sex-Workers are
d0,7 °n.by
for bemg visibly sexual. They are seen as a threat
to the health of their male clients, while their own reproductive health is ignored Since
h is” “ W°tril'rS toVe
soctay
- seen as sJXarZgs
it is easy to ignore their reproductive health rights.
if nm
1
One reason why the family planning programme has not been so successful in India has
^"because the .ssue of sexuality was never addressed when talking about reproductive
info d
uXample d° nOt Hke t0 USe C°nd0ms’ even when they have all the
nformation, because they feel it reduces their sexual sensations.
6
Common Sexual Problems: Sexual disorders and dysfunction
L Sexual dysfunction in men
Loss of Sexual desire -Loss of Sexual desire or libido may be due to different reasons,
including psychological and other factors such as stress, anxiety, fatigue, misdirected
sexual desire, etc.
Impotence and Erectile Failure - It is the failure to achieve an erection. It is a common
be men. Almost everyone goes through a phase when he is impotent. The
problem faced by
most common causes of erectile failure are psychological (e.g. anxiety), neurological
disorders, impediments in the blood flow (e.g. vascular disease), hormonal deficiency,
penile infection, diabetes, etc.
Premature Ejaculation - Premature Ejaculation is <a very common problem, especially
amongst younger men. The condition can be defined1 as an inability to delay ejaculation to
a point when it is imutually desirable for both partners. This duration can vary for different
men. Most causes of premature ejaculationi are psychological in nature (e.g. anxiety) but
some cases are due to physiological reasons. (CAN WE ELUCIDATE?)
Delayed Ejaculation -Some men can not ejaculate soon enough. This problem though
not so common can be as distressing and can make sex unpleasant. This problem also has
psychological as well as physiological reasons. (CAN WE ELUCIDATE?)
Painful Intercourse - There could be numerous reasons why a man has pain during
intercourse including a tight foreskin, lesions on the-peniS, blisters caused by herpes and
diseases like Peyronie’s disease. *
2. Sexual dysfunctions in women
Lack of sexual desire - Lack of desire is a very common sexual problem amongst women,
t can have a physical cause, such as chronic illness, drugs, etc. or (more often)
psychological causes like guilt, anxiety, depression, etc. Counseling and sex therapy can
help find out the causes and getting over them.
ainful intercourse - This is also known as dyspareunia and is mostly due to physical
reasons like a vaginal irritation or infection, an allergic reaction to a douche or a
contraceptive product due to which movement of the penis inside hurts. Sometimes there
is a psychological reason for painful intercourse like when she is not getting aroused. In
such cases, her vagina may not lubricate, and intercourse will be painful.
Anorgasmia - It is the inability of a woman to achieve orgasm with a partner. The main
cause is due to sexual illiteracy on the part of both the woman and
7
her lover. It could also be due to religious and social prohibitions that have precluded
learning orgasmic responses through masturbation. Anxiety (e.g. caused by eagerness to
achieve orgasm) can also impede with orgasm.
Preventive and curative aspects of sexual health
1. Sex education - Sex education for young people and adolescents was an unthinkable
topic in India just a decade ago. A lot has happened since then, and there is a growing
general consensus at least in big cities in India, about the importance of sex-education.
The single most important factor in this change of attitudes is the spread of AIDS and the
growing realisation of the vulnerability of young people. Though there is some agreement
on the need for sex education, the exact content and the age from which it should start,
are still topics of hot debate. Some people believe that sex education should stress
biological and physiological facts, while others feel that morality should be the core
content of sex education . On the other hand some argue that sex education should
include awareness of needs, desires, autonomy and responsibility. There are still others
who want students to learn about only that pan of AIDS awareness which does not
concern sex.
2. Counseling - Counseling on sexuality refers to guidance provided to an individual or
couple by a sex therapist, counselor, social worker, psychiatrist, or doctor on such
questions as conception, family planning, infertility, fear of failure in performance,
unresponsiveness, sexual anatomy and physiology, techniques of intercourse, AIDS/HIV,
STD’s etc. It is a new concept in India.
3. Sex Therapy - Until recently, in the event of a sexual problem, the majority had
nowhere to go. Taking advantage of this, numerous unscrupulous sex clinics erupted all
over India. These clinics offered all kinds of cures, including magico-religious cures, for
perceived sexual problems (which are in fact, not problems at all) like masturbation and
pre-ejaculation. Their clients are mostly men. Women have nowhere to go in case of a
sexual problem. Even today, these sex clinics thrive, but in some big cities there are now
sex counsellors and therapists as well. ( add)
Different forms of sexuality and gender
In this section we describe those forms of sexuality which are defined by the person or
object which is perceived as sexually attractive or arousing, e.g. homosexuality, where a
person is attracted to someone of their own sex. This classification of sexuality is not the
most appropriate one. But it is the single system which society is preoccupied with.
Defining sexuality with reference to the sex it is directed at and then building whole
identities around them, complete with labels and stereotypes, is a typical western
phenomena. It presents a highly limited view of sexuality and only serves to discriminate,
stereotype and discourage or punish that which society can not come to terms with.
Sexuality is much more fluid in India and usually does not limit an individual’s identity to
one particular stereotype.
8
A. Heterosexuality, homosexuality and bisexuality
Heterosexuality: Heterosexuality is the sexual attraction between people of the opposite
sex, i.e, male and female. In the west people who consciously choose to live such a
lifestyle are called heterosexuals. Though rights fcr people opting for other sexual
identities are increasing, this is the only identity w nich is consciously and aggressively
promoted as the ideal form
Homosexuality: The sexual attraction or activity between two or more people of the
same gender is known as Homosexuality. In the w est homosexuals refers to that group of
people who consciously choose to take on a homosexual identity and lifestyle
Bisexuality: The sexual attraction or activity towards people of both male and female
sexes is known as bisexuality. Many psychologists believe that human beings are born
bisexual and that most of us stay that way in combinations of heterosexuality and
homosexuality, whose ratio may alter from one time to another. However, given the
extent of homophobia in society at large, most of us try to suppress and deny the
homosexual aspect of our personality, and thus appear to be largely heterosexual.
Homophobia: Homophobia refers to an illogical fear or hatred of homosexuality.
Institutionalized homophobia can manifest itself ir. policies and laws that seek to exclude,
punish or discourage people who practice homosexuality Internalised homophobia
manifests itself in feelings of guilt, self-hate and suppression of the homosexual aspect of
our personality, while externalised homophobia represents hostility towards or ridicule of
others who practice homosexuality, including by homosexuals themselves. Homophobia in
many parts of the world is an integral part of the social construction of male sexuality.
B. Transvestitism, cross-dressing and Transsexualism.
1 ransvestites: Transvestites are people who dem e sexual pleasure from wearing the
dothes of the opposite gender. Female transvestites are not very visibly in society and are
therefore left alone. Male transvestites usually wear feminine clothes in private. Some may
'-‘-ear them in public and may then be mistaken for women. Transvestites may be
heterosexual, homosexual or bisexual. In many areas in India ritual tranvestism is accepted
on social and familial levels
Cross-dressers: Cross-dressers are people, who like to wear the dresses of the opposite
gender, and there may be no sexuality involved here..
r ranssexuals: Transsexuals are people who beliex e that they are born with the wrong
sex. E.g. a female transsexual may feel she is actually a man with a female body.
Transsexuals frequently describe their dilemma as ’being trapped in the wrong body’.
Surgery can change the outer sexual organs, but they cannot function as reproductive
organs
9
C. Hijras
ermaphrodites and not all Hijras are castrated There is verv littlp inf
•
! ,ta'b''n ,ar6dy "egleCKd
“ “IXh
rest of them join IteXX K XX sVX.'/oXher'r'8'’' 7'
for castratton, though it is allegedly forced on some men.
'
transsexuals °Pr
Hijras practice a range of'sexual activities with men or women or both In the olden davs
jras had a certain place in society and they were assumed to have supernatural oowJs
segments of the communny
SOme
ntercourse which is widely practiced by the Hijras is a punishable crime in India though it
-Xz™ rld h“ -h- “
Xh *
Hijras
■»—"X “X
”voiv™“1s“-™k- ‘h'y « Potentially at risk for HIV/A1DS
°f any o,g“ised HIV pt'oeotion work being conducted with the
D. Paraphilias
Paraphilia IS a condition in which a person’s sexual arousal and gratification denends on a
„,s„d ls
wftchi y,peop e get sexually aroused by very explicit sexual language, others bv
examples ofn partnerSUndress or making their partners undress them. Some common
SX MX
Section Two
10
ISSUES AND DEBATES IN INDIA
I. Human rights and sexuality
After a brief period of openness witnessed in Indian society, there has recently been a
significant conservative backlash, against the surfacing of “sexuality” issues Disturbing
instances have been witnessed in the recent past. M.F. Hussain being hounded out of the
country for painting a nude Saraswati, a sanyasin harassed for praying clotheless
hooligans coming to the street against the screening of the film ‘Fire’ which explores a
esbian relationship, a programme giving information on AIDS and sexuality called “Kam
i baat taken off the air by the government for being “against Indian moral values". And
these are just a tew examples of a concerted effon to limit human expression.
Sexuality has never been acknowledged as a human rights issue in Modern India Indeed
there are repressive laws against many forms of sexual behaviour which in various
advanced countries have become lawful. Marginalised communities like sex-workers or
gay and lesbian people are not considered fit to have any rights and thus live on the fringes
or society.
°
As the concept of human rights gets more firmly entrenched in the minds of the Indian
people, as they get more and more informed, and as their financial independence increases,
more and more people are now getting aware of and demanding their rights as sexual
beings This includes the right to practice with dignity the so called alternative forms of
Xm 'ty’lhat 1S’ th°Se fo™5 WhiCh faH °UtSide the heterosexua1’ monogamous marriage
Indian History' and Sexuality
Ironically, India was once a place, which led the world as a far seeing and liberal country
■ ncient India was surprisingly open on issues related to sex and sexuality We have
innumerable temples depicting erotic images of all kinds of sexuality practiced by both
go s and humans . The Linga, or the Phallus of Shiva is worshipped till date by Hindus
as a sacred power. Garba Grihas and Yoni temples, representative of the Vulva have been
abundant in the past. Kamakhya in Assam and the Bhagawathi temples in Kerala are living
proof of the value ascribed to the Yoni. (That they are now fewer in number has more to"
bo with patriarchy than repressive sexual codes) It is a fact that Indian culture never shied
away from the sexual and cthomc. The Kamasutra. a document on sexual techniques
practices and codes, which is still looked at with awe by the West, was written by
atsyayana in ancient India. It is not a co-incidence that this was also the golden period of
Indian History, where women had more rights than ever.
Heterosexuality the only acceptable form of sexuality
This is the only form of sexuality which is accepted as natural and healthy in our society
specifically, heterosexuality wthm marriage is the idealised and accepted norm There is a
big social gap between men and women in our country. Gender roles are clearly defined
II
and interaction between the sexes is usually cot regarded with glee. Therefore, it is not
asy or young men and women to relate to or communicate with each other and any
interaction on the sexual plane is often purely physical, sometimes even within marriage
Soc.ety at large does not appreciate a man and a woman, who are not related to each
actJill °deVen
in PUbliC' In d’iS Way’ hetero^xuality outside marnage is
actua ly discouraged and suppressed, which makes the Indian sexuality scene a bit
complicated.
7
omen in such situations are suppressed socially and sexually. Because of the cultural
construct, men have relatively more opportunities and freedom to develop extra-marital
affairs or to visit sex-workers.
P
al
The scene 1S gradually changing in bigger cities, with more and more young couples ootine
for love-marnages However, given the big social divide still strictly maintZ!i between
men and women, there are not enough opportunities for them to meel each other in
ppropnate social settings. As a result an increasing number of men and women aJ
leading lonely hves either because they do not want to get into an arranged marriaee
situation or because it is not working for them. FurtheLre, in many foXTnS girls
e not allowed to interact with boys when they are actually thrown into mixed gender
oc.al settings at college or the workplace, they are. often unable to discern rightfrom
wrong and end up making the wrong sexual/marital decisions.
Coming to heterosexual act. vaginal intercourse between two married people is socially
is Z
/ 6 °u Y h°nOrable sexual act’ and any o^er form is discouraged Masturbation
rouded m taboo and all manner of guilt is associated with it. There actually exists a
it hasTe"5' h"3 3nd
lnterC0urse’ with hfe-imprisonment as the sentence, even though
I wife ZsuTfor I aSainfSt h heter°SeXUal C°UPle <and rare|y gainst homosexual one^s)
with he
6
Pr°Ve that the huSband had anal or oral intercourse
Thus in a typical marnage situation, if the husband wants anything other than vagina!
sources
°f his wife He would seek it from other
sources such as sex-workers, male partners or Hijras. .And by the same yardstick the wife
u d not seek any pleasure, discuss her needs or make any requests of her husband She
Y SUPPrSS °r Sublimate 311 her desires’ since outside pleasure providers are
in her case because of the constraints of her gender. Ofcourse very often the
htpro? r Tre""sancti,y ofhis wife and plous,, ” with h»ppy
uisregara tor his wife s feelings.
Homosexuality
12
Being an integral part of human sexuality, homosexuality has existed in all societies and in
a times. However, it has been violently suppressed for centuries in many parts of the
world, the root of which can be traced to the beginning of the Judeo-Christian-Islamic
religions. Most ancient societies accepted homosexuality and even today in many societies
>t is accepted, even expected in cenain forms. Today, worldwide, homosexual men and
women have to fight for their basic rights and dignity.
In ancient and medieval India, though there were no special rights for homosexual people,
homosexuality was not punished or suppressed by the state, society or the religion. The
British brought with them their distaste for homosexuality and enacted a law against anal
intercourse (which was their limited view of homosexuality). This law (Sec 377 IPC) is
still used by authorities to harass gay men in India. Many organisations view this law as a
violation of human rights and a court case is being fought against it.There have been manv
instances of homosexuality both male and female in Indian history and mythology Babur’
Alexander the Great, and Sharmad Shahid are some of the people whose written accounts
of loving other men can be found. Many ancient temples, including Khajuraho have
cpicted male and female homosexuality. Even the ancient Indian sutras on the art of love
making talk of homosexuality.
Today there is a strong social stigma attached to homosexuality in India. Indeed, most
people believe it does not exist in India and is a Western phenomenon. Amongst several
other myths and misconceptions that abound regarding homosexuality is that it is
unnatural, abnormal or a disease, or that people are made homosexuals by others, or that
male homosexuality reflects the effeminate part of a man, while female homosexuality
represents a masculine female.
The biggest and most effective way in which a society suppresses homosexuality is
through what is called the 'conspiracy of silence’, i.e., by not allowing any discussion on
t e subject. Many gay and lesbian people in India live in closets and/or are married Such
marriages spell trouble for both partners. Other problems frequently faced are ridicule, low
self-esteem and guilt - all of which are perpetuated by mainstream messages which do not
allow for any behaviour outside of the heterosexual marriage norm. Many gay and lesbian
people perforce hide their sexuality and pass off as heterosexual which is mentally and
emotionally taxing. Many others isolate themselves in order to avoid such pretense.
Finding a partner is extremely difficult for most, as there are almost no opportunities for
gay people to meet each other socially. Gay relationships, when they do occur, are greatly
tried because of the absence of any support system The problems a gay or lesbian person
aces are compounded by the fact that they cannot talk about their sorrows or happiness
with any other person, not even their close friends and relatives.
Adolescence is the time when one’s; sexuality develops and it is normally a tumultuous
period. Most homosexuals become ;aware of their homosexuality during adolescence.
Dealing with one'ss homosexuality
’
and a hostile society during one’s adolescent, without
any help, can be a truly traumatic experience which1 can stay with the person for the rest of
his or her life. Many men and women commit suicides in India every year with causes
13
related to their homosexuality. Many among them are adolescents. According to a report
on such suicides in Kerala, the cause for their suicide
— iin most cases is not reported. Some
men visit special places which are used by gay men for cruising (a term which refers to
finding sexual partners in public places), such as parks and other busy places. Such men
are routinely harassed by unscrupulous policemen who extort money and often Lrape’ their
victims. Lesbians do not have any place where they can find such partners. Homosexual
people in India face these and innumerable other problems in silence. There is a great
discomfort in all sections of the society (including the state and the media) in dealing with
the issues of homosexuality in a non-stereorypical and comprehensive manner.
However, there is a bigger and very immediate problem that cannot be ignored. AIDS is
spreading fast in India and unprotected penetrative sex between men is one potential route
of HIX transmission. Ofcourse the same is true of unprotected penetrative sex between
any combination of partners who are not aware of each other’s sexual history, but because
of the vulnerability ot anal membranes to lesions gay men are considered particularly at
nsk. Unfortunately, any initiatives to deal with this problem have come from the private
sector and the authorities are highly averse to addressing the issue. According to NACO
figures there is negligible HIV transmission through homosexual routes in India.
Many gay and lesbian support groups have come up in major cities in India which on one
hand are trying to help gay and lesbian people build an indigenous gay and lesbian identity
and on the other are trying to fight social oppression. Many non-gay/lesbian organisations’
are also working with homosexual people through counseling, ATOS networks and other
community based work etc. They are also disseminating information about homosexuality
in the general public to reduce the stigma attached Jo the.issue.
There are not many statistics available in India-regarding the instance of homosexuality.
Whatever is available, is mostly on male homosexuality and hardly anything on female
homosexuality. There is a huge need to carry out both qualitative and quantitative studies
in this field.
(a) Male Homosexuality
In India male homosexuality has a peculiar position. While on one hand there is a lot of
hidden sex amongst men in the form of bisexuality, as long as it is not talked about and
made into an issue, society also condones it. On the other hand, there is a strong stigma
attached to totafofout homosexuality. The important issue here is marriage. If one sets
married and carries on a hidden homosexual life, it is no problem to the society. However,
choosing not to get married and openly professing a homosexual life-style is a big
(b) Female homosexuality
While male homosexuality has from time to time received attention, albeit negative from
society, female homosexuality has largely been ignored. It follows from the same
14
misconception that assumes that females are not sexual beings. Female to female sex is
also ignored because many people cannot comprehend sex without penetration. Female
homosexuality had not in the past met with such vio-lent disapproval as male
homosexuality, though this is fast changing. Lesbianism has always existed in India as in
other societies. There are ample instances of it in our art, history and mythology. There
have been several reported cases of two women marrying each other or committing
suicide together. Women's institutions like schools and hostels inevitably have one or
more women who stay together as couples. Many lesbians in India have been active for
decades in the women's movement, and many sections of the women’s movement have
supported and promoted the rights of lesbians.
Crime and sexuality
1. Child Sexual Abuse
There is a high incidence of child sexual abuse and incest in our society. Unfortunately its
existence in our society is not readily accepted.Its prevalence is slowly beginning to
emerge as a result of work that has been done over the last few years. Also the taboo on
the subject is loosing it’s hold and more and more cases are now being reported. Most
abusers of children are family members, relatives or someone known to the victim. Most
abusers are people whom the child trusts and who enjoys power or authority over the
child.
Research has established that child sexual abuse happens in a range of Indian families
coming from all socio-economic groups. Abusers are people we encounter everyday in our
families and amongst our friends. Children never cause or. provoke the abuse. The abusers
depend on the silence that surrounds sex and in either overt or covert ways, convey to
chiidren the message that the abuse should be kept a>ecret.
2. Rape
Rapes are most often committed by acquaintances, not by strangers, as is commonly
believed. It is not random, but a pre-meditated act on the part of men. There is a strong
misconception in society that ascribes women’s immodest and provocative dress and the
secret sexual longing of women to be raped, as reasons for rape. Rape victims are usually
made culprits by both society and the law. Most rape victims do not want any publicity
because they fear humiliation and rejection by the family. If the woman is ready to take the
publicity, the legal process in itself is a sad and frustrating story.
The police, armed forces and para-military forces ofh a misuse their position of authority
with impunity and commit sexual violence and rape ag» mst women. Custodial rape is also
common. What is surprising is that they are often set sco‘f free by the courts, which
reflects the need for a drastic changes in our laws
3. Eve Teasing and Sexual Harassment
15
«-
be bo>s"
Sexual harassment at work is even more serious. It often spells demoralisation loss of
power. If refused the employers/ bosses will either make life difficult for the employee or
simply find excuses to fire them. Complamrs to higher authorities are usually unheeded
The e is a general feeling amongst employers that if women have dared to come out to
work they should be able to “handle” such “minor” problems by themselves. Low or no
the alt-a’-s
are eXTeZr"'6
Women who move m public spaces’ are perceived to be transgressing the boundaries of
male propriety and are therefore considered a sexual provocation, to be teased harassed
or assaulted. In a society where family honour is linked to the virtue of its female
rape are often used in proper,v “and “0MI
-”ndr 'nKl“lilies
high Like any other society where sexual
ssues are taboo, people do not enjoy sexual rights and therefore suppress their sexuality
an further perpetuate gender imbalances through various displays of power This resufts
huVeCeS 'V; Pr°” “
thoseZL se^i ’
souse, rape and sexual harassment
Section Three
WORKING ON SEXUAL HEALTH ISSUES
Sexual health is emerging as one of the new areas of concern in all sectors- Research,
Advocacy or Service provisions. There is a great lack of proper information or
documentation about sexual health issues and myths and misconceptions about. Education
on sexual health for different sections of the public is also one of the key emerging issues.
Lnless public education takes place numerous people will continue to suffer, unaware of
the nature of their problems and ignorant about the measures they could possibly take
Some of the key areas for future interventions are outlilned below.
Research
T here is a acute shortage of information and data on sexuality and sexual health. For one
the issue has been shrouded in morality as well as myths. Thus there is hardly any
information about sexual behaviour and practices, dysfunctions and problems of the
people in our country. Small beginings have been made by different institutions in trying to
understand these. There is a great urgency for more information on these issues especially
with the AIDS epidemic looming over our country.
Education
Women, men, adolescents and children need to be educated about positive self-identity,
self-esteem, decision-making and relationships based on equality and respect in addition to
ba'sic information about sex and sexuality including reproductive health, STDs AIDS and
HIV They should also be made atvare about gender equality and acquire respect for
diverse forms of sexual expressions and life-styles. Unfortunately whatever little
information is distributed to the public on sexual health mainly relates to diseases. All the
other important aspects of sexual health, e.g. those that promote healthy sexual
relationships and help one enjoy a satisfying sexual life are often ignored. Another area of
concern with regard to sexual health education is the moralising that is often done in the
name of education. All sexual health educators must be extremely cautious in this regard.
Services
Good quality, respectful and confidential sexual health care throughout the life-span
should be provided. Such care should be responsive to user needs and confidential. It
includes providing counselling, clinical services for STDs, HIV, AIDS, sexual
dysfunctions and problems, sex therapy, etc. It also includes supportive and active
response by health care providers to suspected and actual instances of sexual abuse and
violence. There should be an efficient referral system and respect for ethical and quality
standards.
I here is also need to do work to promote safety in sexual relationships. The safety
17
referred to here has many aspects. It induces safety from sexually transmitted infections,
inc uding AIDS and HIV, safety from unintended pregnancy, safeguard from harmful
social or religious practices like genital mutilation of women (e.g. amongst bahai’s in
Bombay), or of men in the Hijra communirv, etc.
Media
The media should promote positive and diverse portrayals of women’s and men’s
sexuality, sexual relations based on mutual respect and autonomy, promote diverse and
diverse male and female images which highlight power sharing behaviours It should
develop campaigns on sexual health issues, e.g., violence against women, sexual violence
and abuse and harmful sexual practices including female and male genital mutiliation
Laws and Policy
Legal aid services to inform men and especially women (including girls) of their human
rights and legal rights need to be provided. .All legal, regulatory and social bamers to
access to information and good quality health services, including age and marital status
restrictions and other forms of discrimination need to be removed. Legislation which ~
prohibits discrimination on the grounds of sexual onentation and protects the human rights
of people who are so discriminated against need to be be developed and enforced. Similar
provisions to ensure a full range of sexual and reproductive health services should be
egislated. Legislation that protects girls and women from violence by criminalizing rape
including rape in mamage and in situations of armed conflict, incest, sexual exploitation ’
and trafficking, female genital mutilation, infanticide and gender-based genocide should be
formulated. The human rights of all people regardless of health status or disability
including HIV/AIDS through legislation which prohibits discrimination should be
ensured.
Organisations working on Sexual Health and Sexuality
As mentioned earlier there are now a number of organisations that have started working
on the issues of sexual health and sexuality. An attempt is being made here to acquint the
reader with the work of some of these organisations.
IFSHA
IFSHA is a non-govermental organisation working on sexuality, gender and sexual
violence through counseling, training research and awareness raising programmes. IFSHA
began in June 1998, though it was working previously as part of SAKSHI a violence
intervention centre in Delhi.
For further information please contact :
Ms Jasjit Purewal,
Interventions for Support Healing and Awareness (IFSHA)
18
J-39, First Floor,
South Extension Part I,
New Delhi -110049
Email- seher@del3.vsnl.net.in
TARSHI (Talking About Reproductive And Sexual Health Issues)
TARSHI is a telephone helpline which was initially started to provide assistance for their
reproductive health related questions. In practice a Large proportion of callers are men and
TARSHI also provides counseling services and information on sexual health over their
helpline. TARSHI aims to make peoples' sexual and reproductive lives more respectful
and free of fear, infections and diseases. They believe that decisions related to ones sexual
and reproductive lives are greatly affected by sexuality and realities of life. Not only this
these decisions in turn affect the life. Tarshi works for the exploration of options in
reproductive and sexual lives. Though they see women as their primary group of concern
yet they reach out to every class, community, age group and people of various sexual
preferences.
For further information about their work kindly get in touch with
Ms Radhika Chandiramani
Taiiking about Reproductive and Sexual Health Isues (TARSHI)
49, Golf Links, 2nd Floor,
New Delhi 110003
Pnones - 011 -462-2221, 4624441
Email-radhi@unv. ernet. in ’
The*Naz Foundation ( Trust)
•
While AIDS is the main focus of Naz’s work, they are.also involved in working on
sexuality related issues. They are involved in conducting awareness campaigns for women,
address Lesbians and homosexual men through the support groups and helplines. They
have also produced a manual on sex and Sexuality.
For further information about their work kindly contact:
Ms Anjali Gopalan
The Naz Founation ( Trust),
D-44, Gulmohur Park,
New DelhiPhones 011-686 2422,685 1970,685 1971
Email- anjali@naz.unv.ernet.in
SI D HIV Intervention Project (SHIP)
This project is primarily working on STD/H1V prevention and clinics in the Sonagachi
red-light district in Calcutta. The unique aspect of this project includes a committee of
commercial sex workers which is involved in campaigning for sex workers rights. This
committe also includes male sex workers.
19
For further details kindly contact
Ms. Mrinal Kanti Dutta ( Director)
SHIP ( STD HIV Intervention Programme)
8/2 Bhawani Dutta Lane
Calcutta-700 073
Phone 033-2415253, 2416200,2416283
Fax 033-2416283
E-mail- ship@cal.vsnl.net.in
RAH I
Recovering and Healing from Incest ( RAHI) is a support centre for women surviving
incest and is dedicated to providing a variety of services in this area. RAHI’s objective is
to make women aware of the nature of incest and its consequences in each women’s life.
The organization also tries to break the silence that exists around incest and to talk about
the way it happens in our society.
Ms Anuja Gupta
Recovering and Healing from Incest (RAHI),
M-79, Greater Kailash-II, 2nd Floor,
New Delhi 110048
Ph- 011-6238466,
Email - rahisupp@del2.vsnl.net.in
20
RESOURCE SECTION
Further Reading
Given below is
i a list of books and journals that w e found useful in preparing this booklet
I. Boston Women’s Health Book Collective, The. 1998. Our Bodies Ourselves New
Century. New York: Simon and Schuster.
2. Carrera MichaeJ A ; 1995; ‘The Wordsworth Dictionary of Sexual Terms’;'
- Wordsworth Editions Ltd.
J
° ’ N6W
Dastur, R.H. 1989. Sex and Diseases. Bomba;.: Popular Prakashan Pvt. Ltd.
4. Devi Shakuntala; 'The World of Homosexuals’
Donniger Wendy; “Women, Androgynes and other Mythical Beasts”
6. Dworkin .Andrea; 1995; “Intercourse”; New York; Free Press Paperbacks.
~r
Family Federation ot Finland, The. 1998. The Evolution of Sexual Health in Finland
How We Did It. Finland. The Family Federation of Finland
8. Gandhi Nandita, Nandita Shah; 1993; “The issues at stake----- 1:„„.
? and practice in
theory
the contemporary women’s movement in India”: New Delhi: Kali for Women.
9. Germain, G. 1984. Sex and Destiny: The Politics of Human Fertility. New York'
Harper and Row.
10. John Mary E. and Janaki Nair (eds.) A Quesizon of Silence.
11. Kabeer Naila; 1996; “Reversed Realities — gender hierarchies in Development
thought ; New Delhi; Kali for women.
12. Kakkar .Sudhir. 1989. Intimate Relations: Exploring Indian Sexuality. New Delhi
Viking.
H Mastere William H., Virginia E. Johnson, Robert-C. Kolodny; 1995, “On Sex and
Human Loving”, Bombay - Jaico Publishing House
14. Nabar, Vrinda; “CASTE as Woman”
15. Niranjana, T. 1994.Feminity, Indianners and Modernity. New Delhi
16. Paglia Camille, “Sexual Personnae”
17 Ranganathan, N. 1994 Puberty, Sexuality and Identity: A Psychological Analysis of
Urban Adolescent Girls. New Delhi.
18. Sabala and Kranti; “Na Shariram Nadi”
19. Selverstone, R. I996.Now What Do I Do? New York: SIECUS.
20. Shephard Bruce D , Carroll A. Shephard, 199G; ‘The Complete Guide to Women’s
Health’; New York - Penguin Books USA Inc.
21 Singh Renuka; “Womb of the Mind” and “Women reborn”
22. Thadani Giti; “Sakhiyani”
23. Wellings Kaye, 1986, “First Love First Sex — a practical guide to relationships”;
Northants, U.K.; Thorsons Publishing Group Ltd.
24. Westheimer Ruth; 1994. Dr. Ruth’s Encyclopedia of Sex. New York: The Continnum
Publishing Company
25. Zeidesnstein Sondra and Kirsten Moore; 1996: ‘‘Learning about Sexuality a practical
beginning , The Population Council Inc.
21
Journals
W/CM7’/Re/Pr°dUC?Ve T111 MatterS’ V0bume 6’ Number 12’ November 1998
O/C ES, Exploring Sexuality - Breaking the Silence, Vol 3 No 1, April 199
a
Other Resources
bCo°omkPrehenSiVe reading lists on the issue of Sexuality may be found in the following
1
Appendix 1 of" Learning about Sexuality - a practical beginning, Sondra Zeidesnstein
and Kirsten Moore, 1996; New York; The Population Council and IWHC
r
u °?k ’
°f Feminist Vis30ns ’ A'ternative Paradigms and PracticesandTkSHARA
Association of Women’s Studies
Videos - Videos on the theme of sexuality include
Subah ka bhoola; NGO-AIDS Cell, AJIMS, New Delhi
Safer-sex, NAZ , New Delhi
My Children should be running through the vast open spaces- MADHYAM, Bangalore
Guhya - Kirtana Kumar , Bangalore
Newsletters
feeTre- ‘
"e"'Sle"erS
“d
a"d ,™sS“d^ People Some or
Network; New Delhi
Bombay Dost; Bombay Newsletter for gay, lesbian and transgendered people.
Arambh , Gay and Lesbian Newsletter.
Inn?"6' San FranCiSC°; F°r S°Uth Asian gayS- lesbians’ bisexuals and transgendered
people.
Pravartak; Calcutta; gay newsletter
Friends India; Lucknow; gay newsletter.
ILIS Information, Belgium, Lesbian Newsletter.
Support Groups for gay and lesbians include:
Drishtikon
ABVA, New Delhi
Humsafar Trust; Bombay
Arambh Support Group for gay men and women; P.O Box 9522, Delhi - 95
Campaign for Lesbian rights; New Delhi
Sabrang; Bangalore
Good As You; Bangalore
Humrahi, support group for gay men, New Delhi
22
Sangini, support group for lesbians and bisexual women. New Delhi
Durbar Mahila Samanwaya Committee c/o SHIP, Calcutta
Resource Organisations
CEHAT (Centre for Enquiry into Health and Allied Themes) - The Ford Foundation
has/had supported a large number of studies on reproductive health and especailly
sexuality. The reports of these studies and other studies can be obtained from CEHAT
CEHAT,
2nd Floor BMC Maternity Home,
135 Military Road,
Bamandaya Pada, Marol,
Mumbai -400059
IFSHA - IFSHA is working exclusively on sexality and provides support in the form of
Information material. Training programmes, Counseling services and so on. The contact
information for IFSHA has been given earlier.
The Ford Foundation - The Ford Foundation is an American private foundation which
has supported a number of studies and interventions in the area of sexuality and sexual
behaviour. For furtehr information pl;ease contact:
Programme Officer ( Reproductive Health)
Ford Foundation,
55 Lodhi Estate,
New Delhi 110003
t
Booklet prepared by
Research and Text- AIok Srivastava, Jashodhara Dasgupta, Abhijit Das
Reviewed by - Kirtana Kumar
23
MH - n - & ' 10
Understanding
Reproductive Health
A Resource Pack
Booklet - Ten
-v <»»;« ><i»
.,-'A.X-zS'
. Mj'
; A . •i. -vi’
HIV, AIDS & STD:
f a’;1
.
Coming to terms with reality
SAHAYOG
-
■:
S’«
i»
CON TENTS '
INTRODUCTION
Section One : AIt)S and STDs Some Basic Information
History
The Origin of the HIV
What is AIDS? '
What is HIV?
The HIV Continuum
Diagnosis of HIV and AIDS
HIV Transmission
Prevention of HIV
STDs
SaferSex
Treatment of HIV related Infections
Section Two : AIDS and Society in India
AIDS in India
Women and AIDS
Human Rights , AIDS and the Indian legal system
Living with AIDS - living positively
Section Three. Working on AIDS
Working on Preventing the spread of HIV
Working on HIV/AIDS care and support
Some Innovative Projects
Resource Section
Further Reading.
Resource Organisations
3
4
4
4
4
5
6
7
9
10
11
' 12
13
15
15
16
19
21
23
23
24
26
28
28
29
2
INTRODUCTION
“-y;-<he ws,
“eM" ’ tas !pr n\“d“ T°^
-
have begunt
br.ng.ng down the infection rate in several countr.es like the Usl and
Thailand. However, in developing countries like India, where the epidemic is
beginning to take root, are badly off. Indeed, thanks to its enormous population niaha
the dubious dist.nction of having the largest HIV posit.ve population in the worid WS
s a special disease in many ways. It is incurable; there is no vaccine in sight It is
nsk ukmg teha^
V^S I® Ci°Sely linked Wlth human sexual Promiscuity
■sk-taking behaviour, drug use, and other desperate behaviour. As a result HIV/AIDS
has never been an easy subject to broach within society. And the epidemic’s spread has
Today5 HTvn/ZsniPankd hVd'T °f di5™nati^ stigmatisation and ostracisation.
ay HIV/AIDS is acknowledged to be a social epidemic first, and then a medical one
s prevention and control require changes in our social value system relationshin
struc ures attitudes and behaviour. The disease has several ramifications including
oc.al, medical, clinical, legal, human rights, and economic ones.
'
§
Squally Transmitted diseases ( STDs) or Sexually Transmitted Infections as they are
o^n 'ailed are one of the most widely occurring diseases in the world. The emergence of
AIDS as one of the main scourges of mankind has focussed the attention on STDs
ecause they share an important route of spread, and the presence of STDs increases the
vulnerability to AIDS manifold.
•
increases the
In thrs fact sheet we shall look at what is kriowfl today about AIDS HIV and STDs
wtthtn the framework of India’s social situation, and finally at some aspects of AIDS
programming for those wishing to work in this area.
Section One
AIDS and STDs: Some Basic Information
History
=”
were sure ™
d„zx^k4"“ bx
reponed a rare skin ea„“U.Z J P T' *"
'l“'r ,wen"es- *“
all eav
region, amongst people who well SO eZ orZTc’i f°Und °"'y ” ,h' Medi»™ea"
rrnmune system's of these young men were also severelyZaSd""'” r"ea'ed
eZ^=z^izP:szx;epMs
the curse of God on people who commit thP
r u Th
"*
—>■"
gh WIng PromPt!y called it
-s clear that heteroZi were“™. „fe”ed tZr”’"'’ B'"
revolution of sexual permissiveness and and !hk „f
t
“ W3S at the Peak of hs
year 1982, the disease was rechristened as the A
™a °n Came as a rude shock. In the
AIDS. During the following vear 19^ a.S,the Acqu,red Immune Deficiency Syndrome or
named the HIV or h Human Imm
Of HIV Vims have tenlsoZd
d cAIDS WaS firSt discovered a"d
Since then three different steams
The Origin of the Human Immuno-deficiency Virus (HIV)
in
°f ,1,‘ “V ™ Fr°”
US government to finish the African
deVel°Ped bV tbe
Conference on Retroviruses and Onnnn Y P°P7U pt,On ' FindinSs Panted at the 6th
31 to February 4, 1999, provide thestrongest' eJidenceJo dale ttam J™”
XTat ZSprobab,y
chj~
,n
preSented ev,dence identifying a new isolate of a retrovirus
affecting a chimn 8
According to Dr Hahn and eol
have
from
h d S’
and
8r°UpS °f HIV’’ affecting humans
Of“V‘1 "
“
What is AIDS ?
ZOdDTie"CV 'ZT A" H,V-'"faed P™
by the Center for Disease“on^ol USS
i,lneSSeS defined
serious illnesses als^can rXe an Am/. HIV-p0Slt,ve Person wh° has not had any
(CD4+ counts). A positive HIV test r^ dla8n0S1S on the basis of certain blood tests
diagnosis of AIDS k
h
d°eS nOt mean that a person has AIDS. A
indicator illnesses) Infecton^ith HIV J1 USin8,Certain clinical criteria (e g., AIDS
i. ™eu1Iy n8hti„g off cmain
X'ZZ
4
po umstic in ections because they take the opportunity a weakened immune system
gives to cause illness. Many of the infections that cause problems or may be lifereatening or people with AIDS are usually controlled by a healthy immune system,
e immune system of a person with AIDS is weakened to the point that medical
intervention may be necessary to prevent or treat serious illness. Today there are medical
treatments that can slow down the rate at which HIV weakens the immune system. There
are other treatments that can prevent or cure some of the illnesses associated with AIDS.
. s with other diseases, early detection offers more options for treatment and preventative
care.
The World Health Organisation has produced a clinical case definition that is used in
India for diagnosing a person as having AIDS According to this if the person has
Two major signs, including a loss of ten percent of body weight within a
short period, chronic diarrhoea persisting for more than a month and chronic
fever for more than one month,
At least one minor sign, including persistent cough for more than a month,
dermatitis, shingles, oral thrush, chronic herpes simplex and generalized
enlargement of the lymph nodes,
and no other known causes of immunosuppression, s/he may be suspected to
have AIDS.
What is HIV ?
HIV as has been earlier mentioned is the'virus which causes AIDS. When a person is
infected with HIV but has not yet developed .AIDS the person is known as HIV positive *
1 hus a person with HIV infection need not necessarily be suffering from AIDS which
leads to the use of the composite tef HIV/AIDS.
Two types of HIV have been identified to date HIV-1 and HIV-2. HIV-1 is the
predominant HIV type in the United States and throughout the world. HIV-2 is primarily
round in West Africa. As mentioned earlier the origin of HIV-1 is from primates most
possibly from chimpanzees. The origin of HIV-2 has been identified as being another
monkey species, the sooty mangabey (Cercocebus atys); Dr. Hahn also played a key role
in that research. This new knowledge about the virus and its transmission can lead to a
better understanding of the evolution of HIV-1. provide insight into species-to-species
transmission of viruses, and increase our understanding of infectious disease emergence
Deeper understanding of strain evolution could in the longer term be of relevance to the
development of diagnostic assays and vaccines.
HIV has a relatively low infectivity, as compared to Hepatitis B vims. It thus requires a
much larger number of viruses to enter the body to cause disease ( check) Further more
the ability of the HIV to survive in the externa! environment is also low, eg. simple
drying kills the virus, a temperature of 56 degrees Centigrade is fatal, chlorination,
bleaching and even plain detergent also kills the vims. This knowledge is very useful in
prevention of the disease.
5
The HIV Continuum
blown WS is
as‘"“°n’0,te^il
Early Symptoms
Some people, hoXerVhive
iUne When,they firSt become lnfected with HIV
vims. They may have fever headache
immune system easily felt in the neck ancf eroL^Th11
within a week to a month and e oft n^mtl ken
eX's thTbody inM
exposure to the
lymph n°deS (Organs ofthe
f°r * de“<,e °r
mV fc,
period of "asymptomatic" infection is hmhly v'anableTornTpeT^
symptoms in as soon as a few months uftereas other Somekpe°p,e
beg,n have
than 10 years During the asvmntnmaV
u
be symPtom-free for more
infecting and kHlmg^fr
decline in the blood levels of CD4+ T cells (also called T4 ,.IS Seen most obviously in a
key infection fighters. The vims initial! , aT4 Ce ~the immune system's
symptoms
y lsables or destroys these cells without causing
of oon.piioaiions Keg,ns
oneif
nodes or"swolleT°md expherienced hy many Peopie infected with HIV is large lymph
symptoms oftenexperienc ! moTh
than three monthsenergy, we.ght loss' frequent feve^andZ^XXtTfr'
3
°f
(oral or vaginal), persistent skin rashes o- fl t ’ ?
frecIuent yeast infections
disaasa k„ow„ as 5hlngles chi|dren
AIDS
are opportunistic infections which rarelv
u . f AIDS-deflning conditions
with AIDS, however these’infections app 1
ln
thy indlv,duals- People
immune system is so’ravaged by HIV that'ThT^
S°metlmes fatal because the
viruses and other microbe^
'
H 'h b°dy Cannot fiSh‘ off certain bacteria.
6
cougten shon
7h C°TOn ‘n Pe0P‘e W'th AIDS Cause such symptoms as
forgetfuteess sJ1655 °f breath'. seizures, mental symptoms such as confusion and
wemht loss ext Vere r P6™516"' diarrh°ea' feVer’ visi°n loss’severe ^adaches,
cramp or difSe fatlSUfie’,n™- vomiting, lack of coordination, coma, abdominal
cramps, or ditticult or painful swallowing.
adutwfthtee?" With
which children
tonsillhis
SUSCeptlble 10 the same opportunistic infections as
& 50 expenence severe forms of the bacterial infections to
specially prone, such as conjunctivitis (pink eye), ear infections and
lol 111L1 o.
7'Ith AIDS are Particularly prone to developing various cancers, especially those
y viruses such as Kaposi's sarcoma and cervical cancer, or cancers of the
immune system known as lymphomas. These cancers are usually more aggressive and
difficult to treat in people with AIDS
8
Many people are so debilitated by the symptoms of AIDS that they are unable to hold
steady employment
may account for their lack of progression to .AIDS, such as particular characteristics of
tims^TfT SyStemS’ °r 7hether they Were ’nfected with a less aggre™ve strain of the
th t
8ene,tlc make-up may protect them from the effects of HIV. Scientists
Pt t u^erstanding the body’s itatural method of control may lead to ideas for
protective Hl\ vaccines and use of vaccines to prevent disease progression
Diagnosis of HIV and AIDS
a nercnn'c hi> hr Infect,on often causes no symptoms, it is primarily detected by testing
00 °r the Presence of antibodies ( disease-fighting proteins) to HIV HIV
^'bodies generally do not reach detectable levels until one to three months following
chn ,10n an my ta,e as l°ng as s'x months to be generated in quantities large enough to
doeT Uft h15130
h10°d tCStS ThlS
perioci when when the person is infected but
ner OH
antlbodies t0 be detectec as HIV Positive is known as the “window
hn 7
i teSt'n8 may alS° be Performed
saliva and urine samples, in addition to
Dioou samples.
Box- Testing for HIV
A Te'il T h1S teSt actually looks f'or antibodies produced by your body to fight HIV
Most people will develop detectable antibodies within 3 months after infection, the
average eing
ays. In rare cases, it can take up to 6 months. For this reason, currently
testing is recommended six months after the las: possible exposure (unprotected vaginal,’
na or ora sex or s aring needles). It would be extremely rare to take longer than six
months to develop detectable antibodies. It is important, during the six months between
7
exposure and the test
to Hprotect
and otners
others from
from further
furtfr possible exposures to
HIV.
’~
‘WLV"1 >yourself
UU,SC11 ana
specific (and
foreign SUbsta„eX^
ELISA, confirmed by the Western blot
anrihodies; the
• R.“” “
EUS:
r U
- ™™f-<ured
~x.0 f.ghl
ZX
otll„ 6,SC
rep,eatedly reactlve resub from the
!™ “IXTw' 00,hfer'? T 7“e
when antibody levels are verv low^r d'fF n
nfirrnatory blood test that may be used
are uncertain. An expensiveTest the ri’p
Western blot test results
* Rapid latex
'requires time and exPertise to perform
'SB
—
—
—
asss=r
«»sz
ie
i^™ MSZXSdtr ";,ZCd b,00d “,ta
someone only recently
T’ ?
'»=»KSX_
(End Box)
L"Xc“d,„pem*
counseling Individuals
f“ “V 8-etie
Can det6Ct the virus even in
k
S
”r ,tat 7“sp J mv “
/ th Cilnics an<^ should be accompanied by
be
which
.
“v
doctor may test for the presence of HIV itself in the blood. The person also
8
hkely to hatXdopeTteSt‘nS
' 13127
antib°dies t0
are more
all bc'aXvbZt0 m°Kher.S infeCted W'th 1117 ma-v or may not be infected with the virus but
»
aHnt'bOdleS t0 fflV f°r S6Veral m0"ths tb-e babies tack
’
be m'^until after
antib°dy tests «
mothers an bodie. T m u
86 By
babieS are Unlikely t0 stili carry their
mothers antibodies and will have produced their own, if they are infected New
infeSn inf tT
being USed t0 more acc“rate*y determine HIV
ection n infants between ages 3 months and.-15 months. A number of blood tests are
^evaluated to dae™„e ifthey ca„ d„g„ose
infec,10n intb"es °ol“ r ,h7„ 3
months.
HIV transmission
fluid or breast milk fro
(includinS Pre-seminal fluid), vaginal
HIV can enter the hod Th'"
the b°dy °f an ^infected person,
vagina the penis them^th^3
' 8'’ lnjeCt’On drUg USe)’the anUS Or rectum’the
or cuts and sor ’ mTh ’i °thefmuC0us membranes (e.g., eyes or inside of the nose)
and bacteria Thes
’,hea,thy sk,n 1S an excellent barrier against HIV and other viruses
to another:
e are 1 e most common ways that HIV is transmitted from one person
•*
by sWmgnTX1111^011'56 (anal’V*gina1’ or oral sex) witb an HIV-infected person
^sharmg needles or mjectton equipment with an injection drug user who is infected
’
a^eT bTrth'infeCted
t0
bef°re °r during birth’ or through breast-feeding
HIV also can be transmitted efficiently through transfusions of infected blood.
Box
•
•
•
c . ,
cannot be transmitted through
Social contacts like touching, hugging, etc
Light kissing
sharing foods, clothes etc.
Mosquitonom other insect bites
using public toilet, telephone, swimming pool, etc. (End Box)
TChipientS beCOme infeCted from transfilsion of a single unit of
source is much lower f
Per'C°nt,aCt Probabll«y of transmission from an HIV-infected
transmit
'"Jectin8-drug-use and sexual exposures. The risk for HIV
Prospective^ZeXnc6 flntravenOUS needle or syringe exposure is estimated at 0.67%.
exposure^ » Tnelm
the nsk per ebisode of Percutaneous
risk associated with the’e"^
™V'lnfected Dlood ls estimated at 0.4%. The level of
infected b ond iTfr
T? °f non-ntact
or mucous membranes to HIVected blood is far less than that associated with needle-prick exposures.
9
1
i
containing HIV-infected blood or less frequently aft 6
'’7m W‘th need'eS
worker's open cut or through splashes in o X y’ u
'
bl°od contact with
has been only one instanceof patient be n
7
6765 °r inSide their nose- There
worker. Th/mvolved! HIV tran mi
by “ fflV-fected health careThe risk for fflv
■ ■
smission ‘rom an infected dentist to six patients
estimated at 0.1%-3%S;^hiSXk pTrX’isode
exposure is
0. l%-0.2%. No published estimates of the ri J f P
exposure exist, £t
exposure is estimated at
deceptive oral
BOX
DT?enfL°fHIV transni'ss«on by various
routes in South East Asia Region
Route of Transmission
Efficiency
% of Total
Sexual
0.1 - 1.0%
80 - 90%
Blood Transfusion
>90%
3 - 5%
Injecting Drug Use
5 - 10%
5 - 10%
Equipment/Needles
<0.5%
<0.1%
Perinatal
15-45%
<0.1%
Source - WHO
Prevention of HIV
outlined below.
for H,V/AroS
“------d rlrusevention
prevent! remains the most
•k ■ r
.
fight agatnst this disease. Some of the preventive stgrategies are
Through sexual route:
• Celibacy
• Having sex only within marriage, if the spouse is HIV negative
With only
sexual P*™'
partner '*>
who » mV negative
• ffZhl", "T
Ty one faithful SeXUal
'Ldoms “ d0
and regular use of
— .j use safer-sex including ■the
Through Blood:
tratfos^Mh^
sufficient advance notice of the need for blood
WoXith^r n^e^
your name, and you should verify that the same blood is being supplied to
vaXtonb::t"00d iS
™V fr“ “d ia laba"“* o'e»rly for iatj””'
10
•
•
Sterilizing the needles, syringes, and other surgical instruments before using on
another person. Use only disposable needles and syringes..
Taking oral drugs instead of IV drugs. Not sharing needles/syringes when taking IV
rugs, f one has to share these, both needle and syringe should be properly sterilized
Sterihzmg tattooing equipment and those used for piercing body parts after each use
Prevention through awareness •
•
•
•
IEC Campaigns in the mass imedia
" for the general public
Training of Health Care personnel at all levels
Change attitudes towards safer sex
Creating a demand in the community for safer medical and related services
Risk behaviour- AIDS recognises no barriers and it can strike people at any age
However some men and women are more vulnerable because of risk behaviours. These
risk behaviours include- engaging in sex with multiple partners, inability to negotiate
safer sex practices like use of condom., sharing unclean and used injecting equipment like
syringes and needles, transfusion of blood or blood products (hat have not been screened
for HIV antibodies
STD’s
Sexually Transmitted Diseases ( or infections ) are those diseases which are transmitted
through sexual contact with another person. These are among the commonest diseases in
the world. According to estimates of the WHO over 300 million new cases of STDs occur
every year in the world This makes them the fourth most common infectious disease
a er diarrhoea, malaria and acute respiratory-, tract infection. The commonest
M
CaUS‘ng theSe Sre chlamydia. trichomona, syphillis and gonorrhoea
Most S I D s are now treatable if treatment is. sought in time. AIDS is an exception which
has no cure.
STD’s symptoms in men
The most common STD symptoms in men include.
• Pain when passing urine
• yellow discharge from the penis.
• Sores and blisters in the genital area, including the anus. These sores can be
painful or painless.
• Itching in the genital area
• Infection of the anus sometimes causes discharge and irritation
• Enlargement of groin lymph nodes
STD symptoms in women
SI D s may not always show symptoms in women. If present they include:
•
•
•
•
Burning feeling when passing urine
Unusual vaginal discharge
Infection of anus sometimes causes discharge and irritation.
Pain in the lower abdomen
11
•
*
Sores, blisters etc. around the genital areas including the anus These sores
may or may not be painful.
Se sores
Enlargement of groin lymph nodes
jXSEXZZ.ZZZZZ1 in“rab"
-
Some of the common STD’s are.
r.
* Gonorrhea
* Syphilis
* Herpes
* Genital Warts
6* Pubic lice
* Scabies
* AIDS
* Hepatitis B
Having an STD izcrcc
increases the chances of a person for getting infected with HIV by upto
10 times.
Prevention ofSTD's:
inClUdi"8 Pr°P,!r
toThe
prevention in which the effort is to rpqtnVt
measures
and partner notification.
~
Y
j a-
°
S 3 S° 3 concePt
’
secondary
”d
y dia8nosis and treatment
Safer Sex
. “ Zh h ”Zz •V'”8 °ral' anal or vaginal s“ °" 'y
le condom" mZ of
Althnnah d be
water’basecl ^bricants should be used with latex condoms
gh some laboratory evidence shows that spermicides can kill HIV nro^nic
chntcal trials, researchers have not found that these products can prevent HIV The'risk of
HIV tmnsmission from a pregnant woman to her foe^s is significSy reSshe
significantly reduced if she
weeks of lift™8 Pre§nanCy’ labour and delivery’ and her baby takes it for the first six
--------- six
Box-
H.V szz .xr' com™niy prac,iced s“uai
|norjsk~
I
““ "■» * or
Masturbation, seeing pornographic movies, fantasizing erotic
massage, etc., using sex toys which are clean and not shared.
12
VERY LOW RISK
Mutual masturbation, petting, kissing, etc., using sex toys
that are shared but cleaned.
LOW RISK
Deep Kissing, Oral intercourse iwith condoms. Oral
intercourse without condoms but not ejaculating in mouth,
Vaginal/anal intercourse* with condoms.
VERY HIGH RISK
\ aginal/Anal intercourse without condoms, Oral intercourse
without condoms and ejaculating in the mouth. Sharing Sex
toys that are not properly cleaned.
Treatment of HIV related infections
When AIDS first surfaced in the United States, no drugs were available to combat the
underlying immune deficiency and few treatment existed for the opportunistic diseases
k
°Ver the paSt 10 years’ however’ therapies have been developed to fight
o
IV infection and its associated infections and cancers. The Food and Drug
Administration of the USA has approved a number of drugs for the treatment of HIV
infection. The first group of drugs used to treat HIV infection, called nucleoside analog
reverse transcriptase inhibitors (NRTIs), interrupt an early stage of virus replication,
ncluded in this class of drugs are zidovudine (also known as AZT), zalcitabine (ddC)
idanosme (ddl), stavudine (D4T), lamivudine (3TC) and abacavir succinate These
drugs may slow the spread of HIV in the body ar.d delay the onset of opportunistic
infections. Importantly, they do not prevent transmission .of HIV to other individuals
Non-nucleoside reverse transcriptase inhibitors (NNRTIs) such as delavirdine, nevirapine
an^ etavireuiz are also available for use in combination wjth other antiretroviral drugs.
A third class of anti-HIV drugs, called protease inhibitors, interrupts virus replication at
a
later step in its life cycle. They include ritonavir, saquinivir, indinavir and nelfinavir
Because HIV can become resistant to each class of drugs, combination treatment using
both is necessary to effectively suppress the virus. Currently available antiretroviral drugs
do not cure people of HIV infection or AIDS, however, and they all have side effects that
can be severe. AZT may cause a depletion of red or white blood cells, especially when
aken in the later stages of the disease. If the loss of blood cells is severe, treatment with
must be stopped. Ddl can cause an inflammation of the pancreas and painful nerve
carnage.
he most common side effects associated with protease inhibitors include nausea
diarrhoea and other gastrointestinal symptoms. In addition, protease inhibitors can
interact with other drugs resulting in serious side effects. Investigators also recently have
reported cases of abnormal redistribution of body fat among some individuals receiving
protease inhibitors. A number of drugs are available to help treat opportunistic infections
to which people with HIV are especially prone. These drugs include foscarnet and
ganciclovir, used to treat cytomegalovirus eye infections, fluconazole to treat yeast and
other fungal infections, and TMP/SMX or pentamidine to treat Pneumocystis carinii
pneumonia (PCP).
13'
Alternative medicine & healing and HIV
Many alternative forms of medicines have offered relief (not cure) to people livine with
HIV virus. These medicines work in two ways. On one hand they felp"re S tie
thf d '™mune’system and als° ^duce further spread of HIV, and on rte other hand
y provide a psychological benefit. These alternative forms of medicine often make use
of ancient knowledge and practices. These include Ayurveda, Acupuncture Yoga Reiki
etc These alternative medicines or healing should not be used on their own but oSy as
complementary to more established forms of treatment
’
Y
Quackery and HIV
Even though there are no cures for HIV virus, many quacks in India and elsewhere have
been c aimmg to cure people with AIDS or to have developed special cures They exoloit
the helplessness felt by many people living with AIDS as far as a cure is concerned
»i.hr'uch”uX
Ver!"Ch
A' pr“e"‘ “'er' iS "°
14
Section Two
AIDS and Society in India
AIDS in India
!hse hX: ™ z1 XT Tre ,har- -5 rrs “fter»"s fct
prospect ”f X? ThT"; “ "e,y 0,her
x:?
considerable inroads against HW/AIDS.
,ha' has ““ f’“ “ Twith the
a8enCies’ have made
‘
The
efforts
were largely
hoiee
Z TZ
8 Y based
baS6d °n thC aSSUmpticn that individuals will make a rational
Information-Education-Communication ITfZZ f
§ Accordingly,
atlon (ibC), and rts concomitanrawareness-raiqina ’
Tub cZ in raWilX 7,hert° Bb“ ,0P'CS °fH1V
-S”
fe
70%
,ho,lgh ,.„ra; areas „ z,
»
“■< ■X into
"" ‘o
commun'trCla fSeX d‘StriCtS tOpped the llst’ and W!thin them chiefly women sex workers'
and more JecemD XlsTdZ
bl°od donors; blood banks themselves’
»hile
XXt “““
~
Donated blood becomes safe In these five years, donated blood has also started
bloodZ8
ln Za’ WltH the phasing out of unlicensed blood banks and professional
blood donors, as we as a vigorous drive to increase voluntary blood donat.on^n e
years ahead. regional blood banks with state-of-the-art facilities for collecting, processing
15
Wi" brin8
eloseT^X'7" “
"'ooO
■n he states tbnt have seen maximum preventive activit.es, Maharashtra and iSadi
P 4T)enaCd ? C10nT(T
,
..
as
WHP i-stimatLS a current national total of over 41,00,000 adults and
“S io'S” dD?T "n“
ssa
der age 15 since the beginning of the epidemic, is 1,20,000. (Caution ■ Such estimates
must be considered with care: on the one hand, they serve to remind us that the actual
othei^
be
the
officialfigures indicate; on the
f m "s
ar‘
a„d ofim
Highest prevalence in areas of maximum focus: Hidden within the numbers such
they are, are also trends that reveal increases particularly in areas that have been as
ave occurred concurrent with prevention efforts. “There is a very high rate of sex Y
worker turnaround within brothels,” says the manager of one of Kamathmura s earnest
rven ions. If a sex worker is found HIV positive, the community will generally expel
Prev IS00nrer hea th
earning ab‘lity begin t0 decline' She wil] be sent home
Prevalence figures are more likely to indicate infection among newcomers ”
arouZbwTf drU§ USerS’ HIV prevalence in ManiPur ^ems to have stabilised at
around 65/o, but serosurveys among IDUs in Calcutta and Chennai show that the number
from
Y prevalence among STD Parents in Chennai and Mumbai rose
from 17% in 1996 to 33% m 1997; it is presumably even higher now.
Women and AIDS
The incidence of HIV and AIDS among women is rising- In 1990, the World Health
h ®s.t'mated that there Were between 8 and 10 million people worldwide
is the rat^at which Mf°re than 3 milllOn of these PeoPle are women.Even more alarming
e rate at which infection among women has been increasing. The number of infected
omen rose sharply during the second half of the 1980's and, in some areas of Africa,
16
> “d increase over a period
of HIV infection among women will eoual anc^n so""8 "" "eX, deCtd'
Prevalen“
World Health Organization estimatesZdu™ hiZZm"’f °f me° Tl,e
children dying of AIDS will rise to 3 millinn r§
0 s’ the number of women and
mf~„y is espeetfd io increast
adult women is thought to be infected andwome
regl°n’
‘n eV6ry tWenty
number of AIDS casts TIkmaior^
5°% °f the total '
the way for perinatal HIV transmitsin to t !
°Peni"8
has estimated that over 85% of the cases f
women s children on a large scale. UNDP
f- perinatal transm^sZ"
WS“mcZ'XId” Wo'r.d HeZo”'
"Z" Of
m.lbon Cbiidten m sub-SaLan AfHcZ^ZhZ^S'X^tSZ
BE~-=Z~9“5-—
Efficacy of transmiss on i t
71
caused by repeated pregnancies
P
transmission through vaginal intercourse.
haemOrrha8e or treatme"t for anaemia
"s “'™«“ of-He leveh of i„fKtion
reporting of HIV inftion andtint' 7 r
COnservative-11 * likely that under
women make nn 7
d A 7 partS of Afrlca> the Caribbean and Asia where
x:» zz::' *infec,ed popuia, on'has “p*1»
10 lhe magnitude of the impact of the fflV
'ea''e "0 d°Ub'35
•!>» men because
»hoZIOt«efiCSem»fromWZ”.i,"d
m°re
the virus time to take root Women I
m
membrane intbe ea.ina and o^T
“ v” *
6 va^lna^ cana^ ^or sometime, giving
s“rf“e
of ™cu1
contracting HIV Women in the age grouo I So? W°men are at an esPecla!fy high risk of
HIV. The correspondine aae eroim fn
P
gr°Up have the h‘8hest rate of
not well lined with profecdve^elll thT™^ 'S “3'J°,yearS- In youn8 women the vagina is
protective cells, the cervix may be more easily eroded and tearing of
17
V'1 ’
the hymen during first intercourse can cause bleedim/ Similari,,
................ .
■ —
The hnk between powerlessness and the risk of exposure to HIV provides the kev to
understandmg the source of womens vulnerability to HIV infection It is he reason whv
HIV infection ,s increasingly a condition of all women, regardless of race colourZ "
economic status. In more developed countries, the fiill impact of these social and cultural
dynamics was not apparent m the ear.v years of the epidemic when theXX of
reported cases was among homosexual men. With dramatic increases in infection levels
shift m th '"i h' i
developed and the developing world, however, there has been a
shift m the global demograph.es of HIV infection. This shift has forced a reassessment of
°r,fcr 10
i"
» da.e is evident also in the way HIVr'etae'dXsIera^AlDTta*”been“'£“1,1
cand.dmsis and conjunctivitis. This has had serious consequences for women leaving
any women undiagnosed or wrongly diagnosed, delaying diagnosis and treatment and
SZ=SiSability and °ther benefitS and
because^not
Women, AIDS and gender - The pattems-of social, and economic dependency that
ender women ,
Le tQ y
dependency■tlw
d foremost they lead to women being deprived of the power todetermine the basis
upon which their sexual relationships with men take place. For many women sexual
tercourse is not a question of choice but rather a question of survival Cultural attitudes
d norms leave no place for unmarried or childless women. A woman's fertility and her
relationship to her husband will often be the source of her social identfty Xeover for
l- £
aS an accePtable practice. The tendency for men to have sexual
oX '„PSm”,S? ,h,eir marr,ase is rei”f°ral
-sradon XebaS al
elsewhere
develoP‘ng
where men leave the village to obtain work
h^sbTnd ent' I*™akernat7 JUt t0 ^P1 the nsk ^at sexual intercourse with their
entahs. They usually have little or no means of support for themselves and their
18
■hem a, an'mTo'rdabtepn™ m"t. women woTnS'bert"
a*ta“ ””avail,ble 10
expelled from the family unit b the h ° *® f°?nd t0 be infected with HIV will often be
often a younger womanwho IsbeJeved 0 be un %
h"" M.'then Seek 3 new
turn, will be exposed to HIV. In some parts of AfricT therTh ther,ef°re Safe and who- in
-reased rape ofyoung g,rls.
beBe
me o , mems o,uppo„
close link between economic need and exposure to HIV ' 7’ t1!8h 'ghtln8 once again the
•s used in this paper to refer to a wide varety of wavs in ‘"h60?0" The term "Prostitution"
intercourse for cash or other forms of economic sunnort fo d 7°|men eXChange Sexual
been a serious distortion of the understan --n r pport’ food> shelter or care. There has
women because of the singling out of sex
epidemic has affected
national HIV/AIDS programmes as a tare^r n
®pidemiologlsts, researchers and
majority of women are not sex workers and th 7 nS gr°Up' The overwhelming
mfection are wives. Recent dataZm MeX ST rT* hlgh
reported AIDS cases have been among se^wnri
S ° Y 0'8 per cent of a11
Similar figures can be found in other countries botVd ,per^ent among housewives.
Senega! where the epidemic is still in 7
„ develoPed and developing. In
population infected), modes of transmissio nTT
tHan 2 percent ofthe adult
were 20 percent acquired iatrogenicalIv 30 n? W°men One lnfect'ous diseases ward
per cent had no risk factor other than beina a wiyTaTS^T1^ (SeX Workers) and 50
proportion of wives to all infected womTS
A T epidemic
pidemic proceeds, the
. ■atrogemcally acquired transmission decreXlT?
* °f
W°rkers and
againstfoem^utTgTnsTallTZen'ft allo-'vTt’h^T 71dlScrimination not only
workers and the wives of these men to Ha "T H T’
the men who infect sex
some benefits to some sex workers HIV preventi^^
however, it has brought
counselling, support and services for these women andT^TT^*011 haVe Provided
action and mstituted condoms-only policies in
Human rights, AIDS and the Indian legal system
Currently. WIthm the ambit a project fitnded by the F V'S'b
—
. Tb.tr stodies
cntsadmg body of lawyers
-=y to lobby
19
advocacy efforts
implementation:
for bringing
about
legislative change
and
more
effective
forVhl dXfof cu^r"5011 Sh°Uld nOt bC 3 8r°Und f°r d,V°rCe Or Judlcial seParation or
Amendments m the I
ma’ntenance’ Inheritance, guardianship, adoption etcetera
XI fXSaw are necessary to remove the ground of venereai d— -
2. The activity of commercial sex work should be decriminalised, and there should be
stnct enforcement agamst trafficking m women/girls.
-V e n ational Drugs and psychotropic Substances Act should be comprehensive!v
renewed thejnedium term, but m the shon term there is a„ trnmlfete need o
promol'e^clean n'eS °f T d™8S' “<i 'nS,i"“ appri,pna,e
in the law to
p
ote clean needle exchange programmes.
be repealed.77
CnminaIises homosexual practices, must
relfST 376 °fthe rPC’relating t0 rape’should be amended to include offences
teXUai offences and non-sexual intercourse between two persons as
aeainsf8
A person shall not be discriminated against on the
grounds of his or her seropositivity;
♦
Being seronegative shall not be a condition for
appointmenLtp a job, or for continued employment,
education, getting medical treatment, avail of travel
facilities, benefits of services and so on.
♦
HIV seropositivity shall not be considered a continued
illness within the meaning of Section 2 of the
Industrial Disputes Act (1947), or be a ground for the
termination of employment.
♦
A person shall not be denied any medical treatment or
insurance cover on the ground of his or her
seropositivity.
♦
All health care workers shall be provided with all the
necessary protective gear and equipment, and be
insured against all occupational diseases, including
HIV.
♦
The practice of testing babies for HIV prior to
adoption must be discontinued
299 ufihe
u “n'!"de<1 “ "“S’1*" the exceptions to Section
8 tea 1, 1PC’ id h a °W f°r the dlsser™ation of messages related to safer sex
and
T
Pr?V,d' f°r "" Pro“““ of
foX Sion
♦
punitive conLX
dX“°”"8 “ Pr°“dUr'
be preSCribed
20
important environmental ro^t'ra^sar hb
the broad basis for an agenda, two
< nstraints are beyond its scope:
they corned"01
Jndividuals whose rights have bee;:n violated unless
mey come forward with a case.
Bo.h erfce
have frustrated activists and lawveTsCNeattUT °f
lnd‘an
cllmate’ ones which
to bringing about changes in the statutes^ft 'S '' l0nS
ofdiligent advocacy
that those who need the laws know ahn t
an even more arduous process to ensure
Because violations of human riZ
kn0W Where t0 g0 for redre«.
re-framing the laws dZa v" ,ObbieS mount Pr“e for
the mequfties are going
going
to occur,
and
lookkJ°
forr WOrkln8’ lmmed‘ate solutions that are
within the powers of
the affected
Am
~.._:°
------- i communities.
Living with HIV or AIDS
living positively
'r8 TiH,v *“»>
the national PLWHA group several S; Th^ "dlan Network rfPositive People (INP+) is
hold national meetings INP-s leaders h
h "
W*th §overnment Ending to
has a workplan that addresses networkStUdy
°f Thai,andPLWHA is represented on NACO bm in ihtf "l DU''d'ng’ ^Presentation and advocacy. A
between NGOs working in HIV ’ h
'S hardly any contact either
worktng m HIV, or between NGOs and groups of PLWHA.
hZ?d PLW^AS: Tl"
thematic issues around PLWHAs
Devehpmenl, a study mduaeffor‘lk UNDP r'* H'\ApDS'l"P‘’l‘c>
for Asia and the Pacific.
gl°nal Pr°jeCt On HIV & Development
national re^p^LV^mTst'reoNe1 Understan^n8 of the Place of the PLWHA in the
adequate conceptual framework withm wh"
COuntrieS’there is no
encourage the greater involvement of PL W A
eXpl°re
effortS t0
advocating with policv makeTtT
gr°UpS ThlS creates difficulties when
to shift people beyond seeing PLWhZ^pX^
“ d'ff,Cult
insufficient theories and mrXlc,
r PatlenU in need of services; there are
and response. While it is accepted^hTpLWA"5 T 3
f0™ ofunderstanding
urgent need to develop sophisticated anal
’ 0 vement should occur> there is an
Place of PLWHAs in and the^r c
1S °f beneflt to focus
the
epidemic
Contr,butlon <0. ‘he integrated response to the HIV
21
’
and,n8 PLWHA organisational development as a process, not a structure
FLV\ HA groups must be treated as processes, not as structures or vertical, sinsjle-focus
programmes. Understanding that the coming together of PLWHA to achieve common
goals is a process, which means that the dynamic it creates allows for evolution and
contorts3011 IS rn°re Pr°ne t0 eV°1Ve Creative resP°nses in reaction to local needs and
pi wua
3. The diverse roles and responsibilities of PLWHA groups. In the west, PLWHA
movements have been shaped around notions of empowerment, activism and openness
out one s HIV status. There are major difficulties while transferring this model to other
countries. Even in Thailand, where PLWHA groups are large and active, many PLWHA
om the middle classes are uninvolved, and not because they have well-develoned
disclolro60^"15}?5 °f threir
Str°ng
°f S°Cial ostracisation that follows
disclosure, the absence of any supportive or protective wider environment the lack of
n/ Prot^ct’ve
and health policies, are some of the reasons why many PLWHA
hide from the public gaze.
J
Jr™ T aCt°rS againSt the ePidemic: 11 necessary to develop and nurture
FLW HA as players in the responses to the epidemic: not only as support or pressure
groups but as resource people willing to speak or write publicly or anonymously, as
members of decision making groups on the community, state and national levels’ as
people themselves trained in couselling to work with other's like themselves and’to
provide the insight that only they can have. In the words of one who has done such work
W h such groups: It is a long, painful process that requires taking on immense
raponsi i ity for the welfare of others who accept to place themselves in the danger of
the public eye... and yet the successes are the most stunning, the most moving the most
effective of any we have seen, and. well worth the uphill battle ”
5 The role-of government and NGOs. The government has particular key ’
responsibilities including providing political leadership, namely making PLWHA
involvement a pnonty; allocation of funds, appointing PLWHA to decision-making
o les an acilitating their participation; conducting campaigns to reduce stigma and
misconceptions which create a national and social context compatible with what PLWHA
are trying to achieve at a personal, family and community level, and the creation of
aPPropnate laws and guidelines
*nd PLWHA sr°“ps is
in environmems
where the PLWHA is not active or being heard, or are still in the early stages of creatine
organisations. In such situations, the PLWHA’s ability to express their needs and
experiences m programme and policy forums will be low; NGOs could play the role of
intermediaries or conduits at such stages in the process.
6 Developments in HFV medicine: Within western PLWHA communities it is now rare
to hear of sickness, deterioration and death. Hospitals have had a massive decline in
patient numbers. Many people who were invalids are now well, and PLWHA groups
working to re-integrate them in the workforce and to plan for their fijture3s
1 his is in complete contrast to the experiences of PLWHA in developing countries
throughout the Asia Pacific region. Many of them are well aware of these developments
m the west but only a small percentage are in a position to access these new treatments.
Section Three
22
i
Working On AIDS
uch successful campaign to combat the scourge of AIDS it is essential that different
knn10^0 S°Ciety llke media’ NGOs, activists, policy makers etc. all get involved Our
knowledge about the disease and its control is continuously evolving and different areas
ot work are getting mcreasingly specialised. Despite all this specialisation and the
complexity of the subject working on the issue of AIDS can be simplified to - working
o prevent the spread of the infection, and working to reduce the physical, personal and
social impact of the infection, and advocacy to mobilise national and international efforts
against AIDS and to secure individual rights and entitlements for the affected Some of
the key features of each of these different approaches are being highlighted below.
Working on Preventing the spread of HIVPrevention of HIV infection remains the key to combating AIDs especially in a country
verv high Where the infection remains relatively low, though the potential for spread is
BoxHIV/AIDS Prevention Package
•
•
•
•
•
Promoting safer sex behaviour through education
Condom promotion provision
STD diagnosis and treatment
Safe blood transfusion
Safe injecting behaviour
(Source-AIDS No Time for Complacency, WHO)
lAmcn,uti°n’ education and communication (IEQ- EC is a key to the prevention of
AIDS, but what has to be kept in mind that the objective of this is to change behaviour
especially sexual behaviour. In order to have a successful EC strategy one must be
courageous enough to address issues of sexual behaviour within our society, a subject
which is usually not discussed in the open. At the same time the subject must be
approached in a manner which does not make people defensive or openly hostile Today
there are a host of EC material on AIDS available in the form of booklets, flashcards,
videos and so on. C
One must choose the materia, carefully depending upon the objective
of ones programme.
Targeted interventions - This refers to activities targeted to specific population groups
who are considered vulnerable . It includes providing information and services to these
groups, ome of the specific population groups with whom targeted interventions are
beinu/T-i 6 lncl.ude cornmercial sex workers, intravenous drug users, truck drivers and so
on. While working on targeted interventions one must not forget that the targeted
population is not the only population at risk.
23
Two other prevention strategies include control and treatment of sexually transmitted
diseases and condom promotion and provision
Working on HIV/AIDS care and support
fre^islse AIDS N
P6"0"’Once the Persons starts developing the symptoms of
disease AIDS is a long drawn disease. It includes periods of intensive medical care
in ersperse wit periods at home. Programmes have been designed which help health
care providers and family provide better care to the infected persons.
be<haI1Sellln|8 H1V/AIDs lnfectl°n is a cvondition with profound emotional, social and
mural consequences. In such a situation just providng medical care is not enough
LnnortSOnlnfeCti°n’ °r CVen may h3Ve the infection needs tremendous
h™ k cnd hl, SUPP°rt C3n be Provided though counselling. The role of counselling
Sanvh^0'6 klnS “ HIV teSt (Pre’teST counselling) and is a" importaznt part of
iiierapy.
*
Advocacy
inJtroduced new challenges to the defence of human rights. Clear laws
need to be framed which protect the rights of persons with HIV/AIDS and to prevent
iscriminafron against them. The different issues which need to be addressed have been
detailed clearly in the earlier section.
National AIDS Control Programme - Box
The National AIDS Control Programme was initiated in India in 1987. This programme
™efS1Sned t0 ’mPlement a Preventative plan including health education and condom
p
otion among identified risk behaviour groups, and screening of blood and blood
, 7comprehensive nation-wide Strategic Plan for the prevention of
AIDS in India was drawn up with focus on research, surveillence, EC, control of STD
cm om prevention and blood safety. The programme was for five years ( 1992-97) and
was funded by a soft loan from the World Bank. By 1992 the National AIDS Control
Organisatiori was started under the Ministry of Health and Family Welfare and was
responsible for implementing this programme. A widespread media campaign was
aunched on the press and TV. A newsletter titled AIDS in India was also started NGOs
we e a“J*8
HIV/AIDS
their
WOrk
^11 funds
were also provided. ■
y ns y e aviours, improve quality of condoms, increase the skilled pool of
counsellors and improving the quality of blood products.
24
i-v ; -
aboul the problem andTsenTe of dem '"p?"” aMe 10 devel°Plhe
of urgency
country.and the number of positive peonloh P'rS'S'tS '"J’'8' P°Puli“'O"s ™thin the
Now the second year phase of the programme (Z" m TV al’rmi"g r‘K
expected that it win benefit fronl
« ^les’’’
" laU"Ch'd ‘nd it “
25
■ **•*
.'’7?^ 'V*■. 'r. '•
•v; vt-’n:rn
Some Innovative projects on STD, HIV/AIDS
There are a large number of organisations working on the different aspects of AIDS.
MtvAmc7 0r8anisatl0ns both Governmental and non-governmental have incorporated
. awareness Wlthin other programmes, be it health programmes, programme
wi adolescents or college goers. In other situations deliberate programmes have been
designed to address the needs of commercial sex workers, truck drivers, industrial
wor ers, youth and so on. An attempt is being made to provide a flavour of the different
in s ot approaches being adopted by these organisations. Brief profiles of the work of
tour such organisations are being provided below.
r
STD HIV Intervention Project, Calcutta
This is perhaps the most well-known STD/HIV project in the country, and is also known
as he Sonagachi Project. This project started as a prevalence study of STDs in a redlight
istnct in Calcutta in 1992, but has since then has developed into a full fledged
intervention. It was initially being implemented by the All India Institute of Public Health
u is being currently managed by an autonomous committee which has sex-workers as
members. The three mam focal issues of the project include - sexual health services
rough clinics, education through peer educators and a campaign for rights of
sexworkers through an organisation of sex workers.
For further details please get in touch with:
Ms Mrinal Kami Dutta ( Director)
SHIP ( STD HIV Intervention Programme)
8/2 Bhawani Dutta Lane
Calcutta-700 073
Phone 033-2415253, 2416200,2*416283
Fax 033-2416283
E-mail- ship@cal.vsnl.net.in
AIDS Research Foundation of India,(ARFI), Chennai
ARF1 was founded, in 1991, with objective of promoting awareness around AIDS and
work towards its eradication. It has worked with and is currently involved in working
w'th sex workers truck drivers as well as industrial workers, ARFI also organises clinics
tor STDs where HIV testing is also done. .ARFI has also organised AIDS aware in
villages by using the effective m;edium of street theatre.
For further information please contact:
Shobha Krishnan,
Field Officer,
ARFI,
20 C, Thirumalai Road ( opposite Kamraj House),
T Nagar, Chennai -600017.
Naz Foundation, New Delhi
26
The Naz Foundation (India) Trust was established in 1994. The main focus ofNaz
Foundation revolves around the development of HIV/AIDS and sexual health services.
ctivities of the Foundation include-Training Programs ( for schools, colleges, NGOs,
ospitals), Healthy-Highway project (involving the mobile population of truck drivers)
Peer education (college students have being trained in HIV basics, and skilled in
in ormation disemination and pass on information to their peers, family and friends) and
Consultancies related to HIV/AIDS.
For further details please get in touch with:
Ms Anjali Goapalan ,
Director,
The Naz Founation ( Trust),
D-44, Gulmohur Park,
New DelhiPhones 011-686 2422,685 1970,685 1971
Email- anjali@naz.unv.ernet.in
JANANI, Bihar
JANANI, is different from the previous three in the sense, that its innovation lies in
making available curative services for STDs and RTIs to women in the remote villages of
Bihar. JANANI is involved in training Registered Medical Practitioners ( unqualified
practitioners of western medicine) to diagnose and treat these diseases using WHO’s
syndromic approach. The RMP works in partnership with a female member of his
household who is trained in communication and interpersonal skills.
For further details of this project kindly contact:
Shri K Gopalikrishnan,
Director,
JANANI,
C-16 .A, Sri Krishnapuri,
Patna- 800001.
27
-••
’’^r-r-ncTrwi VW!W!TiW',.W^^’!m«WWWW
RESOURCE SECTION
Further Reading: HIV/AIDS is a subject of considerable topical interest and there are a
large number of books and newsletters on the subject. Some of the books that we have
found useful in the preparation of this booklet are given below:
Abha Bhaiya and Ratna
Kapur__________
Dept, of Youth Affars and
Sports________
Elizabeth Reid
Fl 994
Elizabeth Reid
1993
Elizabeth Reid, Michael
Bailey_______
Ellen Weiss, Geeta Rao
Gupta________
John Hubley, Shankar
Chowdhury, V
Chandramouli
Julie Hamblin
1993
KIT, SAfAIDS and WHO
Maggie Black
Marge Berer, T.K.Sundari
Ravindran_____
Moni Nag
Sandip Bandopadhyay
Sanjay Kapur and Jaiwanti
P Dhaulta_______
UNAIDS/WHO
1993
1993
1998
1995
Report of the National Workshop on Women,
STDs,HIV and AIDS, New Delhi, Jagori
National Workshop on Youth Action and AIDS,
A workshop report, New Delhi
Placing women at the centre of the analysis New~~
York, UNDP
’
Sharing the Challenge of the HIV epidemic New~
York, UNDP______________
Young Women: Silence, Susceptibility and the ~
HI\~ epidemic, New York, UNDP______
Bridging the Gap: Addressing Gender and
Sexuality in HIV Prevention, Washington, ICRW
The AIDS, Bombay, Popular Prakashan
1993
People living with HIV: The law, ethics and
discrimination, New York, UNDP______
1995' Facing the challenges of HIV, AIDS STDs: a
~
gender -based response, Amsterdam, Harare, *
Geneva_______________
AIDS and Asia: A development crisis, New York
UNDP_________________________ _______ ’
1995
Reproductive Health Matters - Promoting Safer ~
Sex, London, Blackwell Scientific__________
1996
Sexual Behaviour and AIDS in India; New Delhi ~
Vikas Publishing House Pvt Ltd.
1997 The Sonagachi Experience: An Intervention
Project among commercial sex workers, New
Delhi, VHAI___________________ ________
1997 Handbook for Nurses on HIV/AIDS, New Delhi, ~~
Voluntary Health Association of India________
1998 India. Epidemiological Factsheet on HIV/AIDS ~~
and sexually transmitted diseases___________
1994 Candles of Hope, London, Action Aid
Werasit Sittirai and Glen
Williams_______
World Health Organisation
World Health Organisation
1997
1998
World Health Organisation
[ World Health Organisation
1992
AIDS The Challenge, New Delhi,__________ _
Clinical management of HIV and AIDS at the
district level. New Delhi__________________
Understanding and Living with AIDS, New Delhi"
| AIDS Prevention
28
^^dEBhhprgan-sat.on
-^iKHe^Organisation
World Health Organisation
'^LdlilhhOrga^I^r
1996
1994
1995
liZllsldo^rCarrNewr^
LetUTalk about AlDS.7kw PeThl
----------------
1997
Resource Organisations
~^rNX°Zato“s,oday w“ r*Onde
of
mV/A1DS in th- work
This supported be
pampble.s and 01her mter]al for dist„?ution^^^il
Seo)'arfS
NACO is given below:
AIDS Conlrol Organisation
0"'r01 0rSa"««oons (SACOs). The address of
Director NACO,
Indian Red Cross Building,
is Red Cross Road,
New Delhi 11000L
large amounJSerialXb^lXX^mctdV' 0^'"8
whom.a
World Health Organisation- SEARO
Indraprastha Estate
New Delhi -110002
. UNDP
HIV/AIDS Regional Project
55 Lodi Estate,
New Delhi 110003
UNAIDS
C/o UNDP
55 Lodi Estate,
New Delhi-110 003
UNIFEM
228 Jorbagh,
New Delhi 110003
Or8anisati°ns which can provide support to others working on
H1V/AIDS include:
29
Naz Foundation
(For address see above)
VHAI and the different State VHAs
VHAI,
40 Institutional Area, ( behind Kutab Hotel)
New Delhi 110016
NGO AIDS Cell
All India Institute of Medical Sciences,
Aurobindo Marg,
New Delhi -110016
-
'z-
SPARSH
B -163, Indira Nagar,
Lucknow
221010. U P
Booklet prepared by.
r
- 2DaS8,JP,a' “b*' D“
r-Y
Reviewed by. C.Y.Gopinath , Amitrajit Saha
.
-
?•
-.j-.
30
K>H
H.
UNDERSTANDING
REPRODUCTIVE HEALTH
A Resource Pack
BooTdet — Nine
Men’s Health and Responsibility:
Forging new partnerships
SAHAYOG
9
I
CONTENTS
INTRODUCTION
Section One: Establishing Men’s Role in Reproductive
Health
Evolution of the idea of men’s involvement
Men’s responsibility in Reproductive Health
ICPD and men
The need for increasing men’s role and responsibility in RH
Men’s knowledge and involvement in Family Planning
Increasing men’s responisbility
The health system in India and men’s involvement
Section Two : Men’s Health
Men’s health as distinct from men’s responsibility
Men’s halth and its social determinants
What needs to be done
Men’s socialisation and their health
Masculinity
. -Men’s Reproductive Health
Reproductive Health problems of men
Health seeking behaviour and service providers for male RH
problems
Some important Reproductive health problems of men
Section Three: Starting a programme for men and RH
Important Imperatives
Some organisations working on men’s health and
involvement
Resource Section
• Further Reading
Resource Organisations
4
4
4
5
5
6
7
9
10
10
10
11
11
12
43
14
14
15
17
17
19
21
21
22
2
INTRODUCTION
Men’s health and responsibility as a distinct area of interest has emerged fairly
recently The interest in men’s responsibility and partnership was a logical corollary
of the understanding of women’s health in terms of socio-cultural factors If women
are powerless and in no position to take decisions which affect their health, improving
the health status of women is only possible if the persons who are in a position to do
so are involved. In many cases men use their superior social position to consciously
make decisions detrimental to women’s health, for example, decisions to marry off
daughters at an early age, or to inflict violence on partners, or force them into sexual
relations. But there are many other situations where men too are ignorant of the health
implications of many cultural beliefs and practices that they enforce. A third
possibility is that in some situations men too are just victims of societal expectations
and enact roles because they know of no other. But what ever be the reason, men still
play a vital role in determining the status of women’s health, more vitally their
reproductive health. And the realisation that substantive changes in women’s
reproductive health will not be possible without involving men has lead to a number
of interesting experiments in trying to work with men and forging partnerships.
Reproductive health is not exclusively concerned with the health of women. Though
men are in positions of power in relation with women, they are powerless in situations
related to their own reproductive and sexual health. What most men possess in terms
of knowledge is nothing but myths and misconceptions ■culled from equally ignorant
peers or from pornographic material -Recent research has brought to light the ..
tremendous ignorance of men have in such matters. The demands of being a ‘man’
also works counterproductive!y for the health of men in many situations- though
many of these linkages are still being explored.
In this booklet we shall try to cover some of the main areas of concern in men’s
responsibility and their roles with respect to women’s reproductive health and in
family planning. This is an emerging area of study in the country with a lot of
pioneering work being done by both activists and academics. We have also tried to
look at men’s health independently. As in all other sections we have tried to provide a
basic reading list, including the books that we have consulted We also provide
introductions to some of the organisations who have been working on the issue, and
who could be provide further assistance on the subject.
3
Section One
Establishing Men’s Role in Reproductive Health
Evolution of the idea of men’s involvement
In most societies in India a woman is considered inferior to men and much of her
contributions at home, in the fields or even in the workplace are greatly undervalued
if not totally ignored. She has little education or mobility and even less decision
making powers, even in matters crucial to her health and well being. Women’s health
activists have been arguing that it is women’s subordinate position rather than a
cluster of bio-medical causes that has an overwhelming effect on her health. In
countries like ours ( or for that matter most of so called third world countries)
patriarchy is the norm and men wield enormous power and control over women It is
very difficult to secure women better conditions of health within this setup because
women’s ill-health is a product of the very same situation. As such it becomes
essential for strategic reasons to involve men in the efforts of securing better health
for women, so that they do not become enemies but allies, as responsible partners and
joint decision makers.
Men’s Responsibility in Reproductive Health
Today when we talk of Reproductive Health, we can see the need to involve men as
responsible partners in every single aspect. The various dimensions of male
involvement would start with understanding the politics of socially-defined relations
between men and women, and trying to go beyond and redefine them. It would then
extend to equal rights within the household and inter-spousal communication, and
then into the ’nuts and bolts' of health. Starting from the question of safer sex and
responsible sex, this would include looking at illnesses, pregnancy and childbirth,
childcare, violence. Given women’s lack of decision making, it is crucial for men to
emerge as supportive partners of the reproductive choices that their partners make.
Further reproductive health problems affect women quite differently from men, even
where men are the prime actors. In the case of Reproductive Tract and Sexually
Transmitted Infections, for example, it has been recognised that the route is often
through the men ( husbands), yet while it could be asymptomatic for men, the results
can be debilitating and devastating for women (eg. infertility). It is also difficult to
ensure improved obstetric care without the involvement of the husband. Moreover,
there has also been a growing concern all over the world on the way family planning
programmes were only coercively targetting women, which shifted the interest on
how to creatively involve the male partner who is equally responsible for the family
as his spouse. Further, in the area of domestic/sexual violence, which is an important
area of concern for reproductive health, the involvement of men at different levels is
crucially important. On a different plane, the empowerment of women is only
possible if there is equality, autonomy and respect at home and this needs the active
participation and support of the men in the household.
4
ICPD and Men
I he Programme of Action of the ICPD makes a significant point when it tacitly
accepts that there is inequality between the se.xcs and countries should aim at
promoting equity between the sexes, human rights and women’s empowerment The
ICPD PoA further emphasises that it is not possible to achieve this goal without
making efforts to engage men as active responsible partners
It also mentions that information and services have to be equally available to both
sexes thus making men s reproductive health a valid subject of interest in the national
health agendas. These principles are echoed in the Platform of Action of the Fourth
World Conference on Women .
Reproductive Rights include ‘the right of men and women to be informed and have
access to safe , effective, affordable and acceptable methods of family planning of
their choice. Reproductive healthcare programmes should be designed to serve the
needs of women, including adolescents, and must involve women in the leadership,
planning, decision-making, management, implementation, organisation and
evaluation of services. Innovative programmes must be developed to
educate and
enable men to share more equally in family planning, domestic and childrearing
responsibilities and to accept major responsibility for the prevention of STDs ’(ICPD
PoA,VII, A)
There is need to promote the adequate development of responsible sexuality that
permits relations of equity and mutual respect between the genders ’ (ICPD PoA Vll
D)
Jhe Necyj for increasing Men’s Role and Responsibility in RH
The need for increasing men s responsible involvement in Reproductive Health has
been touched upon earlier. If we agree that there is inequality between men and
women and also agree that this inequality has to give way to a situation of greater
social equity and empowerment for women, we must involve men. Too many women
are poor, too few of them are in positions of power and decision making- starting
from the family to the parliaments. Thus social equity and empowerment is essential
even for women’s reproductive health, because it is only then that they will have the
ability to access information, freedom to make choices, to avail services or even to
make decisions about their own reproductive health. Women's present position within
society is defined by a large number of institutions and traditions- family, culture,
religion, laws and so on. Though individual women’s effort to redefine their positions
within these systems are essential, they are not enough. Men’s support and
cooperation are essential, because men can play a key role in eliminating inequalities
between men and women.
At a more mundane level, neglecting or ignoring men in terms of providing
reproductive health related information and services can have detrimental effects on
women s health. No amount of healthcare services or preventive information can help
a woman whose partner refuses to cooperate with changes in sexual behaviour,
practice of safe sex or prevention of unwanted pregnancy. Men's awareness and
sensitivity towards reproductive health issues will have to be addressed to bring about
any lasting difference in the status of women's health. At the same time, while
s
addressing men as supportive partners, they will be brought into the wide range of
reproductive health services (including information services) as clients in their own
right, which will lead to better health outcomes for women as well as men.
It is also important to understand men s sexual and reproductive health needs, which
include the need for information and services Men's own aspirations, fears and
concerns deeply affect their behaviour with their partners, and affect the outcome of
interventions that target them (such as education about condom use, or encouragement
to undergo vasectomy). The preponderance ot myths and misconceptions leads to
high-risk sexual behaviour (for example, sex with a virgin is a cure for STDs). In
fact, mens perceptions about their reproductive problems are usually quite different
from bio-medical reality. These aspects need to be researched and models of effective
service provision developed, which can then become conduits for disseminating
accurate information related to men's role and responsibilities in reproductive health.
Service provision will also have to be very carefully designed as men are reluctant to
associate with any stigmatized images in seeking reproductive healthcare, such as
going to the "Venereal Diseases" department in a hospital.
It is also important to understand that men are socialised into stereotyped notions of
how they should behave from adolescence, so any interventions at changing their
socially constructed behaviour should start with emphasis on the early years.
Moreover, adolescents themselves have special needs for reproductive health
information and services. Despite being sexually active, they are not socially
permitted to seek information from legitimate and accurate sources.
Men’s knowledge of and involvement in women’s health and family planning
While men’s involvement is a very desirable goal, reality is far from such a situation.
A few studies have been conducted which have tried to understand what the situation
is at present. The finding from these studies more or less confirm the assumptions that
men are not very involved, don’t know too much about their partners health, and that
communication on reproductive health between men and women is very limited.
Some of these findings are presented below , but it must be mentioned that these
findings have been collated from a number of studies and only provide a flavour of
what the situation is in different parts of the country.
there is a major lack of communication between the husband and the wife on their
reproductive goals and acceptance of contraception. Whenever it occurs it is
initiated by the husband, and only after 2 or 3 children.
• many men believe that reproduction is a natural process and does not need to be
discussed, most believe that discussions on these issues should always be initiated
by men and about a third felt that they would be offended and would react
adversely if their wives took the initiative to discuss either reproductive goals or
contraceptive use.
• most men are aware of vasectomy, tubectomy, pills and condoms, but the use of
contraceptives for spacing is still an alien concept.
• men prefer tubectomy to vasectomy because they feel its simpler and the latter
requires more rest and makes them weak, whereas they have to earn a Iiving.
•
6
Fathers participation and even the expectation of mothers in bringing up children
is limited
• knowledge about care in pregnancy and delivery is limited.
• men s knowledge of the female reproductive system including menstruation is
very limited
• men get to know of women’s illness only when she tells him or when household
work gets disrupted
• men often do not accompany wives to the clinics when she goes to seek treatment
because it could mean loss of wages or affect employment
• men do not think that their involvement in women’s health is very important or
necessary
• most men are ignorant of the specific illnesses of their wives or women in the
family but have some idea what women’s illnesses are
• some men own up to physically abusing their wives, having sex while she is
unwilling and using physical force for doing
• an interesting finding in a couple of studies has been that men are aware that
women fall ill more, and this is due to the fact that women have to do more work
or face greater hardship.
(From papers presented at the Population Council workshop on Men as Supportive Partners,
1998, Nepal.)
•
If the situation seems very dismal it is because the above is a collection of findings
from a few different studies and does not represent the situation in any one particular
place.
Increasing men’s responsibility
Increasing men’s responsibilitydn the Reproductive Health of women, begins by
examining and defining their roles and responsibilities within the family unit. The
man is usually supposed to be the bread-winner and the head household, and most
care-giving functions are supposed to be delegated to the women. This construct
prevents men from engaging in positive roles in reproductive health matters. This
dichotomy has to be re-examined and this can begin with the realisation of the
different economic contributions that women make to the household in addition to
their accepted care-giving roles. Men need to realise there are several ways of care
giving in the different roles that they occupy in the family- father, husband , brother
or father-in-law. New ideals will have to be defined for these roles . But this is not
going to be an easy task as this involves a lot of unlearning on the part of individuals
and considerable resistance from existing social norms and traditional notions both
among men and women. Appropriate institutional mechanisms do not exist in most
workplaces to encourage men to adopt these new roles (paternity leave ) and then the
individual is vulnerable to ridicule from peers. Finally there are not enough roles
models or prescriptions available which men may adopt. For a start, an indicative list
of different responsibilities men may adopt as caring partners, or as fathers for
example, is given below.
Men as Sex Partners
1
Sex should not be seen as a sole male prerogative and should not be forced upon
the partner. Adequate attention has to be paid to foreplay and to emotional aspects
7
of sex
lake responsibility for safe sex, rather thuan putting the onus on women
In case of an infection (like STDs), getting immediate and reliable treatment and
avoiding sex until fully treated
4. Men should support the reproductive choices made by their partners regarding the
number and timing of children
5. Care of partner during pregnancy and after childbirth, especially diet and rest
This could mean helping with housework and childcare
6. Being sensitive to his partner’s reproductive health problems, support in
preventive hygiene and getting early treatment, and in case of infections, also
undergoing the treatment personally
2.
3.
Men as fathers
1. Planning for daughters to have adequate education rather than being obsessed
with thoughts of their marriage
2. Ensuring that daughters are at least eighteen, and preferably older when they do
get married.
3. At marriage, monitoring whether the daughter will be treated with dignity, rather
than doing financial tradeoffs
4. Supporting the daughter when she expresses discomfort with her husband's
family rather than trying to send her back there.
However, all these are dependent on men themselves receiving accurate information,
both about their partners bodies and health as well as about their own. At present this
is not the case, for men are prey to misinformation, and suffer almost as much as
women from uncertainties and anxieties about their own reproductive health and
^sexual behaviour. Men's problems are also shrouded in secrecy as "Gup.t rog" quite
like the culture of silence that surrounds women’s'gynaecological problems.
Moreover, it is imperative for men to
to renegotiate
renegotiate the
the spaces
spaces that
that society
society has
has granted
granted
to them in terms of relationships with women, and care of women's bodies. At
present men are unable to publicly express concern for their women partners as it
would be taken as a sign of weakness. Neither would men be expected to participate
in pregnancy and childbirth or post-partum care of their partners. As such, men are
reluctant to enter the so called "women's domains" partly because of family and peer
pressures. This makes the whole question of male responsibility in women's
reproductive health extremely complex.
There is also the whole question of dealing with men who are perpetrators of
violence against women. It is common understanding in current feminist discourse
that such men may not be differently categorised (and therefore excused, and other
men excluded) as being social aberrants. As such they are apparently "normal" men
who exhibit their sense of power and aggression through perpetrating violence
against women. The question is, can we intervene at some stage in the life cycle of a
male to ensure that he will not become a perpetrator9 Can we get all males to take
collective responsibility for violence against women (rather than dissociate
themselves from it as aberrant behaviour), and to work collectively to stop this from
happening9 How will this be done? These are some of the very real questions facing
those who work with sexual and reproductive rights of women, and there are no easy
answers.
8
The Health System in India and Men's Involvement
Reproductive Health is a term that has gained currency in India only after the
announcement of the RCH programme in October 1997. To many within the
establishment it still means little and is seen as a new name for the earlier Family
Planning Programme. The Family Planning Programme was heavily geared towards
targets tor female contraceptives. There was no concept of addressing men asresponsible partners. 1 he infamous excesses of forced vasectomies during the
Emergency in 1977 and the consequent political fallout seemed to have made service
providers averse to addressing men for contraceptive services and education. Coercive
methods were used to meet year-end targets, and women were much easier subjects.
Other than the mandatory advertisements for vasectomy and some training of doctors
in no-scalpel vasectomy, not much has been done to creatively involve men in the
entire process. Using their own cultural biases about men’s roles and responsibility
the programme planners have ignored the potential to involve men not only in
contraception but the care of women or in family planning decision making. Overall
the entire health and family planning programme have only reinforced traditional
stereotypes where male involvement is concerned. A small change seems to have
been started with the Target Free Approach in Family Planning which actually tries to
use Male Workers to address men for family planning information and services. It is
hoped that this provision will provide the appropriate impetus in the right direction.
As far as women s illnesses are concerned, the most easily available healthcare
providers - male doctors, have all been brought up oman exclusively biomedical
version of health. Hardly any in our health system are trained in a gender-sensitive
rhanner. They are products of a very patriarchal society and this reflects in the way
they treat their women patients?Most of women’s complaints are considered vague
and often attributed to imagination. Women doctors (who are often as gender
insensitive as their male counterparts) are seldom available outside big hospitals and
cities, and male doctors are left to deal with women patients with little understanding
of their social situation.
9
Section Two
Men’s Health
Men’s Health as distinct from Men’s Responsibility
While men have started off with the disadvantage of being the party in power and the
perpetrator of the inequalities, health relates to individuals while systems ( patriarchy)
breed the inequality. And individual men are often as much victims of the system as
with women. Recent research is throwing up evidence that the individual man is often
as ignorant, ill-informed, powerless in the face of role expectations and vulnerable as
women are. AIDS has been responsible in many ways for generating this interest in
men s reproductive health. Earlier, what most men had for their own reproductive and
sexual health were myths, gossip and quackery. Considering this situation it is equally
important for practitioners to consider the entire issue of men’s health distinctly from
that of their responsibility alone. Of course, there is one school of thought that is of
the opinion that in the current scenario, where the state of women’s health is abysmal,
it would divert attention and resources from an area of far greater priority. Some
argue that focussing attention on men’s need may in fact worsen the power situation
between men and women.
Men’s health and its social determinants
In the socio-cultural model of health (as opposed to the biomedical model) it has been
clearly established, that health and illness are greatly influenced by cultural values
and practices, social conditions, and human emotion and perception. As has been
elaborated elsewhere, women's health is to a great extent related to her situation at
home and the powerlessness that she has to deal-with* This acknowledging of
women's social situation as a determinant of health was the result of rigorous work by
feminist researchers and by the late 1970s epidemiological researchers in the West (
those who are concerned with the incidence and causation of disease) had begun to
include gender as a variable in their work. But until recently researchers have tended
to equate the study of gender and health to studies of only women’s health and illness.
If the use of the term gender and health is not to be restricted to women's health alone,
it leads to the question that does 'being men' also affect the health of men. Descriptive
research findings about the differences in men and women in terms of health and
illness (in the West) have revealed that.
(a) men experience more life-threatening illnesses and die younger than women
(b) women experience more non-life threatening illnesses and live longer than men
(c) women see doctors more frequently than men (not in the context of childbearing).
Feminist theory attributes the situation in women to their additional burden of illhealth to power differences between the sexes, in addition to gender identity,
socialisation and conformity to role expectations. But does this also mean that men
because of their social position are healthier as a whole and when they have an illness,
it tends to lead to their death ’ 1 here are a number of diseases which show greater
incidence in men, but is that preponderance biological or is it social9 Many of these
questions do not have definitive answers, and the area of knowledge concerning the
situation in India is relatively unexplored.
10
When discussing about men's health, it would also be erroneous to deal with men as a
undifferentiated group 1 he study ol men s health and illness needs to somehow
address the differential exploitation ol the lesser-status, marginalised male subgroups
(e g. men of lower castes, poor men) in the changing social order. For example the life
chances of prison inmates and college students, rich businessmen and rural dalit men,
straight and gay men, and professional men and homeless men are clearly different.
Analysis of men s health, needs to be sensitix e to these differences in men’s lives and
explore the relationships between men's social situation and their health in a very
holistic manner.
What needs to be done
The study of how social situations especially gender relations influence men’s health
and illness is at an early stage of development. Early research indicates that men's
health seems to be one of the areas in which the damaging impacts of traditional
masculinity are evident. More and more social scientists, medical researchers, public
health advocates, and men themselves need to be mobilised to decide to think about
and investigate these linkages thoroughly as well. In fact an alternative discipline of
men’s health studies has slowly begun to emerge in some parts of the world. Part of
the mission of men’s health studies, is to carefully research these linkages and to
discuss them with professional audiences and the general public. The socio-cultural
model for understanding men’s health and illness needs to placed in the backdrop of
power relations as well. This means lending weight to feminist theoretical insights
that social inequality irrevocably influences women’s and in this case men’s health as
well, and that differences in political and economic power yield differential health
effects/outcomes.
In order that things change men need to start with personal change. But this change in
men will not be possible without their changing the political, economic, and
ideological structures of the present gender order. And to start at a personal level men
need to challenge their own long held notions of'being a man" and they need
encouragement, positive role models and the space and sense of security to do so.
Personal change needs to be reinforced by structural and institutional changes as well.
To point to a very common situation in India- when a man decides to go in for a
vasectomy, the doctors and nurses first ask the man why is he doing so, is his unable
to get his wife's sterilisation done? If men are going to take up the challenge of
understanding their own behaviour and in some ways to tackle their own health , they
need to set out on a course which may be called pro-feminist because it not only
seeks to redress the oppression of women by men but also the oppression of lesserstatus men by privileged males within the inter-male dominance hierarchy.
Men’s Socialisation and their Health
The social, cultural, and political dimensions of illness have been strikingly evident in
the AIDS epidemic (ShiIts, 1988). Survey researchers have been generating useful
information about how men’s sexual practices, attitudes and risk behaviors are linked
to the growing AIDS epidemic. For men, especially gay and bisexual men, who are
infected with HIV virus, the myriad of meanings associated with AIDS steep into
their gender and sexual identities. In an analysis of interviews with 45 HIV+ gay men
Richard Tewksbury provides insights into how masculinity, sexuality, social
I 1
stigmatization, and interpersonal commitment mesh in the decision making around
risky sexual behaviour. In another American survey of boys between 18-19yrs,
traditional attitudes (towards how a male should behave) were also associated with
such acts like- ever being suspended from school, drinking and use of street drugs,
frequency of being picked up by the police, being sexually active, number of
heterosexual partners in the last year, and tricking or forcing someone to have sex.
Such behaviours which are in part expressions of the pursuit of masculinity, elevate
boys’s risk for STDs, HIV and early death by accident or homicide and also result in
oppression of women by men.
Boys learn to separate themselves from others and evaluate themselves and others
according to status because they strive to fit into male dominated, hierarchically
organised institutions such as marriage, sports, government and business. Hence male
psychology or gender identity derives from and revolves around status and power
differences between the sexes and among men. Another finding with patients of
testicular cancer vividly demonstrates the potential benefits of more flexible
conceptions of manhood for men themselves. Those who coped with it in a
traditionally masculine fashion had great difficulty in dealing with their situation
while those who tried to define a new conception of manhood found meaning and
emotional health .
Masculinity
The meaning of being ‘male’ differs in different cultures and groups there is
something often mystical associated with the masculine identity. This identity is
different from just the anatomical maleness and is a condition which boys aspire and
have to achieve. Researchers have varied in the ways that they have conceptualized
"and measured masculinity. Robert Brannon (197jJ)^identified the following four major
components of the male role: »
1. The need to be different from women
2. The need to be superior to others
3. The need to be independent and self-reliant
4. The need to be more powerful than others, through violence if necessary.
The strong need to be different, and being superior also leads to a sense of insecurity
and many theorists are of the opinion that this sense of insecurity leads their violence
over women. While these findings relate to the western situation, they may be
compared with the situation of men in our society as well.
Gender socialization influences the extent to which boys adopt masculine behaviors,
which in turn can impact on their susceptibility to illness or accidental deaths.
Research in the West ( which is the what we have to go by today) has shown that a
'give em hell' approach to life can lead to hard drinking and fast driving, which
account for about half of male adolescent deaths. The need to be a sturdy oak and to
avoid any resemblances to feminine dependancy may account for the tendency men
have to deny symptoms of coronary heart disease. In the world of bodvbuilding
subculture, where masculinity is equated to maximum muscularity and men’s
strivings tor bigness and physical strength hide an inner core of insecurity and low
self-esteem. Bodybuilders often put their health at risk by using steroids, over
training, and engaging in extreme dietary practices.
12
When strength and physical ability are key components of this kind of'being superior'
masculinity, men with physical disabilities experience considerable difficulties
constructing a workable masculine identity On the one hand, they struggle to cope
with stigma and feelings of inferiority, whereas, on the other hand, they strive to
redefine masculinity in ways that circumvent, transform, or reject dominant cultural
definitions of manhood Sex role theorists agree that the social construction of
masculinity in the American gender order produces negative impacts on men’s health
Therefore it follows that men in the new millenium have a vested interest in
challenging the traditional gender roles and timeworn notions of masculinity that have
proven dangerous to their health.
Men’s Reproductive health
Men s reproductive is one area of men s health which has been investigated to some
extent in recent years. A number of studies have been conducted in order to
understand how much men are aware of their own reproductive and sexual needs. The
findings from these studies have uniformly revealed a rather grim situation. Men have
little or no information about their own bodies and its needs and in the case of serious
illnesses too serious myths and misconceptions abound.
BoxThe following observations were made by the group TARSHI which provides
counselling in the field of reproductive health. TARSHI operates a telephonic helpline
meant initially for women but it is accessed more by men.
more men are concerned about sexual issues, and reproductive issues including
contraception for them comes later.
• '
in the area of sexual and reproductive health men have a need for information
about how the body functions, how to deal with their sexual problems and how to
avoid conception and infections, in that order of preference.
basic sex information queries include those on masturbation, nocturnal emission,
male genitals, sexual techniques and positions, breasts, female genitals, anatomy,
semen, male and female homosexuality, etc.
men's concerns about sexual pleasure have more to do with their own pleasure and
less with pleasuring their partners.
with regard to conception and contraception men ask about contraceptives and
search for an "easy" contraceptive. A large number of men do not know how to
use a condom properly.
- Some men especially those in their first sexual relationship, seem surprised that
conception can occur at any time. Many have heard of "safe days" but the
information they have is inaccurate and leads them often to have sex at the time
the woman is at her most fertile.
many men speak about infertility and emotional problems which disapproves the
myth that it is generally women who are troubled by these issues.
a lot of socially reinforced myths and misconceptions and deep-routed attitudes
abound, e g. most males grow up believing that a loss of semen by any means
apart from intra-vaginal ejaculation leads to a "loss of strength". These myths and
attitudes shape and influence sexual activity, contraception, gender relations and
the enactment of violence in sexual relationships.
( from- Chandiramani R. (1998) Men on the Line; in papers presented at the
*
13
Population Council workshop on Men as Supportive Partners, 1998. Nepal )
These and similar findings from other studies clearly underline the fact that men have
literally been hiding behind a facade of power and authority, where in actual terms
their ignorance and understanding of their as well as women’s bodies and their
processes is as incomplete as that of women This ignorance leaves men also
vulnerable to number of diseases and conditions. There is an urgent need to devise
ways in which men, especially adolescents can access accurate information about
such issues. This will not only lead to their able to negotiate their own sexual
experiences in a more responsibly. It may also be argued that the responsible sexual
behaviour of men will indirectly benefit their sexual partners (women) too.
Reproductive Health Problems of Men
The main problems or conceived reproductive and sexual health problems faced by
men in India, as shown by a couple of studies conducted include Hasthmaithun
(masturbation), Kamjori aur namardi (impotence/ lack of sexual desire),
Shighrapatan (premature ejaculation), Dhai Girna (White discharge from penis),
Tedhapan (bent penis), Khujali (Itching), Dane (boils), Peshab me ^//(burning
urine), Dhat patla hona (thinning of semen) Garmi ( heat inside the body)and so on. It
must also be mentioned that the terminology used is often used to indicate a range of
symptoms and the corresponding medical term may often be difficult to locate. Also,
often times a problem is also perceived as a reason. Thus masturbation or garmi can
be seen both as a problem as well as a reason for a problem. What comes through
from these studies is that the terminology used to describe men’s problems is very
contextual and has to be understood and interpreted carefully. Myths and
jnisconceptions abound and the reasons for many^of these illnesses are often attributed
to practices like going to a public toilet, indulging in excessive masturbation or even
pornography. These reasons are far from being bio-medically correct but are deeply
entrenched in men s minds because the source of health information for men are often
unqualified practitioners or traditional healers
Health seeking behaviour and service providers for male reproductive health
problems
As is evident from the above sections there is a tremendous amount of ignorance on
matters relating to sexual and reproductive health. This has been a taboo subject for
centuries. In the absence of right information, myths and misconceptions abound. And
since there is no place people can turn to if they need sexual information or if they
have a sexual or reproductive health problem, many unscrupulous people make use of
this situation and offer false and ineffective treatments or wrong information and
often harmful drugs. They charge from a few rupees to thousands of rupees for their
services depending on the clientele they are catering to. Such unscrupulous
practitioners abound even in metropolitan cities like Delhi where thousands seek
what could be termed as bogus treatment for a range of sexual problems (including
what is perceived to be a problem by the individual but is completely normal). For
example one can easily find posters all over cities or on walls around highways or
railway tracks, proclaiming to offer guaranteed relief from nightfall, premature
ejaculation, impotence, Dhat, and so on.
14
Another common sight in India is that ol street hawkers selling various kinds of
preparations as remedies for sexual problems or as aphrodisiacs. Some of them are
made out of questionable ingredients Some of these preparations are extremely cruel
to animals, e g. Sande ka tel which is prepared in front of the onlookers. Live Sandas
an endangered species of lizards, are boiled m a container. The liquid is then sold as
an aphrodisiac which will prolong the duration of erection.
There is hardly very little information available about what kind of people run these
services, what kind of treatment they offer, who are the people who visit them and so
on. But hopefully things are changing now AIDS awareness campaigns have brought
discussions on sex and sexuality out into the open, at least in some sections of the
society. The Government on its part has renamed the infamous 'VD' clinics into
clinics tor RTIs and STIs and the new RCH approach makes it mandatory for each
district to have one such clinic if not at each Community Health Centre. There are
also guidelines on how much space such a clinic should have. If this clinic approach
can be complemented by an effective health education campaign, one may expect that
men will slowly stop visiting unscrupulous clinics furtively and seek proper medical
advice for their problems.
Some of the important Reproductive Health problems of men
Infertility: This is an issue of concern because in many communities where a woman
fails to concieve within a short period after marriage she is held responsible and has to
suffer great mental and often physical harassment within the household. It was a
common practice in the past for men to marry7 again in-such a situation. Male
infertility needs to be recognised and efforts made to involve men in cases where
women fail to conceive. Male infertility can be due. tcv various reasons: The most
important of which are a low sperm count or low mobility of sperms.
Testicular Cancer: Testicular Cancer occurs most commonly between the ages of 15
and 40 years, though it can also occur in infancy and late adulthood. Individuals who
have had an undescended testicles are at higher risk of developing testicular cancer.
The best way to diagnose testicular cancer is through self-examination. The usual
initial finding is a painless lump in or on the testis, a hardness or enlargement of the
testis. Less commonly there is associated pain and tenderness or bloody discharge.
Testicular cancer has one of the highest cure rates of all cancers. The treatment
includes surgery, radiation therapy, chemotherapy or a combination of these.
BoxTesticular Self-examination
Testicular self-examination is an important part of routine health of men and should
be done once a month.
Gently grasp the testicle between the thumb and indexfinder using both hands. Roll it
between your fingers applying a small amount ofpressure in an effort to detect any
irregularities of the surface or texture of the testis. After one testis and chord has been
examined one can then examine the opposite side. Often comparing the two sides can
help establish an abnormality in one side or the other.
Fortunately most scrotal or testicular masses are not cancer, but nevertheless one
should immediately see the physician.
15
Varioccle - Varioceles are enlargements of the veins that drain the testicles. Some
varioceles may cause pain and/or testicular atrophy (decrease in size). A variocele
affects fertility due to the decrease in circulation of blood in the testicular area. Many
cases are diagnosed during an infertility checkup. It can be cured through a surgical
process
Hydrocele - A hydrocele occurs when fluid fills the membrane covering the front and
sides of the testicle and epididymis iin the scrotum. This is usually not painful, but is
often uncomfortable due to the increased siz£ of the scrotum. Possible causes are:
trauma to the scrotal area or inflammation or infection of the epididymis. Some
hydroceles need not be treated as they resolve without intervention or remain
asymptomatic. When a treatment is necessary, the best intervention is
hydrocelectomy, surgical correction of hydrocele under anesthesia. Where surgery is
not recommended because of health etc. reasons the hydrocele may be aspirated.
Aspirated hydroceles may reappear. Filariasis is one of the common causes of
hydrocele especially in endemic areas.
Prostate Cancer
Prostate Cancer usually occurs after age 55. Most patients are 65 years or older. In its
earliest stage this cancer may not produce any signs or symptoms. As the tumour
grows one may experience:
- difficulty in starting or stopping urinating
- decreased strength of the urninary stream
- dribbling at the end of urination
- painful or burning urination
- frequent urination, especially at night
-- painful ejaculation
- Blood in the urine
- An inability to urinate
- Continuing pain in the lower back, pelvis or upper thighs
Early detection of prostate cancer increases the chances of a cure. Treatment includes
surgery, radiation therapy, hormone therapies and cryotherapy (which freezes the
prostate and the appropriate nearby tissues).
Sexual health problems like Masturbation , Impotence , premature ejaculation are
bein^ separately dealt with in the Section of Sex and Sexuality.
16
Section Three:
Starting a Programme for Men and Reproductive Health
Important Imperatives
Realising the importance of involving men in reproductive health programmes as well
as the need for sensitising men to their own needs and offering them appropriate
services a number of organisations have initiated such pioneer efforts. Some of these
efforts are being briefly touched upon in this section. There are a few organisation
which has been doing pioneering work with male clients in family planning for a long
time all over the world. Experiences gained in one country are being tried out in
others. Some of the key elements of different successful programmes concerned with
men and reproductive health are outlined below.
Gender concerns - Gender is a fundamental context for work with both men and
women, as it shapes all aspects of clients' lives. Gender issues/which are inevitably
culturally specific, are a crucial consideration in program design. The program should
ensure through trainings that the staff is gender sensitive. The information about the
pressing gender concerns in the community should be procured through various levels
of community sources and addressed in programme design. It is helpful to.form
linkages with other existing services in the community to ensure that the program is
able to address issues like gender-based violence.
Access to services - Reproductive health services must be made accessible to men.
The program may have to overcome cultural biases to achieve this. If possible men
should be provided service seperately ( from woriwh),* but if it has to be integrated
with womens services it should not compromise resources for women.
Service Selection - One very important consideration in program design is
determining what reproductive health services should be offered to men. Such
services should include physical exam, referrals, comprehensive reproductive health
education, education and counselling for contraception and STDs and genital health
and hygiene.
Sustainability - Program designers should plan for future economic and technical
sustainability from the very start of the program. For this the services should be
tailored to what the community wants and needs. One way to do this is to start a
program by asking community members to articulate their needs and brainstorm about
priorities to meet them. The program should be cost conscious. The possibility of cost
sharing with other organisations and cost recovery could be considered. The use of
existing labour pools -- e.g. medical, public health students who might provide labor
at a reduced cost, could be investigated. It is also helpful to gamer necessary political
and other appropriate high-level support
Community Outreach and Workplace Programs - Information and education
should reach potential clients outside as well as inside the clinic setting, for example
at workplaces or in places where clients spend their leisure time. Reproductive health
education can be incorporated into existing school-based and other training
17
programmes (e g. military or police training) Informational meetings can be arranged
IEC materials distributed during community events, such as local festivals Employers
and managers should be involved in introducing and supporting the program.
Counseling - Men have special needs when it comes to counselling for family
planning and reproductive health. Counselling requires respecting each client and
tailoring advice to suit his or her individual needs. All counselors should be good
listeners and communicators who are both non-judgemental and knowledgeable.
Integrating STD Services - Reproductive health services should include HIV/STD
education, prevention and treatment. The issue of STDs may present special
challenges, for example, there may be a great social stigma attached to talking openly
about these issues. The programme should lay emphasis on prevention, including
safer-sex and proper and regular use of condoms during sex. It should also help
providers deal with values and biases related with STDs and HIV/AIDS. Education
and counseling are important to help behavior change. Clients should be encouraged
to be community educators.
The special need of adolescents - To meet the special needs of adolescents setting up
accessible youth centres can be very helpful. Skits and other forms of arts can be used
to raise issues and direct young people to services. Providers should be trained to talk
to and deal with young populations. They should be sensitive to the special concerns
of youth (physiological development, sexuality, peer pressure, etc ). Peer educators
and counselors also play an important role.
Publicising Services and Attracting Clients - When trying to attract male clients to
new or expanded services, male-specific information, materials, and counseling must
be provided. By making use of mass media etc, providers can reach a larger audience
and can stimulate awareness as well as change mindsets and attitudes. Such messages
should be in a culturally sensitive manner. W ell known local groups can be asked to
endorse such messages.
Agenda for Research - While these are some of the strategies that have been tried
out for involving men, these are still far being being universally applicable. There is
need to refine and make these more effective. Towards this end there should be more
research for testing the efficacy of the strategy of men’s involvement in reproductive
health. Research should also be directed towards understanding family dynamics and
roles of various actors including the society in decision making process vis a vis
woman s reproductive health. This will enable such programmes to be even better
planned and focussed.
18
Some of the organisations working on men’s health and involvement
I. SARTHI
Social Action for Rural and Tribal Inhabitants of India, is a registered society working
for integrated rural development in the Sansrampur Tciluka of Panchmahals district in
Gujarat (working in 150 districts). Much ot the population consists of marginal
farmers who are dependent on rainfed agriculture and who also have to migrate
seasonally. The range of programmes include, installation of hand pumps for drinking
water, agricultural improvement, wastelands development, education through nonformal schools, rural industries for income generation, development of alternative
energy sources, wome’s development, and awareness generation.
Driven by demands to add reproductive health services for men, SARTHI has been
running a Community Health Programme (CHP) for men (note:’it says general
community health programme but it seems only for men). Currently, male health
workers run general clinics under CHP in about 60 villages. They are trained to treat
the common problems in the community as middle level health and multi-purpose
workers.
Address. Sahaj/ Sarthi, 1, Tejas Apartment, 53, Hari Bhakti Colony, Old Padra Road,
Vadodara-390 015, Gujarat; Tel: 0265-340223 Fax 0265-330430
SARTHI- Godhra
Contact Person. Renu Khanna, Harish Patel, Balwant Pagi and Nirmal Singh.
2. Deepak Charitable Trust
This trust was established to provide health care services to the communities around
the industries. They are involved in a wide range of activities including various
community health and rural development projects as well as women's empowerment
and information, education, communication. It aims to achieve the goal of small
family norm by providing services for safe mothcfhoo*d, child survival and providing
family life education to adolescents.
The Deepak Charitable Trust has started a Pati Sampark programme to involve men
in the antenatal care of women.
Address: Deepak Charitable Trust, Deepak Medical Foundation, 9/10, Kunj Society,
Alkapuri, Baroda - 390 007, Tel: 0265 339410/ 33 1439, Fax: 0265-330994; E-mail:
dnl.alakhani/dnl.sprintrpg.ems.vsnl.net.in
Contact person: Ms. Aruna Lakhani, Co-director of Deepak Charitable Trust
3. SEWA Rural
Society for Education Welfare and Action - Rural is a voluntary service organisation
working for health and rural development in a tribal region of Bharuch district,
Gujarat. Its work includes running a community hospital, outreach health care through
Community Health Project, comprehensive eye care programme, a technical centre
for rural youth, tutorial classes for potential school dropouts, and income generating
activities along with saving and awareness programmes as part of women's
development.
The society has adopted different strategies over the last few years to reach out to men
in order to enhance their roles and responsibilities in women's health. This includes
sensitisation and orientation of male (and female) health workers, male members of
the family, etc.
Address: Sewa Rural, Jhagadia 3931 10, Dist. Bharuch, Gujarat; Tel: 02645-20021.
19
4. PSS — Punish Clinic
PSS, a registered voluntary organisation has been working in the field of maternal and
child health and Family Welfare in several states since 1978. PSS is afiliated with the
British charity Marie Stopes International which encourage and support family
planning programmes in many developing countries all over the world.
It has set up a branded male clinic called PURl/SH - Male only clinic in Chennai,
Tamil Nadu. It offers an integrated package of services for men with special emphasis
on family planning.
Address: Parivar Seva Sanstha, C-374, Defence Colony, New Delhi-1 10 024, Tel:
4617712/ 4619024, Fax: 4620785, E-mail: pssindia@giasdlO 1 .vsnl.net.in
Contact person. Ms Sudha Tewari, Managing Director, PSS
20
RESOURCE SECTION
Further Reading
Some of the books which we found useful in the preparation of this booklet are given
below.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Akhter H.A. 1996 Male Contraception Dhaka. BIRPERHT
Amin A, et al. 1996. Men’s Perception of illness of the Nether Area Gujarat
SARTHI
Amin A, et al. 1997. Attitudes and behaviours of Men iin Relation to gender and
sexuality. Gujarat. SARTHI
AVSC International 1997. Men as Partners in Reproductive Health: Workshop
Report. New York.
AVSC International 1997. Programming for Male Involvement in Reproductive
Health. New York.
AVSC International. 1997. Men As Panners Initiative: Summary Report of
Literature Review and Case Studies. New York.
Khan M.E, Patel. B C. 1997. Male Involvement in Family Planning. New Delhi:
The Population Council
Ladig Larry 1996. The Society for Psychological Study of men and masculinity.
The American Psychological Association
Mundigo Axel. 1995. Men’s Roles, Sexuality and Reproductive Health, Chicago,
The John D And Catherine T MacArthur Foundation
Sato D, Gordon D.F. 1995. Men’s Health and Illness. Thousand Oaks. Sage
Publications
The Alan Guttmacher Institute. 1996. Reradings on Men. New York'
UNFPA 1998. A new Role for Men: Partners-for Women’s Empowerment New
York
Vissaria Leela. 1998 Men as Supportive Partners in Reproductive and Sexual
Health. New Delhi. The Population Council
Wegner M.N, et al
Men as Partners in Reproductive Health : From Issues to
Action. International Family Planning Perspectives
Journals - These are two journals dealing with the emerging discipline of Men’s
Studies
1 The Journal of Men's studies; c/o James Doyle, P.O. Box 32 Harriman TW 377
48-0032, USA.
2. Masculinities - c/o Michael Kinmel; Dept. Of Sociology; S.U.N.Y. at Story Brook
Story Brook, NY-11794-4396, USA.
21
Resource Organisations
I he whole issue of Men s involvement and participation is relatively new and
unexplored. Some of the organisations which could help by providing information and
materials on men’s health and involvement are as follows
I. AVSC International
The organisation works worldwide to improve the lives of individuals by making
reproductive health (RH) services safe, available and sustainable. AVSC provides
techical assistance, training and information, with a focus on practical solutions that
improve services where resources are scarce.
US address: 79 Madison Avenue, New York, NY 10016 USA
Telephone: 212-561-8000; Fax: 212-779-9439
e-mail: info@avsc.org; World Wide Web. http7www.avsc.org
India address: IFPS Liasion Office, 4/2 Shantiniketan, New Delhi - 110 021, Delhi
Contact person: Nirmala Selvam, Programme Associate
2. PATH
PATH is primarily involved in promoting appropriate technology for health but it has
also been involved in preparing and providing resources for involving men.
4, Nickerson Street,
Seattle, WA 98109-1699
USA
3. Population Council
The South East Asia Regional Office at New Delhi is actively involved in creating
greater understanding on the subject of Men s involvement.
South an’d East Asia Regional Office
*
' '
Zone 5 A, Ground Floor, India Habitat Centre
Lodi Road, New Delhi - 110 003
Tel: 464 2901, 2902, 4008, 4009; Fax: 464 2903
E-mail: pcindia@popcouncil.org
Contact person. Dr. Saroj Pachauri, Regional Director
5. Parivar Sewa Sansthan (PSS)
PSS is involved in trying out new strategies in involving men in reproductive health
programmes.
Parivar Seva Sanstha, C-374, Defence Colony, New Delhi-110 024, Tel: 4617712/
4619024, Fax: 4620785, E-mail: pssindia@giasd!01 vsnl.net.in
6. CHETNA
CHETNA has been evolving new 1training modules
’ ‘ and strategies for
~ 'incorporating
men in reproductive health programmes.
Centre for Health Education, Training and Nutrition Awareness (CHETNA)
Lilavatiben Lalbhai’s Bungalow
Civil Camp Road, Shahibaug
Ahmedabad 380 004
Tel: 079-2868856/ 2866695; Fax: 079-2866513
22
Booklet prepared by-
Research and Text- Alok Srivastavu, Ahhijit Das and
Jashodhara Dasgupta
Review Siddhi Hirve, Bela Ganatra and Saraswati Raju
23
vova- n - <2>;
!
Understanding
Reproductive Health
6.
A Resource Pack
U
Booklet - Eight
^^‘r<
ADOLESCENTS
The Emerging Agenda
SAHAYOG
[
I
sw
Ho?
s
CONTENTS
INTRODUCTION
Section One : Understanding Adolescence
Some Definitions
Adolescent Sexuality
Patterns of sexual behaviour in adolescents
Anxiety around pubertal changes
The generation gap
Peer pressure
Sex education for adolescents
Section Two: Adolescent reproductive and sexual health in India
Minimum age at marriage
Consequences of early marriage
Adolescents and abortion
Adolescents and reproductive morbidities
Adolescents and STD/HIV/AIDS
Adolescents and young people in Inda some facts and figures
Section Three : Working with adolescents
Issues to be kept in mind while devising programmes
Recommendations for actiori
Some Innovative Projects
Resource Section
Resource List of Materials
Resource Organisations
4.
4
4
5
5
6
6
7
9
9
9
10
10
10
10
12
12
13
15
17
17
22
INTRODUCTION
raSnClOSOual cll"nges r,hese chan^es can overwhelm him or her and this phase is often
called a phase of turmoil. Unfortunately, by with-holding information about these
changes and about different aspects of sex and sexuality from the adolescent an already
troublesome phase has become more complicated for many. Further there are added ’
to0^S<t°nS dUe t0 the7anuUS m^hs’.misconcePtions that abound around it, and also due
to the stigma attached to the various issues of sexuality.
In India, despite the fact that adolescents form one fifth
of the
the Indian
their
fifth of
Indian population,
population, their
reproductiye health needs are poorly understood and ill-served. While the needs of
c ildren or pregnant women are acknowledged in national strategies and programs
neither services nor research have focussed on adolescents and their unique health and
information needs. In a country where adolescents comprise about 190 million the health
consequences of this neglect take on enormous proportions.
lLa?tlOna!b\thefrom childh00d t0 aduhhood among females has tended to be
sudden in India. On the one hand, as a result of the poor nutritional status of the average
Indian adolescent, menarche occurs later than in other regions of the world On the other
hand marriage and consequently fertility occur far earlier, thrusting females early into
adulthood. Far more social science research is needed that explores why adolescents'
sexual and reproductive health service and information needs remain unmet and how
health and informafion services can be structured to respond to these needs taking into
Non’stho f the S°tC11 ' CUltUrr’
economcwflstraints that adolescents in India face
on-school going adolescents form a significant part of the adolescent population in
dia. Their reproductive health needs are magnified because of their poverty and
vulnerability for sexual exploitation (e.g. street and working children). There is a Dressing
need to devise appropriate reproductive health programmes for them, and to make^he "
information and services accessible to such adolescents.The proportion of world
Norton ofS'/T lS Thng/aT than th3t °f °ther age gr°UpS'
overwhelming
proportion o 84 /o live in the developing countnes. In India, of the estimatedlQO million
adolescents, 8 million 15-19 year olds are have experienced pregnancy by 16 years.
In the following pages we shall
<'
attempt to define some of the terms used when talking
about adolescence and address some of the current
--------- 1 issues and debates associated with the
subject.
3
Section One
Understanding Adolescence
Some Definitions
Adolescence
Adolescence is the period between childhood and adulthood. It is defined as including
^between 10 and 19 years of age; "Youth" as those between 15 and 24; and "young
people as a term that covers both age groups (WHO/UNFPA/UNICEF Statement 1989)
The Government of India definition according to the draft National Youth Policy (1997)
is somewhat different and defines youth as those between 10 and 35 years of aee
mamZ ni8^6 a8e.°f adolescence < 10 ~ 19 years) and the age of attainment of
maturity ( 21-30 years)
Puberty
The biological changes that adolescence involves is often called puberty. In this transition
*
C anges take place in an individual. For example girls and boys both experience an
increase m the size of sexual organs and in body height. Ovulation and menstruation
hartoZovsWProduction
boys. An important emotional change is
hat-both boys and girls become conscious offtWsexual feelings and themselves as
sexual beings. Since society expects girls notlo be sexual, a girl may feel euiltv about
havmg sexual feelmgs. Boys on the other hand seek informaion and experfence in a very
sly and surreptitious manner, and also end up feeling guilty or confused
Adolescent sexuality
urmg puberty, nsing hormone levels contribute to an activation of sexual sensations and
erot'c thoughts and dreams for boys and girls. It has been shown that boys and girls who
undergo late puberty (around ages 15-16) generally have less and later teenage sexual
ivity - including masturbation and intercourse, than boys and girls who have 'early1
puberty (around ages 12-13). However, in case of'precocious puberty1 (i e when puberty
^s probabl b6 286 9) hhTIS USU I1'7 n° accomPanyinS change in sexual behaviou^ This
behavL nttCaUSe
station alone is not enough to initiate new
behaviour patterns without a state of psychosexual readiness that the younger child
simply hasnt attained. Sexual fantasies and dreams become more common and explicit in
adolescence than at earlier ages, often as an accompaniment to masturbation
4
^74=^^Zi-a
PU.Jdeas ,he,r heads"), limil ,„f„rmatio„ about contraceptive methods censor what
enagers read or can see in movies ("pure minds, pure thoughts"), invent school dress
codes or simply pretend that adolescent sexuality does not eLt. But throuZt the
during adoTesceZ
beCOme
active
Patterns of sexual behaviour in adolescents
mastlXionPMCtjCe|a Wide
°f SCXUal behaviours The commonest of them being
masturbation Mutual masturbation amongst same sex adolescents is also common In
spite of this there is a huge amount of guilt associated with the activity Other forms of
sexual behaviour include necking and petting which are physical contacts in an attempt
alsoTead'toZa
Th°Ut SeXUa‘ intercourse Sometimes petting and necking can
some of the n £ 7'
“r inter“T
ma‘e and female homose™a! relations are
e of the other forms of sexual behaviour practiced by some adolescents.
There is not much data available in India about the percentage of sexually active
descents. Amongst the sexually active adolescents many have single partners7others
ve more than one partner at a time. Many adolescents enter into a sporadic sexual
activity and then keep away from sex. Others indulge in sexual activities regularly
prac"“s a"d "s usase i! very 'ninimal ““s’1
Anxiety around pubertal changes
The changes that start in a child during puberty are’sudden and intense. Since these
socKLTce'th T"'
S6XUal
the Child is nOt PrePared bY
he e chants TaTin^T
°St
'T* f°r
°r her t0 Seek formation about
informed theLpf 8 7 P/™15 °r t6aCherS ‘S tab°0' Peer grouPs often are illforther L J t e65
S t0 8176 mLSleadlnS and
inf™tion, which
further mystlfy the
Whatever an adolescent
from
environment;
problem
865
'dirty'
°f the b°dy’ and this tend * ^avate the
niahtfHn1617 IS U^Ually there for what are only common pubertal changes For example
ightfall, masturbation or menstrual bleeding can cause severe anxiety in a child ?
owever, if some of these changes are unusual or socially complicated like
homosexuality, the anxiety can also drive the adolescent to suicide. There is an immense
Ind a o'work t°
dntS
m‘ddle C‘aSS
P°Or SeCtions of the society
anxiJ
k towards securing a job or employment, and all other things, especially the
anxiety around pubertal changes take a back seat. These issues are often left un-addressed
and can resuit in poor reproductive health even as adults and affect the personality and
elatonsh.p s of the individual long into adulthood. The adolescent has to face a lot of
psychosocial challenges, e.g. becoming independent from parents, developing skills in
5
r ■cope w"h a,s °r her s™aiit’aad •»
VldUUl Io.
i’ .0“X
What is not usually stressed is that adolescence is also a time of discovery and
disco”Try1™”
PreVOT
"«XdX for
The Generation Gap
through a process of disengagement from their families they still need guidance fPm1 S°
difficSv"15'
SUrPnSln8iy’ Parents and y°ung People often have a great deal of
feel -XS
qu> ibnum during ibis period and to continue to support their adolescent sons or
gZX S“psbe,wee" pare"'s and.,te a.d’,t”1 is
«.be
Peer Pressure
can make
example some boys often brag about sexual exploits with the opposite sex (whirJm
may not be true), and with girls rt can stones about a relationship Stonedo
professed behaviours can make some others of the same peer grouo feel inferilrP' u
pressures can sometimes make a person loose his or her self-esteem and confidence^nP
6
can negatively affect his or her personality long into adulthood.The best way to help an
issueTsuchZr11 rtSUCi PreSSUreStIS thr°Ugh 8iving hinVher pr°per educatlon on
ssues such as sexuality, drugs, smoking, etc. as well as on the skills of coping with such
peer pressure, and by providing counseling.
P 8
Sex education for adolescents
Sex e^cadon for adolescents had starred in the west many decades ago, but in India it
and^h haVe Tn |nimaginable a tew > ears ag£> Had it not been for the onset of AIDS
even conTderL^h
Yrt ad°IeSCentS and *oung PeoPie’ * would never have been
en considered. We have still not cone to the stage where sex education is implemented
seriously even in the big metropolitan cities, leave alone smaller towns and villages
fn°.re0|Ver ‘he contents ofsex education leave much to be desired. There is still hesitancy
informaf h '^P0*3'1*56™31 lssues an'd emphasis is more on withholding actual
Y
make
rH
"Oti°nS morality. For example many policy
makers in India are still hes.tant to talk about condoms and homosexuality in schools.
^slo'XSi^^0165^11!515 ' COnXrOVersial issue in lndia- The controversy however
s slowly sh.fting from whether sex education should be there or not ‘ to the subject
and oh0
education’
whether the emphasis should be on anatomic
unacceptabSnc!
nOrm^
n,Orality ,In many cases the ^me itself is
or^pSrr also
ad° going
task
Studies show that adolescents whp receive sexual health information and services are
7n STD Tht0 enga8e in nSky Sexual behaviour> havc unplanned pregnancies or contract
able to cond^
m°k7 Ilkely t0 responsible Partners in their relationships, and better
able to copd with problems in personal relationships.
Common myths amongst adolescents on sex and sexuality
As there is no legitimate source for an adolescent to seek information and
clarification about pubertal changes, and the curiosity
>s high, the adolescent tries to gather information from peer groups
and from pornography both of which provide wrong information
Many myths regarding sex and sexuality have become deep root
ed amongst the adolescent. These myths stay with the adoles
cent for the rest of his/her life and are handed down to the peers
an rom generation to generation. Some of the more common
myths are:
1.
Masturbation is harmful
2.
Nightfall is a disease.
3.
Sex is a dirty word.
7
4.
Boys are naore-sexual while girls are more 'romantic'
Some adolescents however believe that girls are more
sexual.
5.
Certain activities are made by nature for boys only while
others are meant for girls only.
6.
Boys with, smaller penises will not be able to give
sexual satisfaction to their partners or will not be
able to reproduce.
7.
Enlargement of breasts in boys during puberty is a
sign of being a 'female' from inside.
8.
Girls with smaller breasts will be less sexual, will not
be able to breast feed the baby and will not be able to
sexually satisfy hgr partner.
9.
An intact bymen in a girl indicates her virginity.
10.
Boys who have lesser hair on their face are not
men enough.
11.
A girl becomes unclean during menstruation.
12.
One can get pregnant through petting, kissing or anal
intercourse.
13.
Withdrawal before ejaculation will not make a girl
pregnant.
And so on...
8
Section Two
Adolescent Reproductive And Sexual Health In India
As a result of poor nutritional status, menarche occurs relatively late in India; therefore,
the biological onset of adolescence, at least among females, may be later in India than
elsewhere. On the other hand, marriage and consequently the onset of sexual activity and
fertility occur far earlier inIndia than in other regions of the world, thrusting adolescent
females early into adulthood, frequently sooq after regular menstruation is established
and before physical maturity is attained. Unlike in most other countries, adolescent
fertility in India occurs mainly within the context of marriage. As a result of early
marriage, about half of all young women are sexually active by the time they are 18' and
almost one in five by the time they are 15. Correspondingly, the magnitude of teenage
fertility in India is considerable: well over half of all women aged 15-19 have
experienced a pregnancy or a birth. In general, the sparse information concerning other
aspects of adolescents face a variety of reproductive health problems beyond early
marriage and fertility.
Minimum age at marriage - Although India's Child Marriage Restraint Act prohibits
marriage below the age of 18 years for girls, its enforcement has been ineffective
particularly in traditional societies where child marriage followed by cohabitation is a
norm. In such situations often the parents take decisions on behalf of adolescents. While
adolescent sexual behaviour, sexual awareness and attitudes remain poorly explored
topics, and available findings are not entirely representative, a disturbing picture emerges
The available evidence suggests a significant number of adolescent boys and girls are
Sexually’active before marriage. Sexual awareness'seelns to be largely superficial. Social
attitudes clearly favor cultural norms of premarital chastity. Double standards exist
whereby unmarried adolescent boys are far more likely than adolescent girls to be
sexually active; they are also more likely to approve of premarital sexual relations for
themselves; and they have more opportunities to engage in sexual relations. Both
unmarried and married women are vulnerable to being unprotected from pregnancy and
sexually transmitted infection. They are also unlikely to have decision-making ppower in
their sexual relationship.
Consequences of early marriage - Adolescents, especially girls lack the knowledge and
confidence to deal with sexually transmitted diseases. Even parents are able to do little to
help married daughters confront the problem of an infected husband. Pregnancy and
motherhood occur to females who are marriedduring adolescence, and exposes them to
particularly acute health risks during pregnancy and childbirth. The extra nutritional
demands of pregnancy come at the heels of the adolescent growth spurt, a period that
itself requires additional nutritional inputs. Any shortfall can result in the further
depletion of the already malnourished adolescent. All this can result in severe damage to
the reproductive tract, elevated risks of mortality, pregnancy complications, perinatal and
neonatal mortality, and low birth weight. Available evidence suggests that maternal
deaths are considerably higher among adolescents than among older women.Pressure on
9
an adolescent girl to conceive may lead to unnecessary medication and premature
investigations at the hands of practitioners. Some invasive tests
like injecting dyes in the uterus can themselves lead to infertility.
Adolescents and abortion - Information about adolescent abortion seekers is limited hm
,s available gives a disturbing picture Unm.med adolescents “Xe a
disproportionately large proportion of abortion seekers. Especially disturbing is the fact
at unmarried adoiescents are considerably more likely than older women to delay
of laS OrT'On
and henCe underg0 second trime$ter abortion. This is because
of lack of awareness of pregnancy, as welUs ignorance of services and fear of social
stigmatization. Health consequences of abortion are particularly acute for adolescents A
arge number of adolescents suffer complications. Fear and anxiety is also commonly
experienced by the adolescent abortion seekers regarding the abortion, their own sexual
adoZemabo? )S°Cial,,mplications- Sktudies have also suggested the vulnerability of
adolescent abortion seekers to repeat abortions. Adolescent girls especially for a
pregnancy out of wedlock, have to pay much more even at certified MTP centres This
encourages them ,o reson io cheaper but unsafe alternatives A disturbing p”op„nio„ of
adolescent abortion seekers become pregnant as a result of rape or non-consensual sexual
activity, suggesting the prevalence of violence against adolescent girls.
Adolescents and Reproductive Morbidities-: It is far more difficult to deal with
eproductive morbidity beginning in adolescence: young daughters-in-law are expected to
e fit, robust, and endure high degree of discomfort even while shouldering a heavy
omest.0 work burden. They have little choice about being sexually more fcfive Z also
peated childbearing ahead of them. Their parental, not marital family are often
expected to invest time and money in their medical treatment. These factors7make it that
• much more difficult for them to receive support «nd proper care.
Adolescents and STDs/HIWAlDS - As mentioned earlier adolescents in India engage
m sexual acuvity both inside and outside marriage. These relationships could be 8 8
knn inSHUa
COerC1Ve But °ne fact that is m°re-°r-less universal is the lack of
n<ow ledge a bout siife sex or contraceptive use. Despite campaigns by the Government
the knowledge about AIDS is limited especially outside the big cities This Zrance
akes adolescents especially vulnerable to these diseases. Unfortunately thefe is little
ard data available on prevalence figures, but there are evidences from micro-studies that
knowledge on these issues is limitied.
Adolescents and young people in India
Some facts and figures
• 38% women in the age group 15-19years are married
°£women aged 20 -24 years began their first marriage before age 18
64°/ of th
mdlCateS
36% marr'ed adoiescents (13-16 years) and
pregnam XThers
" *" •d0"S“"' fe™'“
•'"»>?
10
Approximately 7% of married women aged 15-19 years use a contraceptive
compared to 21 % in women aged 20-24 years
• Micro-level studies indicate proportion of young females attending STD clinics
ios increasing
Expereinces of a large service oriented family planning organisation indicates
that STIs in the age group 15-19 years has doubled over the course of the 1980s
11
Section Three
Working With Adolescents
those'whodn?^13 3re nOt t heter0gcen0us grouP There are school going adolescents and
;
cio are non-school going. Some of them are married others are not. Some work
others are non-working. Out of those who work some get paid, many do not They mav
be squally and otherw.se exploited. Some are sexually active, while others are not And
course there are the two distinct groups of boys and girls. All of these grouos and suh
groups are distmct from each other. They have different reproductive health aSd other
needs and different values, social codes, aspirations, etc. Anyone wishing to work with
adolescents should understand that a reproductive health package which works with one
group would not necessarily work with the other. There are different ways of approaching
each of these groups. D.fferent organisations work with different groups and sub groups"
specialising in working with their specific target group.
g P ’
Investing in the second decade of life should be a regular activity 3t each level of the
development community - starting from grassroots NGOs to Government policies
Neglec ing young people's health will reduce or negate the benefits of past goverment
expendtures in child survival, chilhood communicable diseases, and education as well
curtail future economic and social development. Despite their fundamental importance
programs and policies for young jpeople remain lacking. The needs of young people are
now only being recognised - often when it is too late - when the become pregnant need
abortions . or are mfected with HIV or other STDs. It is time to end the cE and
policy silence surrounding young people's health and prevent young women and men's
7, :" iS "me ,0
gearedZ.Se
iieeus or tne younger age groups.
'
Issues to kept in mind while devising programme for young people
themZht Z00"8 PTOhPler
•ha, young Jwple fee
•
mOrtality amon8 young P60?^ have falsely 1abelled
undereslim*tes tta'
High prevalence of sexual activity
Low contraceptive use
Increasing STI/HIV/AIDS Infections
Increasing Adolescent pregancies
Unwanted pregnancies and pregnancy related complications
Abortion complications
Barriers to Good health among young people- To understand why young persons
dX'XSXX°.i,repro<l“0’i™heal,h proWems has ,o
12
Low education
Lack of Information
•
Cuta°alX!S'li,n““al’ '‘Eal’ Waphical
wer relations.
Recommendations for action
™e™P>»">l «cles XnX'aXso t^eX iX d“ h
”
the need of the h°ur is to
d
take bold steps, challenge existing notions and e
E=foeas „bieb could he hep. |„ mind
°f ™,Or
larges. gr„7„“"ecS oHhe p^X'"” su'X “““ °f,1 is .he
apita! of youth in order to build a healthy workfo * necessary t0 ,nvest in the human
but also look after the needs of the elderly as t^tT ■
°nly look after ^eif
important to integrate various efforts that address v
increase effectiveness and improve cosl effXv“ess
1S 3 S° 8°ln8 t0 lncrease- It is
'0
d“Pfa,i°" ■
“d,;n
XX
should be made to address the discrenanr 5
education. Special efforts
that could be linked up with are the Balika SamridVh.T'0"'
Government themes
Government scheme.
^amnddhi Yojna or any similar State
which is equally important ThJS’incfude^sh°f y°Uns peoPle is an aspect
or sex eduction, to more elaborate programmesZ auT^T5
hea'th education
services, and counseling.
P Ogrammes for quality, and confidential abortion
Xs
°»"ership is built and the7 X "!iX
■heir needs
C'"C“I ""ShK
r*
™a *—»
X'0"’ ““ Wantntes. so that
« fonder align the progXes to
Suggestions for working with adolscents (Box)
eetcuality XX XeXXp^Xhlch
13
'
could be started in schools or even wiith' young people outside schools. Some principles
which could be kept in mind are as follows1. Individuals yearning for information should be satisfied without imposing a code of
model/moral conduct , but more of responsible behaviour.
Information, starting from that of the body and its processes should be presented as
humanly as possible- without either medicalising-it beyond comprehension or
sensationalising it. The infomration should be objective and accurate
3. It must be remembered that there is no one way of living that can be inculcated in the
young. People are different, have different morms and values, and they have a rieht
to choose hfge-dtyles which suits them the best, without ofcourse harming others"
These classes should promote pluralism and the rich variety of life-styles It entails
Thet should work for increased tolerance other other cultural perspectives.
4. The sexuality education programme should question traditional gender roles and work
towards increased equality between the sexes.
5. It should promote respect for people who have different sexual preferencess like men
and women who choose same sex partners.
6. The sexuality eeducation programme should not be too negative . Programmes that
emphasixe too much on warning against having sexual intercours, against diseases
and unwanted pregnanciesetc. Create a very negative impression of sexuality. Sexual
life is something positive and pleasurable, a source of joy and intimacy - the
programme should reinforce this aspect.
7 The program shold prepare the participants to establish meaningful relationships
8. The program should prepare the individual to say no to sex, if they do not want it
1 hey should be prepared to resist all forms of sexual coercion and assault. They
should learn that sexual associations of any kind must be voluntary
9. Single partner relationships with emotional relationship between partners should be
encouraged
10. Individuals should be prepared to cope with peer pressure that can lead them into
risky bevaiour
11. The programme should respect individuals and any information that they share must
be kept strictly confidential. While participants should be encouraged to share they
i o ph°Uid n!Ver be f°rCed The emPhasis shouId be on feeling comfortable
Finally the programme should prepare the young people to take up the challenge of
living their lives - as responsible parents and partners, and last but not the least as
responsible individuals.
14
Some Innovative Projects Working on Adolescent Health in the NGO Sector
Adolescent health is one of the emerging areas of work in the NGO sector, and since the
sector is emerging most of the work is pioneering and pathbreaking. We have tried to
provide an idea of the different kinds of experiments that are being tried out in our
country. This is a small and non-representative sample of the kind of work that is beine
pioneered.
5
ACTION INDIA, New Delhi
Action India has been working with adolescent girls in urban slums of Delhi since 1990
1 he have two kinds of orgnsiations of these adolescents - the Nanhi Sabla a forum for 912 year olds and the Choti Sabla a forum for 12-18 year olds. Through these fora for a
they work on issues like body and menstruation, preparation for marriage, dowry and
inheritance, status of girls child sex abuse and so on
For farther detils of their work please get in touch with
Ms Gauri Chowdhury, Director
Action India,
5/27A, Jangpura B,
New Delhi- 110014.
Action Research and Training for Health (ARTH), Rajasthan
ARTH had conducted a survey of rural adolescents in Rajasthan which clearly
established that adolescents are extremely vulnerable* as far as their reproductive health
was concerned, and due to reasons which were primarily beyond their own control. The
interventions include community education and clinical services.
For farther details kindly contact:
Dr Kirti Iyengar,
ARTH,
67, Adinath Nagar,
Fatehpura,
Udaipur-313004.
Ashis Gram Rachna Trust, Pachod , Maharashtra
Ashish Gram Rachna Trust started its adolescent programme in 1993 because the age at
marriage of girls had not gone up in the last fifteen years. Its activities include regular
sessions with girls in the age group 9-15, at the village level where topics like personal
hygiene, menstruation, puberty, as well as social issues like dowry are discussed. They
are also taught skills like rangoli. The programme operates in over 50 villages.
15
I
For further details of the programme please get in touch with .
Dr Ashok Dayal Chand, Director,
Ashish Gram Rachna Trust,
Navjeevan Rungnalaya,
Pachod,
Aurangabad, Mahrashtra, 431 121.
SWAASTHYA Project, New Delhi
Ii8ri
Delhii. Their work
,
jof
-------,s UdXt0 understand adolescent reproductive health and
sexuality issues in the community. The findings of this pioneering sWy
; wee very
revealing and the project is now ir.tcr,
'
intervening by providing information
and services to
adolescnets using innovative communication strategiies.
For further information about their work kindly contact
Dr Geeta Sodhi, Director
Swaasthya,
Flat-G-4, s-565, Greater Kailash -II,
New Delhi 110048
Email-gsodhi@giasdl01 .vsnl.net .in
MaCheaTashrtrEadUCat,On’ ACt,°n and ReSearch in Comm“nity Health (SEARCH),
haEtRCH initiate^ itS adolescent reproductive-fiealfh programme in '1995 and the focus
has been on sex education. The main method is to hold six -day camps with 50 to 100
boys and girs( separately) where they topics like menstiuation, reproductive system
forming relationships, relationships etc. are discussed.
For further details about their work please contactDr Rani Bang,
SEARCH,
P O. and District- Gadchiroli,
Mahrashtra-442 605
16
RESOURCE SECTION
Resource List of Materials
( This list was kindly compiled and supplied by Sagri Singh, Population Council, NewDelhi)
ORGANISATION
UNESCO- The
Regional Clearing
House on Population
Education and
Communication
TITLE & CONTENT
Adolescent Reproductive and
Sexual Health Catalogue: an
expanded collection and
database on adolescent
reproductive health
[P/R]*
FOCUS on Young
Adults
Promoting Reproductive
By Ronald C. Israel/Reiko Nagano
Health for Young Adults
FOCUS on Young Adults
through social Marketing and 1201 Connecticut Avenue, NW,
Mass Media: A Review of
Suite 501
Trends and Practices
Washington, DC 20036
Tel : 202-835-0818
|P|
FOCUS on Young
Adults
Health Facility Programs on
Reproductive health for
Young Adults
[P]
By Juith Senderowitz
FOCUS On Young Adults
1201 Connecticut Avenue, NW,
Suite 501
Washington, DC 20036
Tel : 202-835-0818
FOCUS on Young
Adults
Reproductive Health
Outreach Programs for
Young Adults
By Juith Senderowitz
FOCUS On Young Adults
1201 Connecticut Avenue, NW,
Suite 501
Washington, DC 20036
Tel: 202-835-0818
|P1
CONTACT INFORMATION
Carmelita L. Villanueva
Chief, Population Education Clearing House
UNESCO Principal Regional Office for Asia
and the Pacific
P.O. Box 967
Prakanong P.O.
Bangkok 10110, Thailand
Tel : 391-0577,391-0686
391-0703,391-0815
391-0880,391-0879
Fax : (662)391-0866
17
I
ORGANISATION
FOCUS on Young
Adults
TITLE & CONTENT
Reproductive Health
Programs for Young Adults :
School-Based Programs
[P]*
CONTACT INFORMATION
By Isolde Birdthistle/Cheryl Vince-Whitmai
FOCUS on Young Adults
1201 Connecticut Avenue, NW.
Suite 501
Washington, DC 20036
Tel: 202-835-0818
World Bank
Discussion Papers
Adolescent Health
Reassessing the Passage to
Adulthood
'
[P/R]
The World Bank
1818 H Street, N.W.
Washington, D C. 20433
Tel : 202-477-1234
Fax : 202-477-6391
Studies in Family
Planning
Vol. 29, #2 June
Adolescent Reproductive
Behavior in the Developing
World
[P/R|
John Bongaarts and Barney Cohen (eds.)
Population Council
One Hammarskjold Plaza
new York, N.Y. 10017
1998
Tel : 212-339-0500
Fax : 212-755-6052
Regional Working
Papers No. 7
Watering the Neighbour’s
Garden Investing in
Adolescent Girls in India ■
[Pl
Implementing a
Youth A Resource for
Reproductive Health Today and Tomorrow
Agenda in India. The
Beginning
[P/R]
Implementing a
Adolescent Reproductive
Reproductive Health Health Experience of
Agenda in India: The Community-Based
BeginningJ
Programmes
[P/R]
By Margaret E. Greene
Population Council, South & East Asia Grou
Floor, Zone 5A, Lodi Road
New Delhi 110003, India
Tel: 464-2901/2902/4008/4009
Fax 464-2903
By Sagri Singh
Population Council, South & East Asia
Ground Floor, Zone 5A, Lodi Road
New Delhi 110003, India
Tel : 464-2901/2902/4008/4009
Fax 464-2903
By Masuma Mamdani
Population Council, South & East Asia
Ground Floor, Zone 5A, Lodi Road
New Delhi 110003, India
Tel 464-2901/2902/4008/4009
Fax 464-2903
18
ORGANISATION
WHO- Adolescent
Health &
Development
Programme Family
& Reproductive
Health
TITLE & CONTENT
CONTACT INFORMATION
Action for Adolescent Health World Health Organization
Towards a Common Agenda Regional Office for South-East Asia
[Pl*
I P. Estate, New Delhi 110002
TeL: 3317802
Network
Adolescents
*
• Does sex education
work?
• The Tragic Cost of
Unsafe Abortions
• Teaching Teenagers
about HIV
[P/Rl
Family Health International
P.O. Box 13950
Research Triangle park
Nonh Carolina 27709
Network
Adolescent Reproductive
Health
[P/Rl
Family Health International
P.O. Box 13950
Research Triangle Park
North Carolina 27709
Population Reports
Meeting the Needs of Young Population Information Program
Adults
The Johns Hopkins School of Public Health
[P/Rl
J 11 Market Place, Suite 310
Baltimore, MD 21202
Talking About Love and Sex Indu Capoor and Sonal Mehta
in Adolescent Health Fairs in CHETNA
India
Lilavatibai Lalbhai’s Bungalow
Civil Camp Road, Shahibaug
[R]
Ahmedabad 380004
Tel : 079-286-8856/6695/5636
Fax : 079-287-6513
Adolescent Sexuality and
By Kathleen Kurz
Fertility in India-Preliminary International Centre for Research on Women
Findings
1717 Massachusetts Ave., N.W.
[R|
Suite 302, Washington, DC 20036
Tel : 202-797-0007
Face : 202-797-0020
Reproductive Health
Matters
International Centre
for Research on
Women
Tata Institute of
Understanding Sexuality
Social Sciences
among the Urban Youth . A
Study of Mumbai College
Students
By Leena Abraham
Tata Institute of Social Sciences
Deonar, Mumbai 400 088
|R1
19
ORGANISATION
K.E.M. Hospital and
Research Centre
TITLE & CONTENT
Adolescent Sexuality and
Fertility : A Study in
Western Maharashra
[RJ*
CONTACT INFORMATION
By Hemant Apte
KEM Hospital Research Centre
Rasta Peth
Pune 411011
Foundation for
Research in Health
Systems
Use of Reproductive Health
by Married Adolescent
Females
[R]
By Alka Barua
Foundation for Research in Health Systems
6 Gurukrupa, 183 Azad Society
Ahmedabad 380 015
Christian Medical
College, Vellore
A Study on Reproductive
Health of Adolescents
[RJ
By Abraham Joseph
Community Health Department
Christian Medical College
Vellore 632 002
Youth Sexuality
A Study of Knowledge,
Attitudes, Beliefs and
Practices
Among Urban Educated
Indian Youth 1993-94
IR]
By Mahinder C. Watsa
Family Planning Association of India
Bajaj Bhavan, Nariman Point
Bombay 400021
Tel ; 022-2874689
Report of an
Intercountry
Consultation
Strategies for Adolescent ‘
Health and Development in
South -East Asia Region *
[Pf
World Health Organization
Regional Office for South-East Asia
I P. Estate, New Delhi 110002
Tel : 3317802
International Centre
for Research on
Women (Working
Paper No.3)
Adolescent Sexual and
By Shireen J. Jejeebhoy
Reproductive Behavior -A
International Center for Research on Wome
Review of the Evidence from 1717 Massachusetts Ave., N.W.
India
Suite 302, Washington, DC 20036
IR]
Tel : 202-797-0007; Fax : 202-797-0020
Demography India
27(1): 1998:117-128
Adolescents in Asia : Issues
and Challenges
[R/P]
By Saroj Pachauri
The Indian Association for the Study of
Population, c/o Institute of Economic Growl
Delhi University Campus
Delhi 110007, India
Third party
Publishing Company
The Burden of Girlhood: A
Global Inquiry into the
Status of Girls
By Neera Kuckreja Sohoni
IRI
20
ORGANISATION
MAMTA
WHO- Adolescent
Health &
Development
programme
TITLE & CONTENT
Adolescent Girl-an Indian
Perspective
[R/PJ*
CONTACT INFORMATION
Dr. Sunil Mehra
MAMTA-Health Institute for Mother & Child
House No. 33A , Saidulajab
Opp D-Block, Saket, MB Road
New Delhi 110030
Tel : 685 8067; 648 5203
Coming of Age : From Facts
to Action for Adolescent
Sexual and Reproductive
Health
World Health Organization
CH-1211, Geneva 27
Switzerland
[Pl
Population Council
The Uncharted Passage
Girls’ Adolescence in the
Developing World
|R/P|
The Alan
Guttmacher Institute
Into a New World Young
Women’s Sexual and
Reproductive Lives
|R]
The Alan Guttmacher Institute
120 Wall Street
New York, New York 10005
Family Planning
Association of India
Education ‘in Human
Sexuality A Sourcebook for
Educators
[lEC]
By Dhun Panthaki
Family Planning Association of India
FPAI-SECRT, Cecil Courtn, 5th Floor
Mahakavi Bhushan Road
Mumbai 400039
A Notebook on
Programming for Young
People’s Health and
Development
UNICEF
73 Lodi Estate,
New Delhi 110003
Tel : 4690401
Youth Health -For a
Change
By B. Mensch, J. Bruce, M.E. Greene
Population Council
One Hammarskjold Plaza
.. New York, N.Y. 10017
Tel: 212-339-0500;'Fax: 212-755-6052
[IEC]
Choose a Future
Issues and Options for
Adolescent Girls: A
Sourcebook of Participatory
Learning Activities
The Centre for Development and Population
Activities (CEDPA)
1717 Massachusetts Avenue, N.W.
Suite 200, Washington, DC 20036
Tel : 202-667-1142; Fax : 202-332-4496
[IEC]
21
Youth Across Asia
•
•
Coumry Studies on
Population Council
Youth India, Bangladesh, Asia & New East Operations Research and
Nepal, Philippines,
technical Assistance Project
Indonesia
53 Lodi Estate
Workshop on Youth
New Delhi 110003
Across Asia-Final Report r Tel : 461-0913/0914; Fax: 46l-O^l2
P, R, IEC refers to whether the prinicpal focus of the material is Programme, Research or
IEC.
CHETNA . 1994. Training on Health and Development of Adolescents Report.
Ahmedabad: CHETNA.
CHETNA 1998. Health Education and Development of Adolescents. Ahmedabad:
CHETNA.
CHETNA. 1989. Sowing Seeds of Fertility Awareness. Ahmedabad: CHETNA.
CHETNA. 1991. We Can, Because We Think We Can: A Report of A camp for
Adolescent Girls. Ahmedabad: CHETNA
CJNI. Champa: Reproductive Health Teaching Aids for Rural Adolescent Girls. Calcutta
GuptA R B. and S Joshi .1995. Workshop on Strategy Formulation to reduce Teenage
Fertility in Uttar Pradesh. Lucknow: UNICEF.
K E M Hospital Research Centre. Adolescent Sexuality and Fertility. Pune K E M
Hospital Research Centre.
Manadhar. T.B. 1998. Education and Adolescents. New Delhi: UNFPA.
Mehta, S. 1998. Responsible sexual and Reproductive health Behaviour Arnone
Adolescents. New Delhi: UNFPA.
S
Ministry of H&FW. 1998. India Countiy Pape^ for South Asia Conference on
Adolescents. New Delhi: Ministry of H&FW.
Ramarao, A. 1992. Adolescent Girl Mysteries of Adolescence. New Delhi- Voluntary
Health Association of India.
7
Singh.S. 1997. Adolescent Girls Programme in India: A Strategy Note New Delhi
Population Council.
Colon^N^TiJT3' ®eharUr ReSearCh amOng Adolescents Tigri Resettlement
Colony. New Delhi: Swasthya Project.
Villarreal, M. 1998. Adolescent Fertility: Socio-cultural Issues and Programme
implications. Rome Food and Agriculture Organization of United Nations.
Resource Organisations
The following organisations are involved in working with adolescents either through
research or through maintaining documentation centres or by producing material related
to adolescent health They may be contacted for information, materials, trainings or
other forms of support. There are many other excellent organisations providing such help
ana this list can in now way be considered exhaustive.
International Organisations :
zU^ESCC? nThr Re8‘°nal Cleanng H°USe onAp°Pu|ation, Education and Communication
( Asia and Pacific)
P.0. Box 967, Prakanong P.O.
Bangkok 10110, Thailand
Tel - j91-0577-3910686, 391-0703-3910815 391-0880-3910879
Fax- 662-3910866
Population Council
One Hammarskjold Plaza
New York N.Y. 10017 USA
Tel - 1-212-339-0500
Fax- 1-212-755-6052
FOCUS on Young Adults
1201 Connecticut Avenue NW
Suite 501
Washingtoli D C. 20036 USA
Tel - 202-835-0818
Family Health International
P.O. Box 13950
Research Traingle Park
North Carolina 27709 USA
International Center for Research on rWomen
'
(ICRW)
Contact Person - Geeta Rao Gupta - President
1717 Massachussets Avenue , NW
Washington D C. 20036 USA
Tel- 1-202-797-0007
Fax-1-202-797-0020'
CEDPA
The Centre for Development and Population Activities (CEDPA)
1717 Massachusetts Avenue, N.W.
Suite 200, Washington, DC 20036
Tel 202-667-1142; Fax ; 202-332-4496
23
w
Indian Organisations
a;
CHETNA
Contact Person - Indu Capoor
Lilavatiben Lalbhai's Bungalow
Civil Camp Road, Shahibaug, Ahmendabad- 380004
Tel - 079-2628856/6695/5636
Fax- 079-287-6513
email - chetna@adinet.emet.in
vj?.-’
'.''A '
;iL:
*
r*
- •
/,
UNICEF
Lodi Estate,
New Delhi - 110003
Tel : 011-4690401
FPAI
Fami ly Planning Association of India
Bajaj Bhawan. Nariman Point,
Bombay 400021,
Tel: 022-2874689
VHAI
Voluntary Health Association of India,
Executive Director,
Tong Swasthya Bhawan,
■ 40, Institutional Area, ( Behind Kutab Hotel)
New Delhi 110016.
Population Council,-South and East Asia,
Contact Person- Sagri Singh
Ground Floor, Zone 5A, Lodhi Road,
New Delhi 110003, India.
Tel: 011-464 2901/2902/4009
Fax-011-2903.
V
Booklet prepared by-
Snvaslava’ Abh,Jil Das’ JashodharaDasgupta
Additional text and review - Sagri Singh
6
24
=1
U3 H- 11 - S '
■;
-!
r
Understanding
"•' f:
•
Reproductive Health
A Resource Pack
’• •’<'.••
'<•'
,‘rX.Av.t-*’T-;l’r
I
r
Booklet - Seven
•
‘ :■
-
*
CONTRACEPTION
Going beyond Family Planning
SAHAYOG
isSs-i®
SB
?W>
CONTENTS
INTRODUCTION
Section One : Contraceptive Options
What is contraception
Efficacy of Contraception
Brief description of different contraceptives
Natural Methods
Barrier Methods
Methods that prevent fertilisation
Abortion
Hormonal Methods
Permanent methods
Emergency Contraception
Section Two : Issues and Debates in India
Contraception or Family Planning
Male Responsibility for Contraception
Reproductive Rights and Contraception
Government services for contraception - a review .
Violence Gender and contraception
Provider control vs user control
Clinical Trials, Human rights and contraceptives
Section Three : Implementing a Contraceptive Programme
Contraceptive Research
Advocacy
Organisations working (on Contraception and Family Planning
Resource Section
Books and Reports
Videos
Resource Organisations
3
5
5
6
6
6
9
12
13
15
19
21
22
22
23
23
24
25
25
25
27
28
28
29
32
32
33
34
1
INTRODUCTION
Unprotected sexual intercourse on the fertile days of a woman’s menstrual cycle can
result in pregnancy. From time immemorial, there have been attempts to de-link sexua'
activity from reproduction. Various methods have been used in different cultural
contexts. Traditional methods of regulating births included periodic abstinence from
sexua intercourse at certain festivals, during particular seasons, or after the birth of a
child (post-partum). Prolonged creast feeding, and social disapproval of sex after a
certain age also contributed to lowering birth rates. Other methods have also been used
i e coitus mterruptus’, and similar sexual'practices which involve ejaculating outside
the vagina. Herbal pessaries in the vagina, vinegar douches and an equivalent of the
moaern condom are also known io have been used.
Contraception or birth-control refers to the range of methods used by women and men to
prevent pregnancy. Every year several million dollars worth of research continues to
00 for the ideal methods for contraception, and several options are available for men
and women today. Contraception is often called “family planning”, particularly so in our
coun ry. The government through its “family planning programme” targets only married
couples w.thin conventionally defined families. This leaves out a large number of people
who are sexually active, and potential users of contraceptives outside the ambit of
government concern.
While contraception is a very personal decision which should ideally be taken together bv
the woman and man concerned, it has become a matter of public discussion in many
countnes where there is concern about population growth. If the growth is seen as beina
too rapid, couples are urged to contracept when the state desires them to do so such as =
after one or two children ( China. India). Where the population is not growing fast
enough to even replace itself (as in West Europ^ for example), there is a presire on
women to have more children than they desire!
Jhe ICPD resolution specifically says “all couples and individuals (have the right) to
informaf6 y 1 reSpOnS'bJy the number and sPacing their children, and to have the
renroducZ’ ZZ0"
t0 d°
..........and t0 make decisions concerning
p
on free of discrimination, coercion and violence.”(ICPD Principle 8 7 3 1994)
Despite this, the mindset of‘choice’ has not been widely internalised and pressures
continue from governments, religious leaders and donors.
Since the outcome of a pregnancy is borne by a woman, it is important that women are
able to make contraceptive decisions as and when they want. Control over one’s body
and the right to regulate fertility has been a cornerstone of the women’s movement the
world over. However, given the gender disparities that exist, women are often unable to
negotiate contraception with their male partners. State control over fertility in many
countnes (like India) ensures that women have little space within which to negotiate their
rights over their bodies. Moreover, the types of contraceptives available/ being
researched might not be those with which women really feel comfortable or safe
3
avaHableforboTh Wi" ‘T
W’th
Van°US methods of contracept.on
available for both men and women and look at their respective advantages and
oXXZ We Wi" a,S° ,TOk
iSSU6S 3nd deb3teS in
around
ill avcpuon.
4
Section One
Contraceptive Options
What is contraception
«e«XPspe"m. “and 'ihe”g “e'T pr0"u“ '’f ih"”^
«» e®.
°C“rs
bas^ll
1,ning °f the UterUs and starts growing kIT™
688 meetin^> Caches
basically five ways to avoid getting pregnSt:
8 hlS pr°Cess in mind there are
rse i.e. abstinence from
includes the various BarriermerhoT (M
’ri'h th' °P™ This
producing Sperms Example''ofthTindid’e"^'^?'“'"S
’"d/°r ,he
fr"m
from
Comraeeptiee Pills, Injecables and Imp|an,s u„de”?rf l,“,S SUcl'as Oral
d''|„Sv ,V'l0Pcd f°r
"<i “OI"“
also fell in'io th"
™"es
person should ehooZ . mahod"tha
" •PreV'“ P"%mKV ““ each
dangeri“ ’hr?
“ ,s health
lives. Furthermore Shis Is’k"^".1"'
PM”e “y
one's entire life. As one ages or as the nature oionas sex ,ife eZ“ ™“^ve
needs change.
.<> be kep,
• -"Sn
•
m,d when
>s the contraceptive safe or 3 J th
8 ttmg pre8nant
contraceptive be passed
the health °f futu- Mildren the v
woman may bear*?
is the contglVeS protection from HIV and other STDs
w^ti
•
contracepnve method reversible, in case pregnancy Is desired
5
•
’
•
whether the male partner is willing to take an active role in contraception
whether the contraceptive has special contraindications for e.g. not to be used by
women with irregular bleeding, orthose with reproductive tract infections
whether control over the contraceptive is in the hands of the user, or is it dependent
on the health service provider'( end box)
Efficacy of Contraceptives
Each contraceptive method has a different efficacy i.e. how effective it is in preventing
pregnancy. Effectiveness is measured according to a theoretical effectiveness rate, as well
as the effectiveness in real life conditions. For instance, the oral contraceptive pill has a
very high theoretical effectiveness, but if the woman forgets to take even a few pills, the
effectiveness gets drastically reduced. The following table will help to get a comparative
idea of the effectiveness of different contraceptive methods:
Contraceptive Efficacy of Different methods
Pregnancies per 100 Women in First 12 months of Use
Method
Norplant Implants_______
Vasectomy_____
DMPA and Net En
Injectabfes_______
Female Sterilisation______
FUD (Copper T)_________
Breast Feeding (for first 6
months)_________
Combined oral pills
Condoms ______ •
Diaphragm with spermicide
Fertility Awareness
Female Condoms________
Spermicides_________
No method
As commonly used
0.1____________
0.15___________
0.3
Used correctly and consistently
0.1
0.1
~03
—
0.5
0.8
2
0.5
0.6
0.5
6-8
14
20
20
21
26
85
0.1
3
6
6
1-9
6
85
Source: The Essentials of Contraceptive Technology - A Handbook for Clinic Staff, John
Hopkins Population Information Program, 1997
Brief Description of Different Contraceptives
A. Natural methods (Avoiding genital- to- genital contact, especially during fertile
The safest and easiest way to do prevent this would of course be by not having sex at all!
The next best way would be to avoid genital-to-genital contact, which can still be a
6
pleasurable experience. For ages, women have known that it is possible to t*et preunar.t
only on a few days of the month. So, they have known that if sexual intercourse is
avoided on those days, they can avoid getting pregnant. Today the following methods are
available to avoid pregnancy without the use of any artificial means of birth control..
1. The Rhythm (Calendar) method
According to this method a woman is considered fertile after 10 days of the start of the
menstrual cycle, hence sexual intercourse is avoided during these 10 days. The ‘safe
period’ thus is considered to be the week during, before and after menstruation. This is an
unreliable method because it does not take into account variations in the menstrual cycle.
The Rhythm method assumes that all women have 28-day cycles, and that ovulation
occurs in the middle of the month. However, each individual woman has a different cvcle
length, and ovulation may take place at different times. There is also a variation for the
woman herself- due to vanous factors, such as age, stress, following childbirth etc. a
woman’s cycle length varies. At best, using the Rhythm method may slightly reduce the
probability of getting pregnant. It is only slightly better than using no method at all.
2. Cervical Mucus/Billings Ovulation Method
Many women notice that they have some amount secretion (mucus) from the vagina most
times of the month. This is a perfectly healthy sign. The mucus varies in quantity,
consistency and colour. Sometimes, there may be very little mucus, and at other times
there may quite a lot of it. It may be sticky and whitish at times, and at other times it may
be slippery and transparent. The nature of this mucus varies with the stage of the
menstrual cycle. Soon after menstruation, the mucus is usually scanty, relatively dry.
thick, flaky and whitish. As an egg begins to ripen in one of the ovaries, the hormone
estrogen circulating in the body makes the mucus transparent, stretchy and slippery. The
slipperiness and stretchiness is the maximum-durihg ovulation and a day or so after.Thus,
the slippery and stretchy kind of vaginal mucus is a woman’s most useful and obvious
sign of her fertile days. She can thus choose to avoid genital to genital contact on her
fertile days, or use a barrier method such as the condom or diaphragm, in order to avoid
pregnancy.
3. Basal Body Temperature (BBT)
A woman can also note her body temperature at the same time early every morning The
temperature of the body soon after sleep is called the Basal Body Temperature. Towards
the middle of the month, immediately after ovulation this temperature will rise
significantly (about 1-2 degrees Fahrenheit) and stay that way until the next period If this
method is used exclusively, it necessitates avoidance of genital-to-genital contact in the
entire period before the temperature rise, i.e. a period of about 1-16 days. Once ovulation
has taken place, another 1-2 days are considered fertile. Thus, days on which sexual
intercourse is “safe” are relatively few. In addition, the daily trouble of taking the
temperature makes the method a cumbersome one.
4. Sympto-thermal method
It is a natural method by which a woman can become aware of the changes that her body
undergoes every month, so that she can recognise the time of the month when she is most
7
fertile. In addition to changes in cervical mucus and BBT, a woman should look for
changes in the following symptoms. She
fullness of the breasts,
observing changes in the height and softness of the
...j cervix.
5. Fertility Awareness Method
Fertility Awareness is a method by which a woman can become aware of the cyclical
changes her body undergoes ever, month. There are several signs in a woman’s body
which she can learn to recognise - cervical mucus, basal body temperature, changes in
her cervix, breast tenderness etc. A combination of these signs can help her recognise the
period when she is most fertile, ar.d use this knowledge to either avoid or achieve
mtheeh?'
det"rmine her feniIe and lnferti>e days by noticing the changes
the character of the cervical mucus by testing some of it on her fingers at about the'
same time everyday. The mucus is usually found at the vaginal opening itself. With
framing in Fertility Awareness (from a person who has used the method or has trained
other women in F.A), and some amount of practice, a woman can determine her fertile
days with a fair amount of accuracy. The FA method needs special caution if:
• a woman has a reproductive tract infection which may cause changes in the
mucus pattern. However, a woman can recognise mucus due to an infection
since it is usually profuse, discoloured, foul smelling, or accompanied by
itching, pain or discomfort. Practising the FA method, in fact helps a woman todetect infection very early on, since she can recognise the early changes in her
mucus pattern.
• A woman is breast-feeding. Ovulation is delayed for some time after
childbirth. The period of lactational amenorrhdea (absence of menstruation
during breast-feeding) depends on whether there is complete breast-feeding, the
nutritional status of the woman, and otherTact’ors. However, ovulation occurs
before the first menstruation. The FA method, if practiced with care, can help to
recognise the changes in mucus which herald ovulation, and hence fertility.
However, this requires training and practice.
• A woman is approaching menopause. Menopausal changes cause a change
in the menstrual cycle, and also the mucus patterns. Practice of observing body
changes will enable a woman to recognise when ovulation takes place, even
though it may be irregular.
• A woman’s partner is not co-operative about abstaining from sexual
intercourse or using a barrier method during fertile days. In many situations,
women do not have control over whether or when to have sexual intercourse. It
is therefore crucial to make efforts towards changing the power balance between
men and women.
The effectiveness of the method depends on how accurately the woman can predict
ovulation, as well as the strict avoidance of unprotected genital to genital contact during
fertile days. Used correctly and consistently, the FA Method can be as effective as the '
condom.
The advantages of the FA Method are many. It is a safe, reversible method with no side-
8
effects whatsoever. Awareness of the body processes and the reproductive cycle
contributes to greater control over the body. Most women find that using the FA method
g.ves nse to greater self confidence and autonomy. The fact that successful practice of
A as a method of fertility control requires the co-operation of the male partner is
sometimes seen as a "disadvantage” Yet, it can be a positive factor when men are made
responsible partners in the process of fertility control. The experience of many groups
eachmg FA has been that men too are interested in participating in fertility control and
this trend needs to be encouraged.
B. Barrier methods (Methods that prevent egg from meeting sperm)
Barrier methods work by literally forming a barrier between the sperm and egg The
following kinds of barriers are currently available:
1. tMaie Condom
This is a cylindrical latex sheath worn over the penis during intercourse. It blocks the
release of sperms into the vagina. It is unrolled onto the erect penis before any vagina-toP^",S contact because lonS before ejaculation occurs, the man may discharge a few drops
of fluid which may contain sperm, or could transmit STDs. After ejaculation the penis
should be carefully withdrawn from the vagina so as not to spill any semen in or near the
vagina^ The condom is then unrolled and disposed off. A condom should never be used
morelhanjmce. The male condom is one of the most effective and safe methods of
contraception. It has no side effects on the man or the woman. Condoms are also highly
effective in preventing AIDS and other STD's. Another advantage of the condom as a
spacing method is that it is completely reversible. Condoms are the most widely available
contraceptive.
7
A
’•
-
Focussing on Condoms (Box)
Some people, especially men. feel that condoms reduce the spontaneity and pleasure of
sex^ In addition some people are allergic to latex rubber. If condoms are of poor quality
or have been stored too long, especially in a hot place, they may tear or leak If there is ’
not enough lubrication during sexual intercourse, or if the condom is incorrectly used it
may also tear e.g. if it is not rolled on smoothly. The reluctance on the part of many men
to share the responsibility of birth control is a major reason why many men do not use
condoms, even when they are so effective. However, if putting on the condom becomes
part of sex play, it can even become a pleasurable activity. Considering that condoms are
so sate, and have the added advantage of protecting against HIV and other STDs it is
worth putting tn a lot of effort into encouraging men to use condoms
2. Diaphragm
The diaphragm, invented in the 19th century, was a major breakthrough in giving women
control over their fertility. The diaphragm is a circular, dome-shaped rubber disc with a
firm rim inserted into the vagina to cover the cervix and block the entrance of sperm It
was earlier thought that for maximum efficacy, diaphragms and cervical caps must
always be used with a spermicide ( a cream or jelly which inactivates or kills the sperms)
9
However newer types of diaphragms now being manufactured are also used without
emc,cy riu“ w^“,ou, spe™,c‘dc are
■»
The initial fitting of the diaphragm is done by a doctor/health worker since the
Placed n8h
0 place before any sexual contact is made and left there for at least 6 hours after ?
m‘ercourse so that the spermicide can kill the sperms that are left in the vagina
UmSZ^rem‘,V'd’ “S"ed
"* and wa,M- '"““Sl'y
kept away
the dif h 6 C Pr°b ,efmS W‘th the dia?hragm include: local irritation due to the spermicide'
the diaphragm itself may push forward and cause cramps in the uterus, bladder of urethra
me women, this can lead to urethritis or recurrent cystisis. It should therefore not
be used by women who are prone to urinary tract infections, or who have a prolapsed
M ™“uM also push backward on the rectum, causing discomfort
rights^e would hefo!
““ "" d,aphr>Sm “ °f lhe
G«'"S
All th.s may sound complicated, but with a little practice using a diaphragm is verv
simple, t has several advantages. It is completely safe, and has no serious side-effects It
s completely reversible, since one only has to stop using the diaphragm when one wants
womanreSnant A S'gn,ficant advan*age of the diaphragm is that it is in the control of the
promote
use Z e
7
P a§mS
3 high fai,Ure rate *"<* does not
d Sent ThZ H PerienCKe
W°men’S organisatio"S and other NGO's is
effective and saf P t8m’ W
awareness and trainmg has proved to be an
Z esent 2 d C°ntraCeptlVe' ItS other advantages include that it has no side effects
h P esent’.the diaphragm is not easily available in India. A few women’s organisations
Rs
distributing The cost ofone diaphragm is about
hi WhZ h Z Seem a blt exPensive’ ‘t must be remembered that a diaphragm is
reusable and lasts about 3 years if well maintained
ciapnragm is
3. The Cervical Cap
le'5'L3 th,mble-shaPed ™bber cap that fits snugly over the cervix. Like the diaphragm
ea am Z 'P6™
°f
iS deSigned t0 Create an alm“t '
ight sea! around the cervical opening. Suction, or surface tension, hugs it close to the
cervix. It is used with sperm.cide, which both inactivates sperm and strengthens the
Z
JeT ‘hVaP and th£ CerViX' The Cervical caP- because of lts size- may be
Seated
“
dlaphragm 11 is also a g°°d cboice for women who experience
p ted urinary tract infections when they use a diaphragm if this problem is caused bv
pressure from the diaphragm rim. Unfortunately the cervical cap is not available in India
10
4. Female Condom
It
'iS 3 SCT l00Se’flttin8 sheath made of polyurethane, which is closed
one end. The female condom works by blocking the release of sperm into the vagina It
is inserted into the vagina oefore sexual intercourse. A flexible polyurethane rin'
located at either end ot the device, one at the closed end which covers the cervix" and the
other at the open end whicn remains outside the vagina. The ring outside the vasfoa adds
o the protective effects or the female condom by creating a barrier between theTbia and
made'lfterinterc'11
t£male condom should be inserted before any sexual contact is
made. After intercourse it must be removed with care to orevent anv
- uofa coendo8ina’dbed-6
'V°man
UP' The fema‘e COndom c°mbines the fXreT
of a condom and a diaphragm. It is inserted into the vagina in much the same wa- as a
d!aPJhra8IT!’ W.'th0Ut haVing t0 take care t0 directly cover the cervix. Like the male
condom, the female
condom1 can be used only once.
------------The female condom not only covers the vaginal walls but the cervix as well As such it is
ss,: -sax w
the female condom 1S >ts cost. It costs as much as $10 (Rs 450) for a pack of 3 femall
condoms. Since n can be used only once, it is a prohibitive cost. Another disadvantage is
the embarrassing sound produced during sexual intercourse, and also the fact that it§
makes oral sex unpleasant. Since its outer ring covers the clitoris, many women find that
t reduces their sexual pleasure and causes discomfort. Some women may be allermc to
Xilabl
I^H
11 dlffiCUlt T6 a
COndOm' The female condom - not^readily
H1WMDS
USe‘S m°S Y am°nS
or8anisat'ons working on
5. Spermicide
and creams (e.g. Delfen). The spermicide is inserted into the vagina with the help of an
applicator immediately before sexual intercourse. They are
P
not usually used on their own
but could be used to increase the effectiveness of condoms
or diaphragms. The lowest
expected failure rate for spermicides used alone is 6%, while the typical failure
rate is
-6/o. These spermic.des do not generally have any serious side effects though
some
women may experience genital irritation or allergic reactions
Box
Traditionally used Methods
n^method'at’al'?
pr°bablllty of gettin8 Pregnant as compared to using
11
L Breast feeding
After child birth, it takes some time, usually a few months, for the woman’s body to
begin menstruating and for ovulation to take place. Lactational Amenorrhoea is the
period during breast feeding when there is an absence of menstruation. This period is
prolonged in women who carry out “complete breast feeding” i.e. a woman is nursing her
baby on demand, both during the day and night, and she is exclusively breast feeding i.e
no top feed is given. During lactational amenorrhoea, the chances of getting pregnant are
reduced. However, it should be noted that ovulation takes place before the first
menstruation. Hence, it is possible to get pregnant even without experiencing a menstrual period. Such conceptions are called, in somerregions of North India, as “laam ka
bachcha
Combining this method with Fertility Awareness greatly increases its
effectiveness.
LAM - Lactational Amennorrhoea Method
LAM is considered a formal method of contraception by many authorities.
Practicing LAM involves strictly following the following guidelines:
• LAM is effective if the childbirth was less than 6 months back
• The baby should be exclusively breast fed
• The baby should be fed at least once every 6 hours
• Menstruation must not have started
2. Coitus interruptus/ Withdrawal
Traditionally, withdrawal is used throughout the world'as a method passed on from one
generation to the other. It involves withdrawing the penis from the vagina before
ejaculation so that the sperm is deposited outside the vagina.
Withdrawal is not very effective because cannot always withdraw his penis in time to
avoid contact with the vagina and vaginal lips. Often, a man cannot tell well in advance
when he is going ejaculate, and thus fails to withdraw in time. Furthermore, even if he
does withdraw in time, his pre-cum that appear as soon as he has an erection, contains
small but sufficient amount of sperms to cause pregnancy.
C. Methods that prevent Fertilisation
1. Intrauterine Device (IUD)
An IUD usually is a small, flexible plastic device that fits into the uterus. Most contain
either copper or synthetic progesterone. The IUD is inserted in the uterus of the woman
through the cervix. Once the IUD is in place, the strings (usually two) of the IUD extend
down into the upper vagina. A woman can feel if the IUD is still in place by inserting her
finger into her vagina and touching the strings.
The mechanism of action of the IUD is not yet fully understood. The most widely
accepted theory is that it prevents fertilisation. IUDs (especially those that contain
copper) cause an inflammation or chronic low-grade infection in the uterus. These
changes may damage or destroy sperm or interfere with their movement in a woman’s
genital tract, making fertilisation impossible. IUDs may also speed up the movement of
12
the egg m the fallopian tube, causing the egg to arrive in the uterus too soon to be able to
the foreinXd ’
“ ferailSatlOn does mana8e t0 occur.
disturbance caused by
the foreign body in the uterus prevents implantation.
y
The most commonly used IC’D in India today is the Copper-T. These IUDs are useH for
about _-3 years after which they have to be changed. <The IUD must be inserted mlide
he uterus by a doctor, during the menstrual period or soon after to. ensure that there is no
pregnancy at the time of insertion.The IUD is very effective as a contraceptive However
it could have several side effects, some of them severe:
Severe cramps and pain beyond the fast 3-5 days after insertion
anTe'mia'6115'11131
Pe™dS’ P°Ssibly contnbuting.tO
'
Rarely, perforation (piercing) of the wall of the uteims. Embedding may also occur if
the lining of the uterus grows around the IUD. Embedded IUDs cause more pain
. i,nS Treo °V ’ SOmet,rnss ne“ssitating a D&C procedure (Dilation and Curettage)
e vic Inflammatory Disease (PID) [infection in the uterine lining, uterine wall &
allopian tube, ovary uterine membrane, broad ligaments of the uterus, or membranes
eonomho P 7 hl
CaUSed
3
°f infeCti0US organisms including
gonorrhoea and chlamydia] is twiceashkglyJo_occur in women using H IDs as in
women using no contraception
~n
’ usiT’S PregnAanCy is mOre likely (with C0PPer IUDs, there is a 3% chance) in women
using lUDs^An ectop.c pregnancy (pregnancy outside the uterus, usually in the
allop.an tube) is a serious problem that can cause haemorrhage, and lead to infection,
in 1
sometimes death (when urgency medical care is not available)
9 IT hT C50SenJs a contraceptive after careful consideration. If one has never
had a child, it is advisable not to get an IUD inserted. It is not appropriate for women
who are prone to genital infections, who have history of ectopic pregnancy who
suffer from severe dysmenorrhoea (painful menstruation) or who are anaemic.
ost government health centres and hospitals pressurise women to get IUDs inserted
straight after a dehvery/abortion. This can be
extremely daneerous
be extremely
dangerous.
•
2. Non-steroidal pill - centchroman
Marketed in India by the brand name SAHELI or Choice 7, non-steroidal pills work by
accelerating the passage of the ova into the uterus. It works even if fertilisation has
already occurred. Non-steroidal pills are promoted as an ideal contraceptive by the
government. However, athough it is not a hormonal pill, it does change the EstrogenProgesterone funct.ons of a woman's body. Centchroman is also known to have caused
ovarian cysts in some users.
D. Abortion
An abortion is the ending of a pregnancy before full term, by expulsion of the foetus from
the uterus. A spontaneous abortion or miscarriage is the natural termination (ending of
pregnancy. An induced abortion is also called Medical Termination ofPregnancv (AITP)
Despite using contraceptives, a pregnancy may result. Or, pregnancy may be the result of
rape, incest, or some kind of coerced sexual encounter. In these situations, a woman may
decide to have an abortion. From time immemorial, abortion has been used as a means of
13
fertility control. External massage, performing arduous physical activity, scraping the
uterus with a sharp object, consuming abortifacient herbs and potions have been means
through which women have attempted to end unwanted pregnancies. Many societies have
imposed strict religious sanctions against abortion, viewing it as the taking away of life.
Although abortion is still illegal in many countries, legal, safe, affordable and accessible
abortion has been articulated by the women’s movement the-world over as a woman's
right. Induced abortion is legal in India by the Medical Termination of Pregnancy Act
1972.
During an abortion, the foetus and the placenta^are removed through the cervix.
Depending on the stage of the pregnancy, different methods of abortion may be used.
(i) Suction:
It is suitable for a 6-8 week pregnancy. In this method a cannula or tube that is connected
to a suction pump is inserted through the cervix under either local or general anaesthesia.
By suction, the foetal tissue is removed within a few minutes. It does not require a
hospital stay.
(ii) D&C (dilation and curettage)
For pregnancies of 8-16 weeks, the cervix is dilated by a diluting rod and then the walls
of the uterus are scraped clean with a curette, all under a general anaesthesia.
(Hi) Induced labour
For advanced pregnancies of about 16-20 weeks, usually a solution of saline, urea or
prostaglandin is injected into the amniotic sac to cause premature labour and expel the
foetus. This procedure is carried out under a local anaesthesia and requires a one or two
day hospital stay.
Box- How safe is an abortion?
If performed by an experienced doctor under hygienic conditions, an abortion can be
safe. But, it is safest within the first 12 weeks. If not carried out carefully complications
can arise. E.g. if an abortion is incomplete, and some foetal/placental tissues remain
inside, it could result in serious infections and severe bleeding. Other complications
include blood loss, infection in the vagina and/or the cervix, perforation of the uterine
wall and damage to the cervix. The trauma of having to undergo an abortion could lead to
depression and other psychological problems.
Abortions should be considered as a back-up method of fertility control, in the event of
contraceptive failure or pregnancy due to coercion (for instance, rape). Repeated
abortions are a health hazard. Abortions are not safe or legal after 20 weeks gestation.
Government hospitals though they perform abortions free of charge lay down certain
conditions like one has to insert an IUD or Norplant or get sterilisation done. This is
unethical and illegal, and should be resisted.
(iv)The abortion pill
Known as RU-486, the abortion pill is an anti-progestin pill that is currently being tested
out in India. It has been found to be extremely unreliable on its own and hence is
administered along with a prostaglandin vaginal suppository. The RU-486 is effective as
an abortifacient only in the first 6-8 weeks of pregnancy. It works by bringing down the
14
level of progesterone (necessary to maintain pregnancy), thereby creating conditiors
unsuitable for pregnancy.T.ne apparent convenience of the pill has potential for it to be
very widely used. However, nothing can be said with surety about the safety of the mil
and it is not advisable to take it yet. The abortion pill should be taken only under medical
supervision as it could cause uncontrolled bleeding. Some known side effects include
uncontrolled vomiting and nausea, severe bleeding that could lead to a collapse It could
take up to „ days for abomon to happen and one could bleed all that while Moreover
since kL-486 is effective only for very early pregnancy, the effect of RU- 486 on the ’
foetus in case it does not cause an abortion, has not been adequately studied, i.e birth
detects have not been ruled out.
E. Hormonal methods
Causing the woman not to produce eggs and/or the man not to produce sperms.
I O.rm°n.a Jnetl1’ods work b>' influencing the hormones estrogen and orogesterone in the
body and thereby stopping ovulation or sperm production. They also have the effec- of
thickening the cervical mucus (which prevents sperm from entering the uterus) ana in
some cases also by causing changes in the uterus and fallopian tubes which prevent
terulization. Hormonal methods disturb the delicate balance of hormones in the bodv
hey may have serious side effects and may affect various parts of the body in addition to
the reproductive system i.e. they cause systemic changes. At the same time the
government contraceptive providers promote them as an ideal contraceptive because they
are highly effective and easy to administer.
Box-Disadvantages of Hormonal Contraceptives
Women’s organisation have highlighted the following specific disadvantages of
hormonal contraceptives:
°
(i) effect on the functioning of the brain, causing headaches, dizziness weight gain
anxiety, depression, t.redness, hypertension, decreased libido, digestion problems ’
vaginal discharge and soreness, skin problems and loss of appetite, etc. They also cause
cl anges in cardio-vascular functioning (heart disease, stroke). The possibility of cancer
risk has not been satisfactorily ruled out.
(u) menstrual chaos: The high levels of hormones in the body can cause irregular
bleeding, persistent spotting, heavy menstrual bleeding prolonged periods or even total
absence or periods.
(m) return of fertility not certain: current research does not validate the assertion made bv
the government that a woman will promptly regain her fertility if she stops usine the
hormonal contraception. Since these methods are being promoted as spacing methods
this is a serious concern.
nnkPT 8O7rnn,e"t is Promoting these methods without having sufficient information
on the long term effects on human beings.
(V) If a child is conceived due to failure of the method, or immediately after the woman
stops using the method, or if hormonal contraception is used on a pregnant woman the
resultant child can have birth defects, that may show up as late as puberty Neither the
government nor the doig companies have conducted any studies to find out what mi-ht
15
(Vi) Hormonal contraceptives require very close monitoring at every stage by trained
personnel using sophisticated equipment. This should be done before use, to find out anv
contra-indications, during use to determine any adverse reactions, and after use to check
tor possible after-effects. Unfortunately such basic facilities are not available in Indian
primary health centres and government hospitals.
(vu) Besides the pill, hormonal contraceptives are long-acting e.g. injectables (such as
Net tn and Depo Provera), implants such as Norplant, nasal sprays etc. They have an
effect which ranges from 2-3 months (injectables) to 5-6 years (implants). Thus even if a
woman wishes to stop using the contraceptive, the effect of the hormone lingers in her
body for a while after she stops. A further problem with long-acting hormonal
contraceptives is that they place the control over fertility in the hands of the health
service provider rather than in the hands of the woman. Women’s organisations the world
over, and in India, have been opposing the introduction of long-acting hormonal
contraceptives not only because of their hazardous effect on health, but also because of
the potential for abuse inherent in these forms of delivering contraceptives. ( end Box)
1. Oral Contraceptives (OCs)
The Pill was heralded in the 1960s as a symbol of sexual freedom for women. It
appeared to be a 100% effective, simple and wonderful alternative to the methods then
available. Many women first heard about the dangers of the high-dose estrogen pill
(blood clots, heart attacks, strokes, depression, suicide, weight gain, decreased sex drive)
when they read Barbara Seaman’s book, “Doctors’ Case Against the Pill,” published in '
1969. Efforts by women and consumer activists in the late 1960s led to modifications of
the Pill as well as special package inserts listing the possible negative effects and
complications. Because most of the negative effects are associated with high dosages of
estrogen, drug companies reduced the estrogen content of the pill, and also began to
develop progestin-only pills. In the United States,.Germany, and most countries in the
West, the Pill is available only by prescription. In-India, however, OCs are available
over-the-counter (OTC) i.e. without a doctor’s prescription. Recently, vigorous “social
marketing” strategies have resulted in OCs being made available more freely, and
through non-conventional outlets. However, this needs to be viewed with caution. Firstly,
OTC availability eliminates the clinical screening needed to detect health conditions
which make use of OCs risky. When monitoring and follow-up is absent, treatment of
side-effects and detection of complications is not possible.
Different Oral contraceptives include:
Combined Oral Contraceptive (OC)
Combined oral contraceptive pills contain two hormones, estrogen and progestin, in
different proportions. They prevent pregnancy primarily by inhibiting the development of
the egg in the ovary by raising the level of estrogen at the beginning of the cycle. Today's
low-dose combination Pills (like Mala-D) are relatively safer than the high dose
combination Pill (like Ovral). However, combined OCs are not suitable for all women
Box
Who should not use Combined OCs?
Who Should not use Progestin-only
Pills?
16
Combined OC Pills are dangerous for
women with the following conditions:
1. Any disease associated with excess
blood clotting - bad varicose veins,
thrombophlebitis (clots in veins, frequently
in leg), pulmonary embolism (blood clot
that has travelled to the lung, usually from
the leg).
2. Stroke, heart disease, coronary artery
disease
3. Hepatitis or other liver diseases
4. Heavy smokers
5. Breast-feeding and less than six weeks
afrer giving birth
6. Pregnancy ended within the past three
weeks: there may be an increased risk of
thromboembolism during this period.
7. Migraine headaches
8. Moderate/severe hypertension (blood
pressure 160/100 or more)
9. Diabetes with certain vascular
complications
10. Liver tumours or liver cancer, cancer of
the breast (or history of cancer of the
breast)
11 Women who are unable to take pills
consistently and correctly. Forgetting pills
in between the cycle could result in
pregnancy.
Women with the following conditions
should not take progestin-only pills:
1. Unexplained vaginal bleeding
2. Breast cancer
Women'with the following conditions
should use progestin-only pills only as a
last choice:.
Hepatitis
Jaundice
Cirrhosis of the liver
Benign or malignant liver tumours
Functional ovarian cysts
Cardiovascular complications
History of breast cancer
Women who are breast feeding
Women who are unable to take pills
consistently and correctly. Forgetting
pills in between the cycle could result
in pregnancy.
Progestin-only pill
While combined oral contraceptives stop ovulation, progestin-only pills, prevent
pregnancy by increasing the thickiness of cervical mucus, slowing down the motility
(movement) of the sperm as well as the egg, and not allowing the uterine lining to '
develop properly.
The Pill has many advantages - high effectiveness, convenience, no interference with
sexual intercourse, proven reversibility etc. However, there are several unpleasant side
eq ects and long term effects which should be noted .These are highlighted in the Box
2. Injectable Contraceptives
Depo Provera (Depot Medroxyprogesterone Acetate) and Net En (Norethisterone
Enanthate)
—
are progestin-only injectable contraceptives. The contraceptive effect of Depo
17
Provera lasts for 3 months, and that of Net En for 2 months.
Injectables seem to be a convenient method of birth control. However, there are many
short-term side-effects and long-term health hazards associated with use of injectables.
Since injectables are delivered in very high doses, and their effects are long-acting, the
seriousness of side-effects far ourweighs those of the pill. Even if a woman desires, the
effects of injectables cannot be withdrawn until they wear Off in 2-3 months.
The health hazards associated wnh use of progestin-only injectables include:
• Menstrual disturbances ranging from prolonged spotting, excessive bleeding to
complete absence of bleeding
• Atherosclerosis - thickening of blood vessels and cardiovascular disease
• Thromboembolism - development of blood clots at unexpected sites, resulting in
damage to heart, lungs and brain etc.
• Osteoporosis/loss of bone density, resulting in higher incidence of fractures
• Weight changes
• Other metabolic changes resulting in changes in sugar levels, depression, fatigue,
loss of sexual desire etc.
• Return of fertility is not predictable( a serious limitation in a spacing method)
• Cancer risk - an unresolved issue
• Adverse effects on the foetus (in case of accidental pregnancy) have not been
ruled out
That the public health system is in shambles is common knowledge. The Family Welfare
Programme is not equipped to introduce long-acting injectables on a mass scale. Ruling
out contraindications, skill while injecting, timing of the first injection and subsequent^
injections, are of crucial importance. Lack of monitoring and follow up of users, and
inability to deal with medical emergencies make the introduction of injectables even
more dangerous. Lack of informed consent and enforcement of disincentives imbue
injectables with a high potential for abuse. The apparent “convenience” of injectables
further reinforces women’s powerlessness in matters of fertility control. Presently,
injectables have not been licensed for introduction in the National Family Welfare
Programme. They were registered in 1994 for use only by private practitioners and
“social marketing” by NGOs.
3. Sub-dermal implant - Norplant
Sub-dermal implants are a set of 6 rods of flexible silastic rubber capsules filled with the
synthetic progestin levonorgestrel. Each rod is the size of a matchstick. The implant is
usually inserted under the skin of the forearm of the woman . Norplant is designed to last
for up to 5 years. It can be removed only by a surgical procedure by trained personnel.
This progestin-only contraceptive works in three ways: by inhibiting ovulation, by
thickening and decreasing the amount of cervical mucus, and by thinning the endometrial
lining to prevent implantation.
Norplant is a highly effective and convenient contraceptive. Its use, however, is
associated with several health risks common to progestin-only contraceptives, similar to
those of the injectibles. Many of these are seriously life-threatening, especially in a
IS
situation where proper monitoring and follow-up is not available. Many of the side-
Recent y (August 1999), following cases filed in US courts, American Home Products
Coip., the parent of Norplant maker Wyeth-Ayerst Laboratories had to pay over S'-Q
million to more than 36,000 women to settle claims that Norplant caused headaches
irregular menstrual bleeding, nausea and depression. Norplant has completed all the
sfpulated clinical trials in India. However, it has still not been introduced on a mass scale
in the National Family Weirare Programme.
4. Anti-fertility vaccine (under trial)
Anti-fertihty vaccines use the body’s natural immune system to generate a immune
response against hormones essential for pregnancy. The chosen reproductive cell is
linked to a harrier’ molecule like tetanus toxoid or diphtheria toxoid, so that the immune
system perceives it as "foreign” to the body. Vaccines aimed to create antibodies aeainst
the development of ova, sperm, and pregnancy hormones are currently under
development. The most advanced of these is the anti-hCG (human chorionic
gonadotropin) vaccine being developed at the National Institute of Immunology New
Delhi, as well as the World Health Organisation. Phase III clinical trials have been
conducted on a 3-month vaccine, but the efficacy is as low as 80%.
Since Anti Fertility Vaccines interfere with the immune system, their effects on any
existing diseases or allergies are yet to be fully determined. Research has shown that
immuno-complex diseases may result following use of Anti Fertility Vaccines. The
reversibility has not been established beyond doubt - a serious limitation for a spacing
method. If a woman takes the vaccine accidentally when she is pregnant, or there is
contraceptive failure, the effects on the foetus-have not been fully studied. Short term
side-effects include fever, infection, pain and lesions at the site of vaccination,
generalised rash, nausea and giddiness. Another serious concern, especially in the Indian
context is the potential for abuse inherent in anti-fertility vaccines. Women can be
vaccinated without their knowledge and consent. When medical technology is used to
commit human rights violations, such technology needs to be questioned '
The International Campaign Against Hazardous Contraceptives and Coercive Population
Policies (of which several groups in India are members) has been campaigning since
1993 to call a halt to research on Anti fertility Vaccines, on the grounds that the risk to
the health and well-being of users and potential foetuses from the manipulation of the
immune system for contraceptive purposes cannot be justified by any advantage over
existing contraceptives.
F. Permanent Methods
A man or a woman can go for sterilisation through surgery. This procedure involves
permanently blocking or cutting off the tubes which carry the egg/sperm. Such
sterilisation is considered permanent and irreversible. With newer medical techniques, recanahsation (rejoining of tubes) can be performed, but it is not always possible or
19
successful. Moreover, it is very expensive. Sterilisation should therefore be considered
permanent and irreversible. Sterilisation is very highly effective. It is appropriate for
people who have attained the desired family size and are sure that they do not want any
more children.
1. Vasectomy/ Male sterilisation
Vasectomy is a surgical method of sterilisation for men. It blocks the \vas deferens in the
Vl4
male so that sperms cannot travel to the penis with semen. The man however continues
ejaculate and it does not affect his sexual libido or performance in anyway. Adequate and
sensitive counselling can help to alleviate anxieties about “manhood” and sexual
performance.
In no-scalpel vasectomy, only a tiny hole is made on both sides of the scrotum to
expose the vas deferens which is then cut, tied or clipped under a local anaesthesia.
Vasectomy is a minor and simple surgery, but the man should rest for at least 48 hours
after the operation, and should not lift any heavy objects for a week. One should resume
sexual intercourse only after all signs of discomfort have gone, in any case not before a
week.. An alternative method of birth control must be used for at least 2-3 months after
the operation, as sperms can live in the sperm duct for up to 3 months. In case, the
operation is followed by high fever, excessive or continued bleeding, swelling or pain do
consult a doctor immediately.
t is safer and simpler for a man to be sterilised because the male genitalia, unlike that of
the female is external. Hence, sterilisation involves less interference to body organs and
less complications. Recent studies indicate that men who have had a vasectomy may have
an increased risk of prostrate cancer. There are no other major long term risks associated
with vasectomy.
.
2, Tubectomy/ Female Sterilisation
Under this method a puncture or a small incision is made in the abdomen to gain access
to the woman’s fallopian tubes which are then cut, tied or clipped. This is done under a
ocal anaesthesia. It blocks the fallopian tubes in the female so that the eggs produced by
the ovaries cannot unite the sperm. Female sterilisation is very effective if performed
properly, though complications can and do anse. This could include infections, internal
bleeding, perforation of the uterus and/or the intestines. It could also lead to heart
problems, irregular bleeding, severe menstrual pain, and the need for repeated D & Cs or
even a hysterectomy. A doctor should be immediately considered in such a case. Proper
precautions need to be taken before and during sterilisation. One needs to rest for about
48 hours after the operation. Normal activities can be resumed within 2-3 days but one
must not lift heavy objects for about a week. Sexual intercourse can be resumed once she
is comfortable with it, usually after a week.
The risks of tubectomy are those for any major abdominal surgery - cardiac irregularity,
cardiac arrest, infection, internal bleeding, perforation of a major blood vessel. These
risks increase manifold when tubectomy is performed in settings where due care is not
taken, tor e g. in family planning "camps” where huge number are sterilised. Mobile
20
= „e even ™re pratiem,ic sioce ,he poss|bi|i,y of
or
*
”h “
■He e-s. and carbon dlMde
Emergency Contraception - ( box)
reM
situations where a woman has been forced to h
1 *S 0^Part‘cu*ar relevance in
has broken, unplanned sex occurred etc Emereencv^ afa'nSt her wil1 (raPe)> a condom
72 hours (three days) after unprotected sex It fovn^ CO"t[aceptlon can be used only up to
dose oral contraceptives such as Mala-D or Mala-l/65 3 J"8 Standard dose or low-
menstrual period.
unproreaad in.erconrse in .be ^onX^X
emergency contraception it gets reduced to 2%
zzssx: “‘merse“y
“2 °f
°’ and after
- ■“«»
21
Section Two
Issues And Debates In India
Contraception or Family Planning ?
This is a debate that is going on in India for a long time. The government in its different
programmes has always been using the term family planning; to such an extent that manv
service providers see the two as the same. Unfortunately this is not the case Familv
planning takes place only within the framework of the family, where the two partners
make conscious decisions. These include the number of children desired, the timing of
chi dren and the spacing of children. The factors that affect the decisions should ideallv
include the health of the mother and the child, the mental health of the mother, the
financial condition of the family, the emotional care that can be given to the children and
so on. Contraception, on the other hand, is a need of many more categories of people who
may also be sexually active.
BOX- Those whose contraceptive needs get ignored by Family Planning
A significant number of sexually active persons who fall outside the pattern of
monogamous heterosexual marriage may need contraceptive services. Let us look at
some of these potential users of contraception:
Relations outside marriage: Contraception is probably more important in heterosexual
relations outside of marriage (than within it) for preventing conception, STD's,
especially HIV and the medical and social consequences that are attached to any of them
□ucn relationships include pre and extra- marital sex.
Sex workers: They comprise the most frequent users of contraceptives, being vulnerable
to pregnancies as well as HIV/AIDS and other STD's. However they are not targeted bv
the government as prospective users of contraceptives.
Adolescents: Adolescent sexual activity, even though presumed by many to be non
existent, is a definite reality. They are unfortunately denied access to information about
and access to contraceptives. As a result teenage abortions are very common in India
Single men and women: Many single men and women who are sexually active, do not
fall into the target group traditionally identified by the authorities. The number of such
people is increasing in our society because of the delay in the average age for marriage
tor both men and women, and more and more people deciding to keep out of the marriage
institution for various reasons.
Men and women who are attracted to the same sex: Gay and lesbian people who may or
may not be married are not even recognised by the authorities, and no efforts are made to
give them information and access to contraceptives. In fact there have been instances
where (e g. Tihar Jail episode in 1996) access to condoms were denied to prisoners as
they were found to engage in homosexual activities.
Already sterilised person and childless couples: The government keeps out those men
and women who have beer, sterilised, are newly married orotheiwise do not have a child
I
t?65 aLelf/rUCk °Ut °f the TarSet C0Uples reg'ster But these persons are sell
vulnerable to HIV/AIDS and other STD's.
pedons are st. 11
Male responsibility and Participation for contraception
When contraceptives were first promoted in India, male methods like condoms and
there h°mh
'elatlVely niore poPular than the methods for women. Over the years
here has been a drastic reduction in the use of these methods. This is partly due te what'
often described as the emergency excesses’ when extreme coercion was used to
vasectomise men. But this had taken place over twenty years ago, and the health svstem
is snIl reluctant to address men in a forthright manner. What has happened as a result of
reluctance is that over these last two decades women have more-or-less been
eyluswely targeted by the erstwhile target oriented Family Planning programme This
has led to a situation where both men and women have come to consider fhis trend
natural. It is only after the Cairo Conference that the issue of male participation in family
planning has started been discussing openly, but in a society as patriarchal as ours it will
take more than that to change the trend that has been established.
In popular imagery the man who is vasectomised is often equated with that of an
impotent or emasculated person, and this imagery has been responsible for dissuading
many potential acceptors. Condoms have often been discredited for not giving the real
feel and pleasure. And with both these methods conveniently out of the way men have
X u'rf
theke"tirerealrn of takin§ responsibi lity for their own fertility behaviour
ck of responsibility is to the extent that Government programmes often distribute
• Xl™ ”X™w"eby “er re,"forem®,h! im’8e ,ta'
is
““
At this point in time the issue is not how to find a more convenient and effective method
men, but of how to change the popular mindset. The Government has of late started
promoting no-scalpel vasectomy, but the results are far from satisfactory There has to be
mediThT e,mphhaS1S o,n the husband’s and father’s responsibility not only in the popular
media but also through systemat.c training and reorientation of the health department
runctionanes right from the top to the grassroots.
Reproductive rights and contraception
The International Conference on Population and Development (ICPD) 1994 known
popu arly as the Cairo Confereence, is considered to be a watershed in’the field of
Populatl°n and development (see Introduction). Many ground breaking decisions were
taken tor the first time, which will have a long term impact. The following understanding
emerged from Cairo with respect to contraception and reproductive rights : The
Individual should have the right to • Access to services and information
• Highest Quality of Care
• Reproductive Health Choices , Free of Coercion and Violence
23
toXeVaeHm?tedd'a' h mii:- Plann'n? and not contracePtive slices are provided and that
too to a hmited number o: potent.al users. There are a number of provider biases for
woidd h PeRSUt ! C0UP-leS Wlth tW0 or more children ( at Ieast one a male child this
ould then be the desirea family size) to adopt a terminal method of contraception and
ecause women are the soft target’, to convince there about tubectomy Considerations
S
he.3 th.°fWCmen are not Part of the agenda. It is worthwhile to remember
hat what mdiv.dual women need is contraception, or birth control, while the agenda of
e government is population control or reduction in numbers. Often, these two cvOals
come m conflict with eacn other, and in ^e interests of population control, women’s
rights are marginalised.
Government services for Contraception - A review
The Government of India through its Family Planning programme is providing free
contraceptive services for five methods: condoms, IUDs, oral contraceptive pills
tubectomy and .vasectomy. These are available at the PHCs at every development block
and some are available with the ANM(Auxiliary Nurse Midwife) at her Sub Centre in the
village. lExaminmg the services in India provided by the government according to the
1CPD charter brings to light the following:
.decesv to services and to information - Access to complete and unbiased information and
to proper serv.ces regarding contraception by those who need it, especially women is a
das'C nght. They should know about the various contraceptive options available to them
nd the relative advantages and disadvantages of each method, without any information
being withheld, before they can decide on a particular method of contraception However
in India, the government machinery is more often.than not still involved in promoting
particular rnthods, and the client is seldom if ever provided accrurate information about
advantages and disadvantages with which the make her/his choice.
Quality of care - Quality of care comprises of a number of interlinked facets. It includes
ihp
SeTCe provider has for the client.the competence of the service provider
he availability and accessibility of the appropriate service, availability of follow-up
support and so on. If one considers the kind of service that is available to millions of
women in India through the peripheral service delivery system the lack of qualitv care is
clearly ev.dent. The service providers are often technically inappropriately trained, their
behaviour towards the client displays complete lack of respect, follow-up support is
absent when required, the list can be endless.
Contraceptive choices andfreedom from coercion - The Indian Family Planing
programme was well known for its target oriented-ness and the incentivesand punishment
regimes. Since the 1CPD the policy has changed with the adoption of the Target Free
Approach ( in April 1996. which was csubsequently renamed Community Needs
Assessment approach). Unfortunately this change has not been internalised and many
state government and certainly many service providers continue with targets and
incentives. Tubectomies still remain the order of the day, and in many states incentives
24
4
have been increased manifold
Violence, gender and contraception
disparities.,, ts doubt
X^e^SrIS perpe,rattd
»"
” ”” « »ide
“
panners It may be difftc- it tor ><■.
■
ate conlraceptive use with their
responstbhity and u^omra" 'bon TO,? 7 'T
h''
rm"CT tek= “P
when they do not want to use a contraceptiveTan^soTrce thl °UtS,de marT’aSS'
‘respective of whether the woman wants a child or not ^s^tZfT "T
often get saddled by an unwanted nreenancv nr
j 1 ne result of this is that women
the woman has to face a host of othe'complications^he Dre
°f abortion
and to go through many unwanted ones in order to do s<J is also'Tfo
6 Chlldren
associated with the issue of contraception.
°f Vlolence
about contraception
takesXert
to get an IUD inserted before conducting an ah rt'
P °vlders Insist tllat a woman has
inserting an IUD into her) when she comes to deliver^child TheTtler^ T"13"
on the woman by the sen ice orovidpr tn
t
,
Then there is the pressure
contraceptive information and services which leads m^ wom^t
absenSeof proPer
than they would ideally like or tn on thm u
r
omen to bear more children
to *go through unsafe abOnronS
abortions
from the violence angle
“™dered
Provider control vs user control
This debate is not very clearly articulated in many circles but if
These mehtods also have the advantage of lone term
veryPdifficul?toa ensure6'6^018'
h
'
■
6 prov,der
del‘Very SyStems like ours’this becomes
Clinical Trials, Human rights and contraceptives
.ts network of government hospitals, family ptani„g ce„tres a„d KX"g eo"£eg ItT
25
often not committed to the highest standards of ethics. Its personnel are often allowed to
get away with all means fair and foul. So if a new drug or contraceptive is under trial
chances are:
- That you will not be informed that it is being tested upon you.
- That the possible side effects the drug could cause will be made light of.
- \ou will not be asked for your consent to be a partof the trial.
Or all the above will be done in the most casual manner, taking the thumb impression of
an illiterate person on a form which is in English. There have been a number of cases in
recent years when such irresponsible research was undenaken, which have been brouaht
to light.
Box
Informed consent
This is a basic condition for making any individual a part of a trial of a test/research
programme. One should be told about:
• the tact that drug device is being tested
• the risks you are exposed to.
• only voluntary testing, no pressure or incentive.
• one should be given a thorough check up, adequate care and follow-up.
• the responsibility for your well-being during and after the test period lies with the
testing agency.
• you can take action if you are discontent with the treatment you are getting.
26
Section Three
Implementing A Contraceptive Programme
place much eX 2^3““" ”
NGOs ,he pew Motte N-GO Xe has alsoZ “uS
th'
'”
SoSzzzzzss so“:z *is cz,o e“w' ™™-
advisable «, give these greater iptpoZe IhZe co^ZZsTcZ “ “ !”
' g^2ESSSj~s
==a;~==;x.;;;™==~
°te“X°nS “ ,hP “mmU"i,y "
ClKa'’ but re“l‘ POP-raceptives from
Some features which could be included in a contraceptive programme
‘
aCeoXdv:
“W “ P“ka8e
'ta" ■ ”"d
2. It should actively promote male participation and involvement in contracention
3.
The IKshoTd'h °Uld bd 'ntegJated
inC'ude IEC and service Provision
4.
5.
S^aZZSX
in
“P'“">'
LZd“a^
27
methods are concerned
6. Spacing methods should be especially promoted
7. There should be provisions for confidential counselling services
8. Women should be empowered for contraceptive negotiation
9. Services shuld include systematic follow-up care
10. The programme should not ignore the contraceptive needs of other people who are
not strictly eligible couples
Contraceptive Research
Contraceptive research could be of either of three kinds- Research for developing newcon raceptives, research or field studies to determine efficacy, side effects and
acceptability and finally research into contraceptive needs and experiences Thus the
biZa i° d bekbl010g'cal or sociaL While many research laboratories are involved in
b ological research in order to find the ideal contraceptive NGOs can get involved in
social research either in testing efficacy and acceptability or in studying needs and
experiences. In case of either forms of research the organisations must ensure
• Full regard for ethics, insist on informed consent for any testing
• Promote research on male contraceptive methods
Promote qualitative research on knowledge, attitudes and experiences of different
client groups regarding contraceptive use
Advocacy
Contraceptives are a very important issue in a country like India which is so concerned
with its population. There are five methods of contraceptives being promoted through the
family welfare programme, while some others wer^tried but not introduced There were
serious protests against some of these as they were-not considered safe in the prevailing
circumstances. There needs to be constant vigilance by citizens organisations in order °
that the contraceptive needs of the poor are properly met through the government system,
dome of the issues around which this vigilance may be maintained are
• The quality and reach of government services
• Demand for more women- friendly and non-invasive safe contraceptives
• safety °r
C°ntracepti ves being tried and Promoted, from the point of view of
28
Organisations Working On contraception
Contraception AND Family planning
•S
??risa,tas
™ ■*»
Government norm was to fond programmes whic/fn C Go^ernryent Whlle earlier the
Planning , in the last two years the nature of the
eXclusively on Family
used is Reproductive and ChTd Health Tut the PT™63 has changed and the term
and Contraceptive Prevalence
’
mphaS’S remainS On FamilY Planning
which are invoiced
Seva Sansthari and the fTd yphnningT"’17
Jnterventi°"s like the Parhvar
JANANI and Population Services InteLt.oXT
°ther or8anisati°ns like
through the social marketing approach
8 On PrOmOt'n8 ^aceptives
Innovations in FamiiTpiannin^TXtces AgeniyTsiFPsl)1'!"ST
Innovations in Family Planning Services ( IFPS^ h
by the USAID.
which also involved in training on different aspect! ofTmT °f lntematl0nal agencies
rn .he cowry, .here indode CEDPA, AVSC inremariona!. KS^Son
.
vigorously trying to resist the introduction of iniectibles afT’
haV6 beCn
orgatnsations which are involved in research LoS Kp
> T"' °ther
Population Councii, ICRW..CORT, FiSs EMnld LT '““e CEHAT’
Addresses of all the organisations referred to above are given below:
AVSC International
IFPS Liason Office,
4/2 Shantiniketan,
New Delhi - 110021
Centre for Operation Research
Training(CORT)
405, Woodland Apartment. Race Course
Vadodra, 390007
Gujarat
Centre for Enquiry' into Heakh and
Allied Themes (CEHAT)
Floor, BMC Maternity Home,
135 Military Road, Bamandaya Pada,
Marol, Mumbai - AOOO59
LCgJkreforyDevelopment and Population
Jagori
C - 54, South Extension Part II
New Delhi
Tel. 6257015
Itwh
------
c/o Swatija Manorama,
9. Sarvesh,
Govind Nagar,Thane (East),
Maharashtra, 400 603
JANANI
~
------—
C-16A, ShriKrishnapuri,
Patna- 800001
Ph-0612-23 7564; 23 7645
Fax-0612 23 7291
Population Services International
29
Activities (CEDPA)
IFPS Liason Office,
4/2 Shantiniketan,
New Delhi- 110021
C-445 Chittaranjan Park,
P.O. Box 7360,
New Delhi 110019,
Ph-011 648 5022, 648 7589, 642 8375
Fax- 011 646 7419
___ Email- v.del@si.sprintrpg.ems.vsnl.net.in
Population Council
Zone 5 A,
Ground Floor,
Jndia Habitat Centre,
Lodhi Road, N Delhi 110003
Tel-011 464 2901, 464 2902
Fax-011 464 2903___________
Foundation for Research in Community State Innovations in Family Planning
Health (FRCH)
Services Agency (SIFPSA)
84/A R.G Thadani Marg, Worii,
Om Kailash Towers,
Mumbai
19, Vidhan Sabha Marg,
Lucknow 226001__________
Foundation for Research in Health
Saheli
Systems ( FRHS),
Unit Above Shop 105-108,
6, Gurukripa, 183 Azad Society,
Defence Colony Flyover Market
Ahmedabad
(Southside),
3800015
Defence Colony,
New Delhi 110 024
International Centre for Research on
I’RIME/INTRAHWomen (ICRW),
53 Lodhi Estate,
C/o Anuradha Jain,
New Delhi-110003
F-81 East of Kailash,
Phones-011 -464 8891,463 6312
New Delhi - 110065
Email- intrah@giasdl01 .vsnl.net.in______
Parivar Sewa Sanstha (PSS)
28, Defence Colony,
New Delhi- 110024
Phones-011-4617712/9024
Family Planning Association of India
(FPAI),
Bajaj Bhawan, Nariman Point,
Mumbai, 400042
Mother NGO Scheme- Box
The Mother NGO scheme has been launched be the Department of Family Welfare in
the mimstiy of Health and Family Welfare. Under this scheme NGOs are inv.ted to send
projects for becoming Mother NGOS. Mother NGOs are to be those NGOs whioch will
tUDr^UPPOrt b°th financiaII-v and technically grassroots NGOs which will implement
the RCH programmes on the ground. Each Mother NGO will look after a few districts in
the state and support grassroots NGOs in those districts. The selection of Mother NGOs
is to be done by screening applications by National NGOs as well as recommendations
from the local Government authonties. Under this scheme a laaarge number of Mother
Ngos have already been appointed in the districts and they in turn are in the process of
30
'I
identifying grassroots NGOs for implementing RCH projects. For farther details
regarding the Mother NGO scheme please get in touch with
Joint Secretary,
Department ofFamily Welfare
MOHFW,
Nirman Bhawan,
New Delhi 110001
31
RESOURCE SECTION
.Xm* .xvi™of ,he books and rep°ns ,h“ “ fa"d
1. Balasubrahmanyam Vimal, "Contraception - As if Women Mattered"- Centre for
Education and Documentation 1986
2 Re!LRUthhet alCha"8ing Bodies’ Changi^ liv^’: A Book for Teens on Sex and
Relationships. New York : Vintage Books, 1987 (updated 1998)
Heakh^nd RX1 ? (edS')-In SearCh °f °Ur B°dies: A Femi™t Look at Women,
ealth and Reproduction in India. Shakti, Bombay 1987
4. “Z Mo" ““
WeS,“re' “T'’eBi"inSS Me,tod■" Humondsworth:
5. Boston Women's Health Book Collective, "Out Bodies. Ourselves: For the New
Century , Simon and Schuster, New York, 1998
6.
7
Centre for Social Medicine and Community Health, JNU, “Reproductive Health in
India’s Primary Health Care,” Delhi, 1998
productive Health in
8. C Sathyamala, Nirmala Sundaram, Nalini Bhanot, “Taking Sides- The Choices
Before the Health Worker,” ANITRA, Madras, 1986 [Now available in Hindi also]
9. Chayamka, Swatija and Kamaxi, “We and Our Fertility - The Politics of
Technological Intervention” (1990) updated 1999, Comet Media Foundation
LOnginal Hindi Prajanan: Niyantran ki Koshishein, Samvadke Prayas’ 19901
10. Consortium for Emergency Contraception, “Emergency Contraceptive Pills - A
1J CRr°P pC
f°r I?alth Care Providers “^.Programme Managers Date??
1 CRLP Fact sheets on Emergency Contraception: CRLP, New York. Date??
' pilitnre,Cf\BaCara
Deidre English’ “ComPlaints and Disorders: The Sexual
Politics of Sickness, New York, Feminist Press, 1973
13. Forum for Women's Health, “Norplant ki Kahani, Auraton ki Jubani; Mumbai 1993
theT f " Women s Health’ “Some Thoughts on Clinical Trials,” Paper Presented at
onference of Indian Association of Women’s Studies Mysore 1993
15. Germain Adrienne and Rachel Kyte, “The Cairo Consensus - The Right Agenda for
the Kight Time, International Women's Health Coalition,
16. Global Campaign for Microbicides: CHANGE, Washington,
17 Greer Germaine, “Sex and Destiny: The Politics of Human Fertility ” New York
Harper and Row, 1984
18. Hartmann Betsy, “Reproductive Rights and Wrongs: The Global Politics of
Population Control and Contraceptive Choices,” New York, Harper and Row, 1987
19. Holmes, Helen et al., “Birth Control and Controlling Birth: Women-Centred
Perspectives, Clifton, New Jersey, Humana Press, 1980
20. Institute for Reproductive Health, “Expanding Options, Improving Access, Natural
Family Planning and Reproductive Health Awareness”
21. Jutly Sam, 'Men's Bodies, Men's Selves';
32
j
1
k
5
:A
’3
4
'
Long-Acting Hormonal Contraceptives, 1989
’
erdam’CamPaign Against
,98B™" M»'' Th' Mtios of Reproduction" Loudon: Routledge .nd Keg.„ Pau|
" cXXXe“”^^
Perspectives on
26 Rrchter Judttb. "Vacctastion Against Pregnancy - Miracle „ Menace„,
Report, Delhi, 1997
3' MS,
0*1994
^nemical Sterilisations of Women.” A
Va“i” «««* - Women’s Heahh" A
32 St fS“ ?£XnIniS“e C°n,raCeP,iW Na E" ' A Ch'°— of He^th
P*— Ming,- Kaii for
" Women iXW0* ''T0UCh *'
j4. Summary of the Programme of action of the International Cnnfi
Development; ICPD’ 94.
ntational Conference on Population
Regional OfficeT."Swe^m pldfitSS Date"
'’'“"‘"S 0p'iOnS’
Videos: There are a 1large number ofvideos which deal with contraception or more
correctly Family Planning The Go^emmem h”
below is a list of films
fims which
1.
2.
fXS “A *
-=vet
3.
4.
Vaccination Amins, Pregnancy tZ, c s 8P'8S f°r med'Ml re“‘vch.
Vacc^^KLae^u
Sehaa: A firn about ,he Anti-Fertdity
Video films, as well as a complete catalogue of available films can be obtained from:
1. Jagori,
C - 54, South Extension Part II,
3.3
New Delhi
Tel. 6257015
2. Netwaves,
C/o KP Sasi,
139, 10 A Cross (2n‘‘ Floor),
J.P. Nagar, Phase I,
Bangalore, 560 078
Tel. 6553117
Resource Organisations
Some organisations from which technical support may be obtained from are:
Parivar Sewa Sansthan (PSS)
aiinSirTlliHter°fMarLe St0PuS Internationa1’is Probably best known for its Marie Stopes
Clinics and for providing cheap and safe abortion services But they are also involwed in
renning comprehensive Family Planning programmes in different areas
budha fiwan, Director,
28, Defence Colony,
New Delhi - 110024
Phones -011-4617712/9024
Family Planning Association of India (FPAI)
?G0S,i" ,he uPhere °f Family Planni"S an<i ““option They have
“ .“I"
s‘a"su"
cames
comprehensive programmes addressing all
aspects or Reproductive Health.
Nina Puri, President
FPAI,
Bajaj Bhawan,
Nariman Point,
Mumbai 4000021
Phones 022-2029080, 5134
UNFPA
This UN body is exclusively devoted to the Reproductive Healath agenda. They produce
MiehL??!na ?Or1 the 1SS„Ue’ especially related t0 figures from all over the world.
Michael VlassofT, Country Representative
UNFPA,
55 Lodhi Estate,
New Delhi 110003
34
/
Wl
Office of the Chief Medic, Officer i„ ever, Dislnct. They can p.
informaaion, contraceptives as
provide you with
well as different EC materials that
Government from time to time
-t are produced by the
VHAI and state VHAs
Alok Mukhopadhyay, Executive Director,
>-• '• ~ * .
40 Institutional Area, Behind Kutab Hotel
New Delhi 110016
Organ.sat.on which are active in promoting an alternative perspective include:
«■
F0R women's health
x-jjc.v v
•he eamXZS hZdoT/cS™™^ coin™lv'd
P
c/o Swatija Manorama,
9. Sarvesh,
Govind Nagar,
Thane (East),
Maharashtra, 400 603
Tel.5423532
d coercive Population control.
r^.'7'<•
JAGORI
campaign hSain«‘lttou7con1)^ies‘,<Z^i0"1W! ‘l'’"- r‘tae<l
“d ,he
„„ Women.s issues Md hXe^~™'. •-.n8 -•«« and
s. A-.-‘»
‘.'•A. ’-■ .-
c - 54, South Extension Pan II
New Delhi
Tel. 6257015
Email: system@jagori.unv.emet.in
SAHELI
^1
I
.s-.,
in ,he rpais" —
<n medical research and informed consent have also
“h™nal has been produced in English and ffindi
15
ISSUeS °fethics
1W'K' newslnws “d
oAricLl
Unit Above Shop 105-108,
Defence C0!0"7 Fly°Ver Market <Southside),
New Delhi 110 024
Tel. 4616485 (Wed & Sat)
Booklet prepared by ■
'
------------------------
35
I/O H - H •
Understanding
Reproductive Health
Resource Pack
:■ \ j ?
Booklet-Six
■■
Women's Health - 2
I
r-
l
The Promise of Better Health
• •*•.4•
•
/' f
ij-,
• ■
'■
'’-I:
SAHAYOG
'A
’
r
f
s^«
CONTENTS
INTRODUCTION
Section 1: Understanding Women's health problems
Determinants of women's health
Socio-cultural determinants
Bio-medical determinants
Economic determinants
Environmental degradation and women's health
Violence as a determinant of women's health
Domestic violence
Violence in displacement and conflict situations
Common gynaecological morbidities in India
Common women's health problems
RTIs
Abortion
Infertility
Some other health problems
Women's health in later years
Menopause
Health problems of the elderly
Section Two : Important issues for operationalising women’s health
Role of traditional and home remedies in women's halth
^Womenjs access to health care
Understanding the language of women
Women health care givers
Empowering women for health
Section Three: Working on women's health
Different approaches of working on women's health
Strategies for change
Training for women's health
Some Innovative community based women's health programmes
Resource Section
Further reading
Resource Organisations
2
4
4
4
5
• 5
6
6
6
7
7
8
9
10
11
12
12
13
15
15
16
16
17
18
19
19
19
20
21
22
22
22
2
INTRODUCTION
concerned, and thus welad MuiteXaT/paS^
a great step forward fro’ the
" “h
capacities were
°f ™"' “
While formal medicine has a separate sectton devoted to the health
treatment of conditions in women which were special! v enr,? ?
proPerly the
system ( but not with child bearing)- gvnaeenl™
Y .°nCerned w,th their reproductive
for such health conditions to be dealt within a pSiceh31emph Bm auhe’^ SPaCe
the women s health conditions as dealt within the ambit of re a
Jh
me tlme
beyond mere gynaecology , because reproductive healthls also^?'6 7 Vk
determinants of health and disease It has been «h
1
concerned with the social
•Jar rhe sratus of heairh
“'“I'
their socio-economic condition, as well as the degree of pencil i rn’
ateb with
that is inherent within the family and soriptv p
j g
reIated discrimination
consrraiprs end is concerXS^^^
services and quality of care) as well
social factors as well
’
rhoiu •
L J h th facil,ties ( aaccess,
challengtng and bringing about change in the
umversal. The manifestations are different across’ space and t'imeVd
.
1CSS
have been largely responsible why many of women's most acute hX^5^^’3.! faCt°rS
-not been considered important for so long a time-Bufnow3 m
h Pr°blems have
it is increasingly becoming evident that L
f
3 6 sens,tlve research,
have to bear in silence- from the shame of retrnj" ?;f.?PrOdUCt'Ve.'ll‘health that women
and pdifal ditaats
°f repra<1“''e ,raa
•» •»= rdigieu,
c°mT rei’™“ini™
t
morbidities. There are number
lnclu(hng
the social dimensions of these
these situations which have been tried^ndil aTddth10neenn8
ofdealinS with
kept in mind in these experiments have also been diseased Fhnallvlh’b"5 3
some examples of these innovative nmieete 7 uiscussed. bmally the booklet provides
organisations on this issjl
’ '
Pr0V,te “ exh’“s,iv' list °nesource
I
Section One
Understanding Women’s Health Problems
Determinants of Women’s Health
Women s health has been a largely ignored area for a Inno
.
that some amount of documentation is being done on thelbmet Th
Onl>
more one is convinced how comolicated thl’m3ttP ' u bject' The more one learns the
in bio-medical terms and ev Z y'T t0 fne heakh °r
some of the major determinants of women’s health '
W‘
H
t0 eXpl°re
Socio-cultural determinants
health status to a gr^eXlrThis induS ^eXe^tuTfoTd^T5"’8 ’
—~~,d
■focus, a, depend upo„ the po„er a womt ’;“apde Szlyal,on a female
rhfch 'rd<"™how ,he foiiowers
functions, contraception and so on Manv of th
T
On mOral behaviours> bod>ly
r=li8.o„s
.u.nX.a, “toZ S ZZs 8'”5
°f 'h' '"“S
XZvs„;tZZ”ifS bvZZZrfrom reli8ion ,n ,he s“se
.cplicaZs oZZ s Z.h S "
eZZ ^ “ °fWOme"
C‘S °f ,radi,i0- WhiCh
is profound aZZy ZZiTZ
4
Bio- Medical determinants
pBhy‘iS fa^oVbeingTemlLTF"1 bi°’medical determ'^nt in as much that the
butynot an) ome:“r£:”uS:^tsr,th “
pregnancy and childbinh. Cancers, bleedingTd sor^
consequence.) of
reproductive tract are tvpical to women In fact th^ disclne nf “
°?S
t0 the
medical sc.ences is concerned exclusively to such disorders.
8ynaeC0,°gy In rhe
Nutritional status - While this is a bio-medical determinant it k
f
~
the socio-cultural situation as well Thp widp
’ 1 s Pro^oun^ly atrected by
bio-medic.1 terms ,s d““ iXf nro JX ’T'™'*"
childbirths ( biology) Ar the qq
r \ n
mensturatton and repeated
t inoiogyj. At the same time the amount and nualitv
*
• , ,.
has “ u"toe° cw,“
Economic Determinants
Poverty Poverty is a very important determinant of women’s health Thk k nnr i
the general poverty of the whole family but also the relative nove^v t
u" Y
household Women have much Ucc
<■
j
at ve Poverty °f women within the
this makes women th^poore
P
eCOn°mic reso-ce
»he„ .. «
x Wlth
xx±xe,ask of
dszzx^=x^ESF~
U»g .„d this ,eads K a„ ,ncreased burden on phe po rs xxxxxx.sar“
5
3«US. ^.0^0^^^^
pmns^erine descent and so on it goes witit saying that her
Violence as a determinant of women's health
against women ate linked io the same familiar causes ; their ower soXllaZT
notion that women are the ‘property’ of men, and that it is accentahi a f
control over them, by whatever means.
cceptable for men to exercise
epidemic', because
ofp™a"elce
b”tXp::ofT;"
1“'“'"
*“ '■ir
‘SS’SSSE?1™™-'
•
•
Kegard domestic violence as a public health issue
Undertake more specific research on its causes, consequences and me.hods ro proven,
few means to protect themselves from violence Armed config
haV6
battlefield in .ts struggle to appropriate institutional power and JheZ" ' R^i “ '
phenomenon. Sexual assault against woimen is seen asTX™
[ ' P°1,tICal
s-tuations of armed conflict leave women vulnerable to sexual XZ t
311
violence which may lead to ohysieal
J
al exploitation and sexual
course rhe whoie r,„8e of menu,
RT'S ““ STIs' "d
6
S:,i,e ,ife • ‘ ■____ - ehikl'bmh al"o become
ot refugees, they have to suffer
— . is hardly any privacy for mundane acts Jike
and
for maintaining menstrual hygien.
nutshell the total health
Common Gynaecological morbidities in India
” r 'T“ y‘ars h“e
’ »-
P—ce. Tbe_
□
i
n
Table 1
'
reealenee of self-reponed and clinically diagnosed gynaecological morbidilies six
community -based studies in India
Women Reporting
Percentage
Self reported conditions
• Menstrual problem
33-65
• Excessive discharge
13 -57
• Lower abdominal pain
9-21
• Lower backache
5-39
• Painful intercourse
1-7
One or more condition 55— 84
Clinically diagnosed
conditions
• Vaginitis
4-62
• Cervicitis
8-48
• Cervical erosion
2-46
• Pelvic Inflammatory
1 -24
disease
• Prolapse
<1-7
One
or
more
condition
-------26-74
Koenig M, Jejeebhoy S et al. 1998, Investigating Women7
No. 11 (May). 84 - 96
J
S
y’ ReProductive Health Matters. Vol 6
Common women’s health problems
7
There are a large number of gynaecological disorders which affect,
■
women. In this section
.....
Reproductive tract infections (RTIs)
diseases ^th
profound social anVEtZcZ^
neglected health problems RTIs are related in •
°
°f th world s m<,st
(STISr Sexually
“Xn
undean nens.™! do^ZionoX™““
increase a maie partner's pleasure, prevent pregnancy or mi nd
J Vagma t0
childbirth or abortion techniques.
8
lnduce abortion, and unsafe
cervix) and in thf absencetf eZyUeatmlnnhe Z*’
8en‘ta1’ Vagina and
fallopian tubes and ovaries) Though spread of RTIsfrZZ t0
UPP6r tract(uterus’
tract takes place spontaneously but^proceduref
t0 UPP6r reProdu^e
birth can cause greater risk becaZ inZ
,
ertl°n’ abortlon’
child
these procedures.
men S arC lntroduced through the cervix during
■«<,,
a „umber
pregnancy and childbirth; second they have to bZ thL burd
IS infectious in approximately 25% for men and 50®/ for
is (r s"a,er for
r COmPllcatI0^ from
h h °ne partner
Prab'="’S
■ntercourse with an infected man or to insist that he use
'
t0
monogamous. Both within and outside marriage they can not t°
remain
partner's sexual mobility. Can not negotiate ZdrZ
?h
Say ‘n the'r Sexual
seek treatment for STIs.
US6
nor as^ t^ern t0 Set tested or
8
■S that it is dirty, soCtWnTtTLf7eSRpIe7aI^n!t^
ab°Ut RTIs in soc.ety
—-s
esteem, illiteracy, and the fear of XTfr?’"5^65
reinforeed b>' 'o- se f
members Fear ofexposure andX"
fa-'y
treatment RTIs have an add.tional elemeXf shame aZ m6"'t0 Seeking STI
thZl6 Z 3re Cons,dered unclean. The invisibility and tab”' 'atIOn
women
............. —==."=tSi““ “
Abortion
can survive outside the utemls ctdled^borfion TbortS7
embry° °r tOetus
spontaneous. Induced abortions can be safe n
Can either be induced or
it is done and where it is done. Spontaneous abortions rer^"? °n Wh° C0nduct5 it> how
— One in six
-
Who demand a righ^ovenhXw^SX
betWeen women
iXSSra,so a
a tool in
Abortion as’a health, social and political iss..P tC '■ L
tnduced abortion. An unwanted pregnancy for w h-Z mam heaRh probIem of women is
'"dueed abortion. The reason, for ("he "„wa“Ld oX™ r“0" ‘s
”*in fac,or behm>)
ahanT'1’'1''1 “"re- tein8 ""■"^d and/or single Xtd a,"
m“y ’
Prefere"“abandonment or an unstable relationship.
§
coercion or rape,
ichoose not use
aCCess t0 contraceptives, or
means the right choice. For no matter hZZ A °f cfontraccptive, which is by no
repeated abortion has inherent risks Hence it shouW notZ^
abOrti°n 'S Performed
regulatren. But at the same time access to sa e ahn ?
“ a means »f fertility
Pl the state in India. Unfortunately despite befeX 2 TT remains a resPonsibility
thus remains a promi.se on paper Women ca oH
k
" neW RCH PWamme
care providers provided they are willing r^av for7t\
Governmenl ^alth
t .0
privaty and conridemMty smice proSSplS”
despite not wan'ting te^o'sm They Zv^ZreZ^ t0
repeatedPreSnailcies
rebuke from the family. They choose to so Z
abortions secretly, for fear of
./Us which „ ofle„ .provilfed by
or
~ ^denda.
9
women arc argeuedfo?^'ivt-from
mMy P„ of
™
SZ * 'rand
‘" -X
00^ of
°f U'Omen’s
health activisis for a long time. Women are victimTofTh
where abortion is illegal for evidence of th^In Nlnal
are poor women who were desperate for an abortmJ
"eighbourin£ countries
Y
* W°men Wh°
in jaii
complications of uns^oAlSabortSn^ 7?rb'dity
mortality due to
Seventy percent of maternal deaths in developing coun^0"PUbIiC hSalth problem'
obst^>c compiication5. of which unsafe aboS is one
by °ne °f five
about 15% ot all maternal deaths Twentv millinn
r bJ,nsafe abortlon accounts for
95% of them take place in the devJopm^itake
each
'
with extremely high risks which may result in seriojJcomnit'r
nS?e
term disablllXrthlTX^XXce3 dlt^unTafe Xi
±”aMd
of induced abortions are illegalXXd byXS
themselves. About 12% of maternal mortiity is due to
Short
10 ■- ,ndi“-»*
19?I) * largC ProPortion
Infertility
if they have failed^o cXeXwl'thm o“
C°nSidered possibIy infertile
frequemly held view is that 75-80% of lhe '.win .Z h * ° regu unPrmecied coitus. A
»uhi„ one yea, of reguiar unprotocied sex. A™ he!if A? want so
Hence some 10% or 15% of couples are unablnX °% S° by the end of sec()nd year,
secondary infertility is also very ^“2.“'A'3 Chi!i Tl,e incid““ «f
have subsequent children. But if you ask a childle«
she will not relate to any of these dry statistics h»■
iggest curse, and the cause for most of the mi’sery in
SG COlUp es who 316 unable to
What infertility means to her.
'S perhaPs the
physiological. Xh^gS^TsoS XongX Of|infert!lity a'd they arc
before puberty and after menopause andXo durinJ°gldal Causes infertility is a rule
early the lactating period conception often does not tSTnlX^'p" X Pregnancy- Also >'>
-ferubty are attributed to both men and women. In menLsesi oSSy^oor'
10
quality of semen (not enough sperm, weak sperm, not enough semen etc) or th * i h r,
aSiXZ ‘hfein7.g,",a; ,n,po;r -—y
opponuou.es .o cohabit during fertile period, or prolonged absen™ of * "
8
trau infections are the most ctunmon. AccordilgiVa
M o?SSd wX"d
OTSe’u““s' STIs ““»atribuublecausein^-”'
IS
»d abused by soctet, fite jeopanian^S,
“ X™
divorc'd oXp'ly Z"n »,'oEe”Z,’’” taws‘sitTisE e™ wE
x=sh“~”..
Some of the other health problems include -
5£SSSSi=S=
Lower Urinary Tract Pain - This is a very common problem with women from all
asses and sections of society. While it is often dismissed as cystitis or UTI this
are often a i
not have toilets
:.s■ X5::1=S“S:- 11
mahgnanc.es, but breast and cervical cancers arf not oni th
■n women, but their prognosis and survival rates are deoend X m°St C°mniOn CatlCers
condmons. Breast cancer is commoner in develooed c
On S°Clal and econom'c
commoner in our country. The survival rates from both the"65 Wh'le CerV‘CaI CanCers are
they are detected and treated early. This is facilitated noTnCerS
Preay hea,thy if
awareness of the condition but adequate medical facilhies^ \ Y
perSOnal
cancers are easily detected as lumps during personal breast deteCtlOn and care- Breast
Physmal examination and mammography fiJes an advanta eXam,nat,on and Aguiar
cancer on the other hand not only has a ortfereX r
86 f°r SUrvlval Ce™cal
childbirth, too many or too frequent births and
°r poorer women with early
impossible because the facility for screening is notXaT'H hyS,iene' Early Action is
vaginal bleeding, vaginal discharge,) are often ignor^136'6
s™0"13 ( irre^ar
Women’s Health iin later years
Menopause
and fare we wmd^usssomef’of Jthe imknortenSlrUatiOn
'S SCen 35 one in many places
has gained some importance in research worXide
t0 Though menstruation
understood topic.
a wide, but menopause still remains a less’
end orrepraducLmb
of 45-55yoata. Thia
biota"™!”'"' “ssa,ion of mensinialion at the
botweao the 4*'
-(oestrogen and progesterone). This interferes wirfi-nvS ■
female-hormones
of ovulat,°n and menstrual flow. Side by side there are am TX’ resulting in inhibition
opm tubes, uterus, vagina, vulva, breast, bladder and ureX
°VarieS’
pa tents, life style and environmental IX 80X0^.? ^ St3tUS’ reprodu^e
role in women’s menopausal experiences.
‘
H CU tUre aIso plays a significant
"hnute., ttauany at
al n,gt|IS)
and depression
■
can ttecnr. Feminists say that these ehan
"0 Ofer swms „„
swat,ng for , .2
12
at mid-life than
Sh°WS
Wl’"1Cn
n0 more likc|y t()
depressed
Box - Treatment of menopausal problems
hormonal. In non" hXoValJea^
tW° Ways’ non-horn-. onal and
XhC*
replace the amounts of these
be^sS’-d
drJgS t0
and alter menopause.One has to be cautious about usina HRT^n Y 6 °VarieS during
hke treatment of hot flashes, treatment of symptoms of
t
PCCrtain benefits
osteoporosis, there are many more side effect St , 8
atr°phy and Prevention of
effects are breast tenderness and L d retenbon
.
The m0St commo" ^e
oestrogen are secretions. skLlushesX
h
°f side effects °f
intolerance to contact lenses, vaginal spotting oJblefdZ s'iS ^ff60^’ pigmentation’
•ta proges,™,«
tel (en^aMomina,
Health Concerns of the elderly
the pXTwho SXXlX"' St’"7 T
»T“=~shc
she is a widow. At the same time the process ofa” 6 3
°f vulnerablllty especially if
functions of her body. The health of the elderlv w § 3 S° aftects many of the vital
many such physical and social factors.
rCSUlt °f the interaction of
iXt'Sr™;have ,o 6“ire
“■»
menopause, poverty contributes tn th^
weakening in women soon after
lows this process. Elderly women easilyTecome
en°U8h calcium t0
in rural women faces
-t;?e ° tcause for
ta *>i- >1-
provide her with support. As women grow old^r the^slowlv lo^
°f
autonomy and need to be cared after more actively The rlv feT T'
change. The family has to be sensitive to when .Ha
j Physical and emotional needs
progress, ve nuclearisation of familiesJ rum Indt
W‘th
on family support which was earlier accessible.
6
Y WOmen 3re ,0SlnS out
13
I
Section 2
Impomn,
(■„ op„ationalj]ing women,s hej|i|t
Role of tra<lit,ona| anil h(lme remedi|,s in WomM,s hea|((]
adopt Traditional
3 even led to the
remedies OneTeTso^X^Xl^inXl is tarn °f ,'adi'i0"al ““ ta»=
modern medicine, which tends to treat individual
?
h°,istic than
"Clude Physical, social and spiritual aspect and ! " ' °n' Traditi°nai ™hods
therapy. The second argument given is the issue ohc e T 'k'317'6
d'et with
medicine is not available. If the drugs are amiable a ref hi
many CaSes modern
medies as the name implies is available at home and
6 th,e.rapeut,cian '« not. Home
a auna and so can be easily available Other herbs ca "h trad,tl0nal remedies utilise
nancial aspect too comes into comparison and local r
j 6 Sr°Wn ‘n the =arden- The
cheaper. Another reason in favour of herbal and home emed’eS are more often than not’
avaHable for a large number of the comp fo ^h t
‘S
there are theraP-es
effect.ve While these therap.es may be different m d ff
7
many °f lhem
done in the last few years have proven that they work- F u P
muIti-centre studies
remedies builds upon women’s existing knowleZ .
V traditi°nal and h°me
’ .ZT-1116" USe as chdd-n or event Lults rJmX
MaJly
have
nto their consciousness only lately. While modern ‘
has made inroads
her t ntan7US CUreS thr°U8h injections, traditional and ho
C°me W'th 'ts mag'c of
heritage. Many of the changes that have taken place in I f T
are pan of their
devaluation of women’s knowledge and reinfn '
'nJ.,feStyles have led to the
-med.es is seen as a means giving
remedies, and many othe X^tZTpXXtthtraditi°naI and home
systems of medicines is not one system and includls
hfemselves realise Traditional
unnani, tibetan, siddha etc.) and even informal system Z
SySt6mS ( T^venda,
also considered pan of it The theranies nJ , 7
( exorc,sm, faith healino etc ) are
thumb rule to consider all therapies which aZar in ch
efficaCy h is often a
hand many of the votaries of these therapiesagree
35
On the other
located by western science. There was a large mulf S
d'Sagree on the methods
groups to test out the efficacy of traditional and h
C Study done bY women’s
methodology was widely different from classical XicalZ7 ■.,Sh°dhini stud-v)> but the
about the universal applicability of traditions It is wZl Z S' he SeCOnd -nation is
practices are harmful, thus the practitioners and nrom t V kn°Wn that many traditional
which praactice they promote and which they do nZ WlT mUSt
Careftjl about
Hue dividing practices and theCX^~^Xd
14
reservation about traditional systems is that traditional systems are situated in a specific
cultural context and as has been discussed earlier, the position of women in the traditional
cultural context is against the interests of her health and rights. Thus this angle needs to
be critically explored by the women’s health practitioner. Overall the opinion is that
traditional and home remedies have a definite role in improving the status of women’s
health, but it needs to be promoted only after the group has -fully understood the different
socio-cultural determinants of women’s health.
Women’s access to health care
Access to health care is related to all those concerns and conditions which determine to
degree to which an individual or group is able to obtain the needed health care services.
This access has to timely and one which allows the individual or group to achieve the
best possible health outcome. Access is also affected by attitudes to health and health
care, gender and social and cultural factors. If one considers the access women have to
health care services, one will have to consider a number of factors. These include factors
which are present in herself and her family which determine whether she will be able to
go to a health service. Then there is the condition of the health service and how it
provides her with care.
Women possess a very low sense of self worth and thus are reluctant to pay great heed to.,
their complaints, especially if they feel they will also need to bother others. Going to seek
health care is also an economic decision both in terms of the money it costs and work
time lost. The distance to the health care provider, the sex of the provider, attitude
towards the provider also determine whether she will be'able to go and visit her/him.
Once the woman actually goes and meets the health care provider, there comes in the
entire question of how competent the provider is irr Understanding her problem and
dealing with it. The atmosphere ih most clinics and* hospitals hardly provide women with
a sense of security, privacy and concern. Even the most qualified women doctors are
often unable to understand the problem of women, beside arriving at clinical diagnoses.
In such a situation it is not possible of her to get the best possible outcome. And any way
the health care provider most women meet are far from being the most qualified. The
kind of service delivery environment that is best suited to women’s health needs have
already been described in the first booklet on women’s health.
Understanding the Language of Women
Where it is culturally inappropriate for women to discuss problems of the reproductive
system, where women have been socialised to think that their reproductive organs are
dirty and polluted, and where women have to suffer and live with their different
reproductive health problems in silence, they develop new ways of dealing and
expressing their problems. For the health worker it is important to understand this
language. Where functions and problems of the reproductive tract are concerned, women
have a reluctance to discuss details with some one else, a phenomenon so widespread that
it is referred to as the 'culture of silence’.
15
•r
dXZ"
07dX
7 a“'pt vaEor"even
“! discharEe
discomfort
duringnintercourse,
chronic -pelvic pain nainfi.l nrinat; > 7“
! L
-
accompany some reproductive disorders as an inev,table pa “
someth,ng to be endured along with other reproductive health nroWe™ H o
'
situations women can complain of vague aches and Dains
i.
/ S°lnie
problem is elsewhere. Women aiso i th refa to thTp^bZlTpul'"^ V
I
after patient questioning that the real nature of their proHem becomes evident.
*
Persons trained in health care often tend to think in terms of diseases and rhP'
-m
causation. Women on the other hand refer to their disorders Z
P°S
problems. They have their own system of under andm e..
a"d
complex interaction of social customs and heliZ 1
CaUSatlon whlch often involves a
thmk is health related beh™ In or^
transgressions what they
person also needs to culturally attuned. For the sensitive health™™
WOman
challenge to undrstand the real problem or the individual becauseTt isTnkaftV'th' '
understood that healing can begin.
’
1
■ after th,s ls
Women health care givers
. SjSSSiESBSSS"
i’sdZ,“rkno™
“™m
The important question that needs to be asked is that if there are women Hn ,
j
women and their health problems. Women health care nroJd
'n.'tS P.ercePt,on of
naturally assimilate this and we have situations were the Znen St care "T171
violently wtth women in labour, berate them for their illnesses scold them fP
K ts too late. In such a situation the trauma of^S ^^Zry
16
system may be more severe than the illness. What is important even for women health
care providers is to considerate, patient and sympathetic to the client and this :s only
possible if the provider understands the situation from which the woman is coming from
and the complex social factors which have influenced her problems. Even while training
local women as health care providers it is important that they understand these
determinants. While it is easier rural women to understandrthese, as they also operate in
their own lives, generations old empathy for women that traditional birth attendants (
dais) had , are known to have been replaced overnight through single training events in
hospitals.
Women healers are not uncommon in rural India. Though they may not command the
respect that raids do, these women are an important resource for other women in the
community. Very often it is the traditional birth attendant (dai) who is also the healer and
many of them have a ftmd of knowledge about gynaecolgical problems. Strengthening
these healers through additional training in new skills and perspective is one way many
voluntary organisations are trying to provide health care services to women who need it.
Empowering women for health
Women’s health is one aspect of women’s lives over which they have little or no control.
control
In order to help women exercise greater control over their lives and movement toward
empowering women for health has been started in many parts of our country by different'
organisations. Two of the key features of this approach is described below.
Self help - This belief stems from the realisation that women have been dispossessed of a
lot of knowledge about their own bodies, both by society and by the medical profession.
The goals of self help are to put information and control in the hands of women,
developing a health care system that meets womenjs.needs and makes the services
available to women. Teaching women about their bodies and its processes and the use of
home and herbal remedies are two cornerstones of this approach. This not only allows to
understand the bodies and its problems better, but they are in a better position'to obtain
appropriate health care earlier and at their own terms.
Advocacy for health - Knowledge about the body and herbal remedies for simple
complaints are a great step towards women gaining control over their own health, but is
not the final step in this direction. Women will continue to need the public health care
system to meet other health needs. Unfortunately this system is at best unable to deliver
many of services required by women. Keeping this reality in mind women in many parts
of the country have organised themselves into groups and are demanding better treatment
and services from the public system.
17
n
Section Three
Working on Women’s Health
Different approaches of working on Women’s Health
Working with women and their health has for long b^n one of the main areas of activity
for NGOs. Over the years many organisations shifted shifted their focus from a strictly
maternal and child health orientation, to gradually include other aspects of women’s
health. NGOs were among the first to draw attention to serious problem of reproductive
tract infections that women suffer in silence. Over the last ten years of so NGOs have
tried a number of novel experiments all over the country which are addressed towards
assisting women achieve a better health status. Dealing with reproductive tract infections
has been one of the key element in most of these experiments. Some of the common
approaches are described below.
Clinic based approach - This approach is being tried out at a small number of projects
where the special clinics are being operated for treating women with RTIs. The work at
the clinic are supported by community based health education for awareness raising and
for referral of symptomatic cases.
Community based approach - This is the more prevalent approach where the
programme includes community based health education, training of paramedical workers
in health education and primary treatment either through herbal medicines or using
modern medicines. The strength of the community based approach lies in mobilising
women in communities to realise their own situation and taking steps towards changing it
the process of change is very slow, but there are enough evidences to show that it is
possible. Once women learn to accept their own bodies and its processes as natural and
something not to be ashamed of, they show a.keenness to learn more about it and take
active measures to keep healthy. Once women are willing to learn more, many take up
the challenge of learning herbal remedies, grow and make medicines, actively engage
with others in the community for changing their attitudes and so on. ’
Clinic -cum community based approach - In this third approach the community based
approach is strengthend by an organisational referral systtem , but this is only possible
where the organisation has an in-house or on-call gynaecologist. Often the gynaecologist
is asked to come on a camp basis and community based workers are involved in
screening and selecting cases for the gynaecologists visit.
Strategies for change
The different organisations that are involved in working in the area of women and health
have all adopted different strategies for enabling wormen access better services and
gather more--------control1 over their their health. Some of these strategies are as follows:
18
Organising women- Almost all the organisations that are working on the issue of
women's health have organised the women in the communities into groups or mandals.
These groups are an important fora for health education, discussing new ideas with
women and beginning the process of new learning. These women’s groups are also an
important vehicle for facilitating change in attitudes and behaviour. When women learn
new things about themselves and start challenging some of-their most strongly held
notions the group of peers provides a secure atmosphere for making these experiments.
Raising awareness about the body and its processes- This forms one of the core
strategies for change. Different organisations have used different methods -modular
courses, informal camps, regular meetings, self examination and so on, for raising
women’s awareness of their own bodies and its funtions. From early childhood women
develop very negative feelings about heir bodies and these efforts allow women to start
knowing and appreciating their bodies for the first time. Once this has begun women are
willing to be more assertive to keep their bodies in good health.
Building local capacities - This involves the training of local women in different aspects
of women’s health with which they not only help themselves but other sisters in the
community. This has been to the extent that in some projects local women are now
competent in the use of speculum for gynaecological examinations. In some places
traditional birth attendants (dais) skills have been upgraded, in other places young people
have been trained as health workers. The focus is that the women in the community
should obtain some degree of self sufficiency in dealing with their own problems , before
they need to visit a doctor.
Use of herbal and traditional medicine- This aspect has been discussed in detail earlier.
Training for women’s health '
One of the main challenges in implementing a woman’s health programme which takes
into account women’s health needs, their vulnerabilities, social realities, is to develop a
training strategy which will enable the training and reorientation of different memebrs of
the team who will take up this work. This includes training of managers field workers as
well as the community. Most learning experiences are usually through very hierarchical
models where there are teachers and learners, with a strict heirarchy of knowledge and
power. If one has to slowly build the confidence of women to learn to accept their bodies
and to start a process of questioning many of her previously held notions, the facilitators
role is very different from that of a teacher. And this facilitation has to be done by the
field worker and the manager as well as the nurse and the doctor. Thus these workers also
need to go through training programmes which allows them to develop a degree of
sensitiveness and empathy towards the women’s situation. Even for technical trained
persons like doctors, it may involve developing new skills in communicating with
women. Different experiments have already started in developing training modules for
middle level managers, field workers as well as doctors and nurses in equipping them to
deliver more sensitive and need-based services to women.
19
Some innovative community based women’s health programmes
There are a large number of organisations involved in innovative work on women’s
health Brief outlines of the work done by four organisations is being given here A more
ReXt'section51
°r8aniSatiOnS W°rking °n WOmen’s health Prided in the
f
haS
at
forefront of usin« and documenting the use of herbal
remedies for women s gynaecological problems. They have been a partner in a country
wide documentation exercise through the. Shodhini network and since then have been
actively involved in training women healers in the use of herbal remedies 4t the
community level they are involved in organising village level health grouns ‘arogya
Zfc
™“Bed ,0
h~t0 “
* nudd-r
MASUM- MASUM is a rural women’s collective based in Pune. Its goal in addressing
the sexual concerns of women is to get women to fight for their rights at all levels rathlr
an negotiate at the last resort. The major reproductive health intervention of MASUM
has been the running of atemimst health centre Streevadi Aarogyakendra The centre is
staffed by a consulting gynaecologist, a full time nurse and a visiting health worker The
staffrisPr0V > d™
M'eS and f°ll0W UP SerViCeS' Thr0Ugh its heahh educatij the
are stressed m
th°
i?
h
°f rat'Onal dru8 theraPy- Exe™e and quality of life
are stressed more than pills in this programme
-
RUWSEU - RUWSEC has been one of the pioneering organisations in developing
interventions in the area of women’s health. The organisation works in the Chingleput
district of Tamil Nadu. Today they have a very-comprehensive women’s health
programme which integrates women’s health with women’s education and women’s
educauoTwhiL Y T" l^r86 health7°rkers in Priding first level of care and health
includ MTP
r
3 Chni? Pr0V,,deS SeC°nd 16761 Of care The s^ices provided
dude MTP, surgery, gynaecological clinic, screening for STIs and so on.
distri^of M3hA^H Tn" 0rSanisati0n 7hich works wi‘h the tribals in the Gadchiroli
attention t^thpT 5
J °rganlSatlOn has been one of the first in the world to draw
attention to the burden of reproductive morbidities that are faced by ruraal women Their
Reproductive Health programme includes four components - participatorv research
mass education in sexual and reproductive health issues commnnitv haoa
j
^±are ar rer “tt *
Oynecological problems and also advise referrals.
Addresses of all these organisations are provided in the Resource Section
RESOURCE SECTION
Further Reading
• Andina, M. et.al. 1998. Trust . An Approach to Women's Empowerment. Los Angles:
Pacific Institute for Women's Health.
• Bajpai, S. 1996 Her Healing Heritage. Ahmedabad. CHETNA.
• Berer, M. 1989 Living Without Children. United Kingdom: Blackwell Sciences.
• Berer,M. 1998. Women's Health Services . Where are They Going.United Kingdom:
Blackwell Sciences Ltd.
• CHETNA. 1996. WAH- Curriculum Revision and Development. Ahmedabad:
CHETNA.
• Dixon- Mueller,R. et.al. 1991. The Culture of Silence. New York: International
Women's Health Coalition.
• Dutta, D C. 1994. Text Book of Gynaecology. Calcutta: New Central Book Agency.
• Germain, A. et.al. 1992. Reproductive Tract Infections. New York: Plenum Press.
• Gopalan, C. and S.Kaur. 1989. Women and Nutrition in India. New Delhi: Nutrition
Foundation of India.
• International Institute for Population Sciences. 1996. Selected Readings on
Reproductive Health. Mumbai: International Institute for Population Sciences.
• Jacobson , J. 1991. Women's Reproductive Health: The Silent Emergency.
Washington: World Watch Institute.
• Joseph, A. 1996. Maternal Mortality and Morbidity, Bangalore.
• Khanna, R. 1992. Taking Charge: Women's Health Empowerment. Vadodara: Sahaj.
• Lemcke,D.P. et.al. Primary Care of Women. Norwalk: Appleton and Lange.
• Llewellyn-Jones, D. 1993. Every Woman. New Delhi: Penguin Books.
• Mukhopadhyay, A. 1998. Prevent Unsafe Abortiorf. New Delhi: VHAI.
• O'SuIlivan,S. 1987. Women's Health: A Spare'Rib Reader. London: Pandora Press.
• Padubidri, V.G. et.al. 1994. Shaw's Textbook of Gynaecology. New Delhi: B.J.
Churchill Livingstone.
• SHODHINI. 1997. Touch Me Touch Me Not. New Delhi: Kali for Women.
• Stein, K. et.al. 1998. Critical Issues in Reproductive Health: Abortion Expanding
Access to Safe Abortion Strategies for Action. New York: International Women's
Health Coalition.
• VHAI. 1993 Women and Health: Gynaecological Disorderes. New Delhi. VHAI.
• VHAI. 1999. Infertility. New Delhi: VHAI.
• VHAI. 1999. Menopause. New Delhi: VHAI.
• Women's Health Action Foundation. 1995. A Healthy Balance. Amsterdam:
Women's Health Action Foundation.
Resource Organisations
There are a large number of organisations working on Women's Helath either as a
grassroots implementing agency or a support organisation. Addresses of some of these
are being provided here.
5/24 Jangpura B
Action India
21
Community based project .Herbal, Material
preparation
(ARCH
~
--------- --------------Community based project. Research
Aikya
—--------basedproiect.Trainini, HerM
New DelhTTlOm
Phone 011-6467470
----- '---------------
--------------p'stt Bharuch393 150(Guiarat)
Phone_02460-40140 401 <4
A 8,h
Phone 080-6645930 843"363
-£^080 6631564 attn, Aikya
BMC
----- ---------------------1 st Flo°h BMCfOfficTBuiiding---------- ‘
Innovation with the government system
Nehru Road, Vile Parle(E 3
Mumbai 400 057 (Maharashtra)
.
Phone
022-6162436
CHETNA
--------------------L1,avatiben LalbhaiTBU^I^-----------Research, Material preparation,Training
Civil Camp Road, Shahibaug
Ahmedabad-380 004 (Gujarat)
Phone : (079) 786 8856, 786 5636
----- g™il:_Shetna@adinet,erne-in
CINI
--------------PBJVo~16742=========-------------Research, Community based project,
Calcutta 700 027( West Bengal)
Joining, Material preparation
----£
ma^~ c'ni@cal2.vsnl.net.in
?
Deccan Development Society
A’6 Meera ApInTn^ms '
Research, Herbal, Community based
Basheerbagh
project
Hyderabad-500 029 (A.P )
Phone 040-231360, 232867
_ Fax 040-231260
rwrD
Sabla and Kranti
Training
-A/201 Vasant View D'monte Lane
Malad (W) Mumbai 400 064
Phone & Fax- 022-8886237
—
i^lLdS£
anti@bom5.vsnl.net.in
masum
1 Archana Apartments
Community based project. Research
’
rd
Floor, 163 Sholapur Road, Hadapsar
Training
Pune- 411 028(Maharashtra)
Phone- 0212-675058
Fax- 0212-611749
_^nail[-_admin@masum.ilbom.ernet.in
RUSWEC
----------- “-----ot No. 12, Peria Melamaivur Village road
Research, Community based project
Vallam Post,
Chengalpattu-603 002(T.N.)
Phone
04114-30682
SAHA J
;’r'C)as APan''^Haribhik-ikrilonv
Action research
Old Padra Road
Baroda-390 015 (Gujarat)
E-mail
Lsahaj.locost@sml.sprintrpg.ems.ysnl net in
22
SAHAYOG
Community based project, Training,
Research, Material preparation
SEWA
Community based project. Training,
Material preparation
r.
SARTHI
Community based project. Herbal
SUTRA
Community based project. Training,
Material preparation
VGKK
Community based project. Government
WAH
Training
Premkuti, Pokharkhali
Almora 263 601(U.P.)
Phone 05962-33029, 32919
Fax 05962-33029, 32919
E-mail- sahayog@vsnl.com___________
Opposite Victoria Garden
Ellis Bridge, Bhadra
Ahmedabad-380 001 (Gujarat)
Phone 079-5506477
Fax 079-5506446
P.O. Godhar West, Santrampur Taluka
Via Lunawada, Panchamahal-389 230
Gujarat
Phone 0265-340223,
Fax 0265-330430 a/c 88, attn. Locost
E-mailsahaj, locost@sm 1. sprintrpg. ems. vsnl. net, in
Jagjit Nagar via Jubbar
Solan 173 225 ( H P.)
Phone 01793- 8725, 8734___________
B.R. Hills 571441
Yalendur Taluk
Mysore District (Karnataka)
Ph 08226-84025
Fax 08226-84004____________________
Mira Sadgopal
Renuffrakash-A/Srd Floor
817 Sadashiv Peth
Pune-411 030 (Maharashtra)
Phone 0212-470314
Fax 0212-476451
Booklet prepared by
Research and Text Alka Agarwal
Reviewed and additional text - Abhijit Das
23
»
k3H- n.g; S'.- -
Understanding
•>/ fl’. J-
Reproductive Health
A Resource Pack
■ k'i-.‘-i
./..‘■-.I ■
Booklet -Five
r_'i •
Women’s Health -1
Maternal Health is^till Important
•
£•' i*1. *.• ••
SAHAYOG
t > •».v>»-y '+■ v»y
0^01
CONTENTS
INTRODUCTION
Section One: Understanding Women’s Health
What is women’s health
Women's health and the socio cultural context
Gender and women’s health
r
Women's health and the health care delivery system
Women's perception of their bodies
Menarche, menstruation and menopause
Menstrual problems
Section 2- Maternal Health and Safe Motherhood
The importance of safe motherhood
Reasons behind unsafe motherhood
Ensuring safe motherhood
Antenatal care
Supplementary programmes of the government
Care during childbirth
Post partum care
Section 3-Impiementing a Maternal Health Programme
Understanding the community
Strengthening community capacities
Preparing for referral
Dealing with traditional practices
*
Health education and communication strategies
Some Innovative Projects In The NGO Sector
Resource Section
Further Reading
Resource Organisations
3
4
4
6
6
7
8
9
9
9
10
11
11
12
13
15
15
16
16
16
17
18
20
20
23
2
INTRODUCTION
The heal th of mothers has been a subject of national interest in India since independence
ffe hea!l f eiLm
ln
documents of how cn.cially important
the health ot mothers ts for the health of the children and of the ftiture generations
Spec.ally targeted programmes have been implemented within the larger family planning
programme looking after maternal health. But over the last fifteen years or so the^e has °
been a growing unease (all over the world) over the exclusive concern for women only as
mothers or potential mothers ( cases tor contraception). This single-minded attention to
p£d“ “Zf ’
l”al,h slso re"ec,s ““overa"
Women’s health Is a very complex issue- it is influenced by a host of soc’ >1 and
of theThC d SUeS
Patnarch"1 SOcial setuP that we 'ive in, women’s own perception
of their bodies ar.d health is very low, and it is controlled and mediated bs numerous
mores and practices. In such a situation women often do not even bring forward different
complaints - especially ff these have any thing to do with their reproductive tract
Women s reproduct.ve morbidity has been referred to as a silent emergency taking into
it is'not iu^th h"
Seri°US tHe Pr°blem is' Current evidence 'indicates that
not jus the burden of reproductive morbidities that women, have to silently bear but
some so-called public health diseases too show increasing preponderance in women not
because of their sex but because of gender.
We have tried to cover the different issue and concerns around women’s health in two
booklets. The first booklet tries covers some of the-basic determinants of women’s health
along with maternal health, while the second booklet deals with issues like abortion
mteHihty cancers ^and so on. As in other booklets of this. Resource Pack we have
me uded brief profiles of organisations working on the issue as well as different resource
material that is available.
3
Section One
UNDERSTANDING WOMEN’S HEALTH
What is women’s Health? : The term women's health is complex issue -nd
encompasses the entire gamut of social cultural and medical aspects of a wsman’c rr
wh,e .free, her be.l.b - cl.I.er pbsl.iveiy or more b,le„
7£'
clearly establisheo .I... .he soc.o-cultural determinants of health are equal!-, important
the bto-med.cal determinants. This is more so in the case of women whose lives are as
'
controlled by numerous social norms and.practices For understanding thes-r
i
need to look no further than the different customs and tab^ asS^
"
mensturation, pregnancy and childbirth. Examples of how other socio-ecommir
affect women’s health will be discussed at greater length later
*
°rS
The term women's health has also to be understood with reference to some other
i
terms like maternal health and reproductive health. Maternal health is the oldest of these
concepts and clearly relates to health of women those who are involved in bearine
children. It excludes the health of a whole range of women who cannot do not want to
cr
simply not involved in the process of becoming mothers. Therefore it excludes a large
group of women - all their lives ( women who are infertile or do not choose to bear
§
children) and all other women for most of their lives ( as adolescents, adults not in the
p ocess of bearing children, or older women). Hence it can be argued that following an
exclusive maternal health approach limits the system to viewing, or giving importance to
women only as child producers. This reflects the intrinsic value^uch a system places on
exZ? Lo^;nS|On,y °r m0Stly at WOmen as P°tential cases for contraception is an
extension of this limiting approach.
he term reproductive health has arrived recently in India. Though this term is eouallv
applicable to men and women, its use is often more closely associated with women The
International Conference on Population and Development has defined reproductive health
as a state of complete physical, mental and social well-being in all matters relating to the
reproductive system and to itsfunctions and processes. When applied to women the
canvas of reproductive health is much wider as it includes women who are suffering from
gynaecological morbidities like reproductive tract infections, cancers, infertility and so
on. It also addresses the health problems of adolescents. Maternal health is part and
parcel of reproductive health. The framework of reproductive health includes the socioco TC d,eterminants that have been mentioned earler. The only limitation of this
concept is that it is restricted to the health concerns around reproduction
(RChTo31 y’
PItr 311 the hullabal0° over the new Reproductive and Child Health
(RCH) programme, for many people in establishment reproductive health is iust a new
name for maternal health and family planning
J
"17" '’J'*1'''
‘>"ly 7“'s ^Productive health and maternal health but also
inc udes other concerns, which are generally seen as public health concerns Thus anv
women^fahi”™'1™ W''“h
8e"<ier are
women s health There ,s mereaatng evtdence to show that women are more susceptible
4
to a number of health conditions because of the differential gender relations which
include poverty, workload, violence, lack of decision making and so on. Thus if women
sutler from tuberculosis due to certain circumstances which have to do with them beinn
women, then it is a women s health issue. Similarly with malnutrition I..
In some countries.
of the world women's activists have got together and advocated for separate
i women’s
health policies. Three countries where such policies have been framed are Brazil
Australia and Columbia and South Africa is in the process of doing so.
Women’s health and the socio-cultural context - The relationship between toe socio
cultural situation in wmch a woman is and her health are very closely inter-related
arher there was a tendency to view health purely in bio-medical terms but there is an
increasing awareness that a woman’s health is a product of complex social, economic and
cultural (perhaps ever, political) circumstances in which she lives. While these factors
affect the hea th of all individuals they affect women’s health more. Some of the different
socio-cultural factors affecting women’s health could be seen as follows - economic
situation education, religion, cultural mores, patriarchy, mobility and so on. Interestingly
socio-cultural conditions are not just contributing factors but consequences as w ell of °
women s health situation. A small example will illustrate this situation. Son preference
leads to a woman undergoing repeated pregnancies and/selective abortions. Due to the
inability to bear sons, she also has to face social alienation and even desertion And this is
just one example.
Gender And Women s Health : In India ( as in many other countries) women's low
social, political, legal and economic status contribute to the health problems of <nrls and
women. Unequal gender relations are one of the strongest determinants of women’s
health. Right from the womb there are a number of gender based discriminations which
affect women s health. Selective female infanticide and female foeticideis common in
our country. It is common knowledge that girl children are given less care and nutrition
and are less educated. The work load of women is greater from childhood itself- work
they hardly get credit for. Then there are numerous restrictions - during mensturation,
uring pregnancy, and during lactation. Added to this women are rarely allowed to
influence decisions in the family and community. They often have no rights under
traditional laws and have no control over money or other resources. All these factors
contribute to women’s poor health in numerous ways -by preventing them from getting
timely or adequate medical care, limiting the amount of money that can be spent on food
or other necessities for women
women, and of enures
course subjecting their bodies xto_ r_
far.. g:greater wear
and tear. There is a basic inequality between men and women in which• more women than men suffer from poverty,
• more women than men are denied the education and skills to support themselves,
•
•
more women than men lack access to important health information and :services.
more women than men lack control over their basic health care decisions.
And as mentioned earlier these inequalities affect their state
of health Usually, except for
---------------women s reproductive abilities, the health needs and concerns of men and women are
considered equivalent if not the same. But women are not only biologically different front
men, they are socially, politically, and economically different. Women’s roles, and way
5
Ji
f
they are treated ;s different from men both at home and wig
health consequences of such inequality. Fortunately thICPD^a^'^r d^^
many
of the important determinants of reproductive health but r °
lnclu,dec Sender as one
p„„cip,e of ,lle c.,ro
seB im<> prMlce «£££“
Women’s health and the health care delivery system - ThP n iv ru
women usually receive is unsatisfactory at almost all levels Most heakh
providers from nurses to doctors are all trained in the bio nwrT
health "^e service
and are inexpenenced about the d.fferent soJo-cu tuJ ft
J
°fdisease
health. This often leads to a gross insensttivity to worn nThealth need"' TT’5
reflected in their treatment of their clients needs in ter™, f
r
? ’ and thls 1S
of advice. The problem partly lies with limited availability of^
°f
and nature
Seethe se. ice
“Xu
their problems. This will enable them in deli’veri'ngser^ic™ ”n” “
U"dMand
/friendly manner.
g ervices in a more women centred
sZXXXiZTulZ'”510 del,ver ™men se',s',,'e hMhh
be gender sensitive,
respect diversity of women’s health need,
respect women’s cultures and local health traditions
be based on epidemiological and women’s expressed health needs
■eep socio-political reality of women in mind, and finally
j™ ,„.ersec,or., coordmat,on of al, policies an<J progranlm(is affecling
normal and anything differing from thatZa d °diety
Standards which are considered
inadequacy in many0women Different soci/l t'/ 001 nOrmal 8ivinS nse to a sense of
setting standards and .IXin^^hat ts rmaT I
" ' faCt°rS P'ay * Vltai role in
and AW), market ( advertisements, beauty pageantsTpfer X
'd'6 °f
(pnPt
some of the most influential. Women’s selfWorth s also shW U.P,and marr,aSe market are
inequalities they see and experience being in the family and
Y
numerous
irnot fram ib. womb. Ah ibis
6
Indian cultures Consequently women shrink in and are seuresjated to their little
dunng menstruate, pregnancy and childbirth. For example shame and noil o SPaC6S
vious in most menstrual practices and taboos. Pollution comes to the forefi
unng advanced stages of pregnancy and after childbirth The new born infam"' T6"
sZe'days later11 COnS'dered
P°,1Uting
have taken a purifying bath
SSS—ESESs.
s-asssss.
seen in her phenomenal silence about gynaecological morbidities.
P
fY
a1v.dedi„1^zz^zz=zzz9X”':zzZb
(8eni,als>an<i aecoodarf bai"S
»hich becoml evrdem after
P
y( body hair, breasts, timbre of the voice etc ) Menstruation and child h^a •
two fundamental process differences between the two sexSUni o-me
’term-"8 "
dZ Z’Z
Shetdlng °f Ut6nne *ining aPP—ZZZ30
being
bZLn 11 r h time Wh6n tHiS Pr°CeSS firSt Starts- The usuaI ™ge
ng between 10-16 years and menopause the time menstruation finally stops This
szszsr bMwe“ °f4MS w50»a,,
»“elihAm ens"?*a''0" »n<l menopause are not just biological events but social events
all pemd^ns Fi^vthe^
of menstruation are perhaps the most
htaX r
8'
y h
ignorance and incomplete knowledge about the bioloaical
asts ot menstruation among women in general and young girls in canicular The/th
are the numerous misconceptions And this is .me not only oia Zeriahve socfe" Ze
ndia but also ofa more open, free and progressive society like America as shtnvn hv
Smse" es'Z”
Z“
’
emselves as prepared for menarche not only have incomplete knowledge about
Zc ZndZ" ““ 7”“” Vln"V Of ““Z"S but aisoZr
lledgo
"d m°”" “•
nf rr,ent eSP'te the faCt that onset ofPuberty (and menarche) is celebrated in some parts
is oZ nmllZedT'1^^"13" °ren
P°llutlng’ lmpure and ^holy. She
Placed in term f? Panicipatc tn reltgtous or soc.al functions and restrictions are
placed terms of living space, mobility, diet and so on. In other places an unmanned
7
girl’s menstruation is not acknowledged even by her mother ( if it is, then s.he starts
becoming impure) and society colludes in maintaining this secret. Interestingly in this
very society, the menstrual cycle of each married woman is observed very closely by
community elders. It is also common practice in this society to celebrate when the
daughter-in-law has her first period ( perhaps a symbolic menarche celebration) (
Dasgupta and Das 1998)
Studies ( Chaturvedi and Chaturvedi 1991; Sveinsdottir 1993;) have also shown that
socio-cultural and biological problems or comforts faced by a menstruating woman
detine her attitude towards menstruation. Women who report considerable''menstrual
problems consider menstruation to be “debilitating” and have an “unhealthy’ attitude
whereas those who have premenstrual well-being consider menstruation to'be a natural
event and have a "healthy” attitude.
Menstrual Problems - Pain or general discomfort (cramps, backache and breast
tenderness ) felt by some women around the time of menstruation is known as
dysmenorrhea. Some premenstrual symptoms ( bloated feeling, some weight gain
headache, .mtability, mood changes etc.) may or may not associated with“cysmenorrhea
1 here is no single cause for dysmenorrhea but water retention, hormonal imbalance and
other chemical reasons are suggested as possible factors. Social perceptions also mediate
the amount of pain and discomfort that is felt during this time. But menstrual pains can
also be due to medical problems such as an infection, tumor or endometriosis. The term
premenstrual syndrome or PMS is used to refer to those causes in which the woman has a
particularly severe combination of physical and psychological symptoms (as mentioned
above) premenstruaUy. Interestingly for a long time-PMS was not accepted as a true
health problem by the medical profession and was considered an imaginarv situation or
an over-reaction. It is important to realise that woman who have repeated and severe
discomfort and change in behavior before menstruation should be advised to seek
specialised medical attention.
Menopausal problems are being dealt separately in the second booklet
X
Section Two
MATERNAL health and safe motherhood
The Importance of Safe Motherhood According to WHO figures there is a sreat
difference between the maternal mortality rate (MMR) of developed and developing
countries. Maternal mortality being defined as the death of a woman while pregnant or
within 42 days of the end of her pregnancy from any cause related to or made worse bv
he pregnancy regardtess of the duration of pregnancy. In developed countnes 1 out of
1,800 women die from the complications of pregnancy and childbirth whereas in
developing countnes the risk is a far higher 1 out of 48. A regional variation of women’s
lifetime risk of dying from pregnancy and childbirth is given below-
Region_____
Africa
Asia
Latin America and Caribbean
Europe
North America
Risk of Maternal death
1 in 16
1 in 65
1 in 130
1 in 1400
1 in 3700
In India the lifetime risk of a woman dying from pregnancy or childbirth is about 1 in 37
and any nsk more than 1 in 100 is considered high risk. The MMR in India is about 400
(per 100,000 live births) and this is probably a low figure because of the inadequate
reporting system in our country When going through these figures it is important to
realise that this is the situation fifty years after the countiy accepted that maternal health
would be a priority area of concern.
Reasons behind unsafe motherhood : The high risTc of maternal mortality and morbidity
are surely consequences the poor socio-economic situation in a country as is clearly
illustrated in the figures given earlier. The availablity or lack of trained personnel and
equipped birthing facilities are also an important determinant of maternal safety. Young
poorly nourished, anaemic, multiparous ( with low interval between childbirths) women
with low social status and lack of appropriate knowledge about health, when pregnant
have far greater chances of complicated pregnancy and delivery. It is difficult to predict
complications in many cases. But the delay and appropriateness of decision making
which often depends on the economic situation, the availability of appropriate emergencv
services the communities faith in them, and the intrinsic value of the woman concerned
makes the difference between life and death for the mother.
In India, the incidences of early marriage and childbirth are so high that they pose a
serious threat to the life of the mother and the child in question. This teenage pregnancy
is not only socially sanctioned but in many communities is seen as ideal. We have a law
regarding the minimum age at marriage, but this legal restriction has made little
difference because of the lack of political will to enforce it. Health care service delivery
is extremely poor despite years of pursuing a maternal health agenda. Antenatal care is
restricted to anti-tetanus injections and an overwhelming majority of childbirths take
9
are ohcn id-eqmpped and die current promises ofFRUs ( First Referral t nits) and
Xg L™Xcy Obs,e,r'c Cen,res are ,heonly hope
Box
"
C ommon causes of Maternal death
1 he mam causes of maternal mortality may be divided into 3 categories
and available health care facilities.
ocia.l, medical
Among the social causes are
• early marriage and pregnancy,
• repeated childbirth, son preference,
anaemia,
• lack of information,
• ignorance and so on.
Among the medical causes are
obstructed labour.
haemorrhage,
toxemia and
infection.
And among available health care facilities are
• lack of essential supplies and trained health'personnel at the centers
• non-sy mpathetic attitude of health personnel,
• deficient medical treatment of complications and
• inadequate action taken by medical personnel.
(Safe Mo,herhood in India 1994; The Need for Comprehensive Policy and Programmes
Ensuring Safe Motherhood : Safe motherhood means ensuring that all women have
akTAS tOi.thAe lnt0™atl0n and servlces they ^ed to go safely through preenancy and
c i dbirth. As outlined in the ICPD (PoA), maternal health services should include
• education on safe motherhood,
• prenatal care and counselling with focus on high risk pregnancies.
• promotion of maternal nutrition,
• adequate delivery assistance in all cases,
• provisions for obstetric emergencies including referral services for
pregnancy, childbirth and abortion complications,
• post natal care
Antenatal Care Infant and maternal mortality rates (IMR and MMR) of a country
io
reflect the socio-economic development, accessibility to health care and nutritional status
of that country. Hence 1MR and MMR which still remain pretty high in India not only
represent a loss of precious lives, but also discredit India’s health and welfare
programmes. Such a high rate of IMR in India persists for want of political will
professional commitment and people’s action. Though with the implementation of
in iLT TXdT re‘ated t0 matemal and Ch‘ld health there has been some reduction
m IMR and MMR but it is far from adequate. Proper antenatal care (ANC) is perhaps one
oi the first things tha: can assist in this direction.
Ante natal care refers to- health education and regular medical check-ups given to a
pregnant woman in O'deMnafae the outcome of the pregnancy safer. ANCAs also
necessary to screen high risk pregnancy (HRP) and high risk labour signs . Regular
check-ups done during pregnancy include history taking of any past and present
pregnancy related problems, abdominal examination, height and weight monitoring
momtonng of blood pressure, testing for protein in urine and so on. Most of these Tests
are very simple and can be done with minimal training. Nutritional and other relevant
counselling and provision of tetatus toxoid injections are also part of mandatory antenatal
care. ANC can help reduce cases of maternal morbidity and mortality through early
detection and treatment of pregnancy related common, and by identifying the women at
increased risk of complications of delivery. The task of high-risk screening can be done
by the most peripheral health worker.
In India within the given socio-cultural milieu regular check-up during pregnancy are still
not considered a desired practice in many parts of the country. Any kind ofcheck-up or
preparation to deal with emergency is seen as an ill-omen, something that will bring on
the mishap. But even for those who would not mind getting the service, the moribund
state of the health system in many parts of the country, ensures that this simple but
essential ante-natal care, is not available to millions of women in the country.
Supplementary Programmes of the Government- To achieve the goal of Safe
Motherhood the government has implemented many schemes and benefits which aim at
the health of mother and child. These benefits are part of the Mother and Child Health
package of the Department of Family Welfare. In the recent past the package has been
renamed from the CSSM ( Child Survival and Safe Motherhood Programme) to the RCH
(Reproductive and Child Health Programme ). In actual terms the services are mostly
limited to the provision that every pregnant woman gets 2 Tetanus Toxoid injections and
100 tablets of iron folic acid tablets. In many places the regular check-ups for high risk
screening are not done. Besides this the government also has Maternity Benefit Act 1961
under which 3 months maternity leaves are given to all pregnant women working in
organized/ unorganized sector who have worked for a period of at least 80 days with the
present employer. Another scheme called the National Maternity Benefit Scheme
provides women above 19 years and living below the poverty line, financial aid of
Rs.300/- for her first two children .
Care during Childbirth : Childbirth is a normal physiological process and in most cases
it happens without any mishap. It is only iin some situations where problems occur, and it
11
IS necessarc to have possible arrangements available to take care of these problems
Physiologically abour cons.sts of three stages, in the first stage there are contractions of
the uterine muscles, leading to labour pains. In the second stage the babv is pushed
in fheSthi
?°W
°pened CerViX thr0Ugh the Vagina and int0 the outs;!de world. And
in the third stage there is separation of the placenta from the uterine wall and its passing
of it out of the body as the “afterbirth"
..
P
°
surroundings ( for child birth is considered impure and defiling), cutting the cord with
?6
6 °r knife and aPP'V'ng dung or turmeric on the placenta are unsafe On the
other hand there are practices which are women centered and healthy for example
S“o dn„Pt““±inS lab0Ur' "1SSaS’ng ,he teCk Of,he ™m“There are differing points of view on whether labour is best conducted in an institution
under technologically managed conditions or under more natural surroundings But one
thing is certain, it we have ensure safety it is essential to have expert obstetrical support
close at hand m case there are any problems. Unfortunately there are a number of labour
related complications which cannot be predicted. For real-life situations in rural India the
best option is to have a trained person conducting the delivery, with a clear emergency
plan chalked out before hand. The FRUs and the EmOCs that the Government his '
promised, when fonctiomng will prove the best bet for managing emergencies.
Box - Natural and other forms of Childbirth
his modern technologmtif age there is an increasing demand for universalisation of
institutionalized delivery so that many of the complications can be can be adequately
handled. On the other hand there is small but vocal view point view point of home
ehvenes, championed by feminists. Their argument is that if due care is taken before
“e chS 7 ^" conducting deliveries at home is perhaps best for the mother ami
the child. According to this point of view institutionalized deliveries not only deprive
IfthotZ COtmf7ing and suPP°rtive atmosphere( of people, surroundings etc.) but also
ithotomy position (in which many institutional deliveries take place where the womens
egs are hiked up and put in stirrups) is not woman friendly, and only keeps doctor’s
convenience in mind.
The focus of most prepared childbirth methods has been two-fold : drugless techniques
childbtnh who advocated slower, deeper breathing exercises for this purpose Mtchel
theXT
"'d darkneSS t0 faCilltate the natural Process and advocated
tne use or water pools in labour.
12
In 311 these methods the emphasis of giving control of the birth process to the mother.
hus birth[becomes more than just a hospital procedure. The essence of these methods or
natural childbirth is respect for the wisdom of the birthing process, trusting nature to
work in the most efficient way for each particular mother and child. When a\'. oman is
taught to move beyond pain and fear, she can then work in harmony with her labour
reducing or eliminating the use of interventions. She can be mobile throughout the
labour, can choose positions that allow gravity to assist the birth process, and she can be
hr y conscious to appreciate the coming of the baby. These methods do not have many
followers in India, but many of our traditional birthing practices also use some of these
principles, (end of box)
Post Partum Care The six-week period after the birth of the baby during which the
mother’s body gradually returns to non-pregnant state, and she adjusts to the presence of
the baby in her lite and in the life of her family is known as post partum period and care
provided during all this is called post partum care (PPC). After delivery a woman has to
make both physical and emotional adjustments and she needs support and understanding
borne of the medical disorder during this are peurperal sepsis or infection of the uterus “
and surrounding tissues, urinary infection, acute prolapse of the cervix and puerperal
psychiatric illness. It is important to diagnose and treat these conditions as early as
possible as some of these may lead to more serious/life threatening complications
Soon after delivery many women feel slightly depressed, scared or low and experience
some of the other problems women sometimes go through. The main reasons cited for
these feelings are hormonal changes and the adjustment to a new schedule. Women
usually overcome these feelings with rest, comfort-and support in caring for the baby but
it these persist then professional counseling should-be sought. Post partum care includes
the mother’s recovery to normal physiology, establishing healthy breastfeeding and
contraception and not just the treatment of complications like haemorrhage and sepsis.
Box - Elements of Post partum care
The elements of post partum care are • medical management of post partal complication / morbidities,
• promotion of optimum practices of breastfeeding,
• timely and appropriate choice of contraceptives,
• promotion of adequate rest ,diet and hygiene of the mother,
• promotion of timely immunization.
As with pregnancy and labour , different regions of our country have a host of
cultural/traditional practices for the post partum period. Many of these affect the health
and wellbeing of the mother and the child adversely, while others are beneficial. Much of
the attention in the postpartum care is focussed on the well being of the child Care of the
mother is a relatively neglected area. And this true both for traditional practices as well as
for the health services.
13
1
India has been implementing a Post Partum Programme sinrP i oaa
and post partum and after medical termination of pregnancy (M™I ” Thl
’
out to pro vide an integrated paekage of maternal aVeMd LaTa’„d JamTSf""”' “*
14
Section Three
IMPLEMENTING A MATERNAL HEALTH PROGRAMME
Maternal and Child Health Programmes are among the commonest interventions in the
sector of Health by NGOs in India. Earlier the trend was town charitable clinics and
hospitals but over the years MCH programmes have become more prominent. As it has
been already mentioned the condition of the state-run health services are so poor in mam
parts of the country that poor women in the rural communities seldom get access to the
various schemes and programmes meant for them . The economically well off not only
get better services from the state functionaries but they also access private services
elsewhere. It has already been mentioned that the Maternal Mortality figures in India are
pretty high. Thus even in the age of Reproductive and Child Health (the new
Government programme) the need for an effective Maternal Health programme cannot be
over-emphasised.
Despite the over-medicalisation of pregnancy and childbirth in urban areas, a large
proportion of pregnancies and childbirths can take place with the minimum of Trained
supervision. Fortunately it is possible to run an effective maternal care programme with
paramedics and nurses but with an effective referral support system. It must be mentioned
here that the effectiveness of such a programme does not lie in technical expenise, but
often on the degree to which the programme is able to identify with the communities and
vice-versa.
Understanding The Community - On the technical front the programme may be
reduced to a set of simple discrete activities like • * identification of pregnant women;
'
• providing at least three check-ups for high risk screening;
• providing tetanaus toxoid injections, iron and folic acid tablets; and
• giving the relevant health education about rest, diet, travelling, medicine intake
intercourse and so on.
But if the programme is taken up in a mechanical manner not taking into consideration
the actual reality within which the pregnant woman lives, it might not succeed, just like
the government programme. In some places it might be culturally inappropriate for
daughters in laws to rest during the day. In others it might be that some food items are
proscribed which we would like her to include in her diet and so on. In such a situation it
is essential to first understand what the normative beliefs and practices are in the realm of
mother care before embarking on any health education programme. The community
cannot be just directed to adopt some new practices without first resolving the conflicts
with their earlier traditions.
The first step is to realise that getting the community to adopt new behaviour is complex
and there are no ready made answers. One has to explore the existing social and cultural
norms, beliefs and practices around the issues of pregnancy , childbirth and care after
birth. The community itself needs to be thoroughly convined on the need to change
behaviour and practices, before it will willingly do so. Participatory Rural Appraisal is a
15
and“tZe“„XiOin'ly
’’"’h'''" “‘b
ptart!
,ndrVet"10d bBe"^t^Z^Xancallv
deVe,°pment inritiatives- Traditional Birtn Atttendants
(TBA^'are often c
~of any effort towards
and seIf-
lnom?beaseadrtdeOKndia
f°r institutional deliveries just do not exist and thus
home based del.venes wdl contmue to remain the norm for large number of Indian
context' But'itXlt h m
del,VeneS aSSUmeS great imP°rtance in this
context. But it must be remembered that in many places it is often the mother-in-law or
any older woman who assists during the childbirth. In many places dais belong to a
specific caste (often lower castes) and their role in childbirth is very limited One should
TBZamttwbne"8
COmmunity before adopting a universal pattern of
train the f
hlle arranging TBA training it must be kept in mind whether we want to
ean but unfo" °r bu‘ldT°Rn'heir exIstin8 skil1^ Much has been mentioned of the five
cans, but unfonuantely TBA training programmes all over have often resulted in TBAs
losing some of their vital skills especially with respect to their woman-centered-ness '
while acquiring some extremely bad hospital practices. For example instead of waiting
for labour to take its normal time they insist on giving pain inducing injections or prefer
lithotomy position over sitting or squatting position.P
' laZrA,8,hFKr Re?rr!" ’ A large f>r°P0,’i°n ’f “ ,,,realen,"S ev“ts l"W'" <1“™S
„“
,h,s po"“;0 '""7™"” a“™ » often of no use and and .he only way ou
has been “co|",sTd
P
85
“,h,S J““,Ure
lh'
^ decide to seek expert help (often this depends on the men in the family their
attitude towards women and financial resources ),
• have available means of transportation and
• Visit a facility which is competent to handle the complication
The FRUs and EmOCs mentioned earlier are meant for this purpose But at the
community /family level there must be adequate preparation before hand so delays may
be avoided, decisions taken and the right place reached.
Y
Y
Dealing With Traditional Practices- up until some time ago traditional practices were
uniformly considered harmful and all efforts at health education were directed at
XoS Wher'el ” h“*7^‘J"''1'4®'’“d P™*'* There iseno.her school
MhJoflo .
Th'’'
8
I
rS rCVerCd One has 10 be carefcl "«>>> Ml into
either of the traps. There are a number of practices which are verv useful and others
which are equally harmful. Before either condemning or recommending, the particular
bettedeftTlo h
Y UnderSt0°d Harmless or nocuous traditional practices are
better left alone because changing an established pattern of behaviour can take a lot of
16
energy.
BoxHealth Education And Communication Strategies - Some points which could be kept
belo^ Wh' 6 f0rmuiatins a hea!th education and communication strategy are given
•
•
•
•
•
•
•
•
It should respect local knowledge,
It should keep local socio-cultural factors in mind,
It should raise questions on existing gender, caste discriminatory practices,
It should encourage people to raise questions on unhealthy practices relating to
maternal health prevalent in the community. But that should be done only after giving
scientific information on the issue,
It should be such which is sensitive to otherwise marginalised sections of the society
viz. women, dahts, minorities, illiterates etc. Promotional materials should have more
visuals, should have signs to which these people relate to easily and should have
names which are not necessarily referring to one particular community,
It should be interactive, should not be one sided
It should encourage people to think of solutions
It should provide necessary health information and information about rights and
services
17
There are a large number of voluntary organisations working in the field of safe
motherhood. Here we provide an introduction to a few such interventions This is no was
dXrrent kinds of approaches and
CINI , West Bengal.
responsibility ot running the MCH programme at the village level. Services include
growth monitonng, immunisation, ante-natal and post natal care, health education and
low cost curative care. They also have a programme to support poor pregnant women
Further details about their work may be obtained from
Dr S.N. Chaudhury, Director,
CINI,
Village Daulatpur, P.O. Pailan via Joka,
Dist 24 paraganas(s). West Bengal - 743512.
Email- cini@cal.vsnl.net.in
SEWA-Rural, Gujarat
Sewa-Rural is a unique organisation because the Gujarat government handed over the
PHC to the organisation ten years ago SEW A- Rural thus has to follow many
. government guidelines, and is a place to experience how the government system can
“ SseZJS. “ ’ ‘lare' h0SP“-1 n,n bV 'he "rSa"is*,ro"
For further details contact:
Dr Lata Desai, Managing Trustee,
SEWA-Rural,
Jhagadia, Dist Bharuch,
Gujarat- 393110
VGKK,
Karnataka
Vivekanada Girjana Kalyan Kendra is an organisation working exclusively with the
r hTk J3 S ‘n Mysore dlstnct' The organisation has been experimenting^o integrate
n a er a systems of medicine with modern medicine in its MCH programmes They
also involved in training tribal girls as ANMs. The MCH programme'is part of a Y
larger community health work.
P K
part Ot a
For more details contact:
Dr H Sudarshan,
Director, VGKK,
B R.Hills, Yelandur Taiuka,
District Mysore, Karnataka-571441
emailSewa Mandir, Rajasthan.
uSiSta h.! w'h"'1? yTrs ,g° aJnd wks primarily in the
»r
For further information please contact:
Shri Ajay S Mehta,
Director,
Sewa Mandir.
Fatehpura,
Udaipur, Rajasthan 313001.
19
RESOURCE SECTION
Further Reading : Some of the books that we found usefid in n
were;
G usetul ln preparing this booklet
Akhter.H.H. and T.F. Khan
1997
Arkutu,A.A
1995
Boston Women’s Health
Book Collective,The
Carrera,M.A.
1998
Chaturvedi,K.S. and P.S.
Chandra
Chawia,J
Selected Reproductive Health Elements and
Interventions. Dhaka. BIRPERHT
1"
en,Heal'hy
NY
O'"' Bodie, Ourselves NY : Touchstone Rockefeller
V.'CI 1II C.
1992
1991
The Wordsworth Dictionary of Sexual Terms
Herfordshire : Cumberland House.
Soc.o-cultural Aspects of Menstrual Attitudes and
MediZ™' pS™? ”
1994
S0Ci-1
an<' C“"‘,re- N Delhi ““ S~*l
CHETNA
1994
Family Care International
HymanJ.W. and E.R.Rome
1995
Jeffery,P. et.al
1985
Contaminating States and Women's Status N Delhi:
Indian Social Institute
IK",p,iCati°nS °f M™t™ation and
treatment°n RUra' W°men’S LiveS ilnd
treatment Seeking Behaviour. Baroda . Operation Research
Koff,E.and J.Rierdan
1995
Ministry of H &
FW(Bangiadesh)
Nobel Forum
“Early Adolescent Girls’ Understanding of
Menstruation”Women and Health 22(4): 1-21.
Safe Motherhood.
1994
Safe Motherhood in India ( Symposium Report).
Population Council
1997
^TdU?Ve Heal‘h ApprOach t0 Post Partum Care
022sh°P ReP°rt)- Population Council : S.E.A. Registered
Sathyamala, C. et.al.
Shephard,B.D. and C.A.
Shephard
Weisenheimer,R.
1986
1990
Taking Sides. Madras . ANITRA
The Complete Guideto- Wo
. jman’s Health. NY . Penguin.
1994
Dr. Ruth’s Encyclopaedia of Sex.
1994
Where There is no Doctor. Palo Alto: Hesperian
Foundation.
Joshi, A?et.al
Werner, D
Thematic
i nematic Meeting
Meeting on Reproductive Health : The need for
cSf P°liCy and
Ahmedabad
Sexual and Reproductive Health Briefing Card
PreTs
8
Se'VeS f0r Love- California The Crossing
A-/111UC.
20
Werner, D. and B. Bower
1987
Helping Health Workers Le,arn. Pa.o Alto. Hesperian
Foundation.
Where Women Have no Doctor. Palo Alto: Hesperian
Foundation.
BOOKS IN HINDI
Shirali, K. et.al.
Eklavya
Eklavya
Stri Sharir Ki Pahchan (A set of 8 books ). Jagjit Nagar:
Sutra.
Bitiya Kare SawaL Devas: Eklavya.
Bitiya Bari Ho Gayi, Devas: Eklavya.
Some recent research articles on Maternal Health are:
Bhatia. Jagdish. 1993. "Levels and causes of maternal mortality in Southern India." Studies in Family
Planning. 24. no. 5 (September-October).
,n *"*■
**•
Bhatia. J. C., and John Cleland. 1999. “Health seeking behaviour of women and costs incurred- An analysis
of prospective data. In Saroj Pachaun and Sangeeta Subramanian (Eds.) Implementing s Reproductive
Health Agenda in India: The Beginning, The Population Council, New Delhi.
Bhatia.„J_C. and John Cleland. 1994. "Obstetric morbidity in South India: Results from a community^
survey. Social Science and Medicine, 43. pp. 1507-1516.
Chhabra. Rami and S. C. Nuna. 1993. Abortion in India, an Overview. New Delhi: The Ford Foundation.
Ganatra BR. Hirve SS. Walawalkar S. Garda L, Rao VN (1998a): Induced abortions in a rural community
inwestem Maharashtra: Prevalence and patterns. Ford Foundation Working Paper Series.
Ganatra. B R.. K. J. Coyaji, and V. N. Rao. 1998. “Too far, too little, too late: A community based Case
Control Study of maternal mortality in rural West Maharashtra.” Bulletin of the WHO 76, 6. pp 591-598
Ganatra. B. R.. and S. S. Hirve. 1995. "Unsafe motherhood: the determinants of maternal mortality "
Journal of the Indian Medical Association. 93. 2. pp. 34-35.
Gupte Manisha. Bandewar Sunita. Pisal Hemlata (1999): Women’s Perspectives on tire Quality of Health
Care: Evidence from Rural Maharashtra. In MA Koenig and ME Khan (ed) Quality of Care within the
Indian Fanuly welfare Programme. New York. Population Council. Forthcoming.
Gupte Manisha. Bandewar Sumta. Pisal Hemlata (1997): Abortion Needs of Women: A case study of Rural
Maharashtra. Reproductive Health Matters. Vol 9, May 1997 pp 77-86.
International Institute of Population Sciences (UPS). 1995. National Family Health Survey (MCH and
Family Planning), India 1992-93. Bombay: UPS.
Jejecbhoy. Slureen. 1999. "Women's autonomy in rural India: its dimensions, determinants and the
influence of context". In Harriet Presser and Gita Sen, (Eds.) Female Empowerment and Demographic
Processes. Moving Beyond Cairo. Clarenden Press, Oxford (forthcoming).
Man BhaL P. N.. K. Navaneetham and S. Irudaya Rajan. 1995. "Maternal mortality in India: estimates from
a regression model." Studies in Family Planning, vol. 26. no. 4. pp. 217-232 (July/ August).
21
4
McCarthy. James and Deborah Maine. 1992 "A framework for onoi •
u
mortality." Studies in Family Planning, 23, 1 (January-February)
yS'ng lhc det<3™mants of maternal
, Esas&stsro°X"? o'e”“ i”l
•» ■—»—<» ■
WOTM Heahh
22
RESOURCE ORGANISATIONS
There are a large number of organisations providing technical support on the issue of
maternal health within the country. We are listing the names and addresses of some of
these organisations here.
VHAI- As far as maternal health is concerned VHAI is important for the material that it
publishes VHAI is one of the best sources for slides on maternal and child health. Its
newsletter Hamari Chithi Napke Naam , (and its various translations) is very useful for
the village level helth worker. The different stgte level VHAs are more useful as training
resource organisations in the different states.
Voluntary Health Association of India,
Tong Swasthya Bhawan,
40-Institutional Area, (behind Kutab Hotel)
New Delhi -220026
Email-vhai@del2.vsnl.net.in
CHETNA - CHETNA is perhaps the most important NGO resource organisation on the
issue of women’ s health in the country. They have large number of publications and
material which is freely available by post on payment. For organisations in Rajasthan and
Gujarat CHETNA provides resource support in the area of training in Maternal and Child
Health. CHETNA has two units devoted exclusively to providing resource support in
Women’s Health and Children’s Health.
CHETNA
Lilavatiben Lalbhai’s Bungalow
Civil Camp Road, Shahibaug,
Ahmedab’ad
•
380004, Gujrat
Phone . (079) 786 8856, 786 5636
email: chetna^adinet.ernet.in
Various State Voluntary Health Associations - The state VHAs are important resource
organisations for material and training support in the regional context and in the
appropriate regional language. Addresses of the different state VHAs are available from
VHAI.
SAHAYOG- is primarily involved in providing training and technical support and
produced manuals and material for organisations in the Hindi speaking region
SAHAYOG,
Premkuti, Pokharkhali,
Almora, U.P. 263601
23
o W A.C, ri.
Near Sanatan Dharam Mandir,
Sector 16, Panchkula, Haryana 134109
Ministry of Health and Family Welfare - The MOHFW is involved in preparing and
Box- Resource Materials-
These include• Manuals - including training manuals and kits
• Flash cards, and flip books,
• Videos,
• Posters,
• Pamphlets,
• Weighing scales, and growth cards
• And so on.
All the different organisations listed above are actively involved in the preparation and
distribution of such resource materials
ANM Training - Nursing schools attached to missionary and voluntary- organisation
hospitals are some of the best sources for training Auxilliary Nurses or even General
nurse. These schools usually have their students sign a bond for a specified periods
service in exchange for the free education. Many of these organisations take candidates
sponsored by voluntary organisations. Kasturba Trust in Indore also runs such an ANM
training institute.
Training of other field based workers- There are a large number of organisations
trraining for field based MCH workers some of these are the State VHAs
SWACH’ SAHAYOG SEWA-Rural, Comprehensive Rural Health Project
TBA Sin^™^ (LUCkn°W) and S° On' Many
these organisations
organisations also
Many Of
of these
also provide
provide
Training of Managers- Training of managers for MCH programmes are less common
and some of the organisations involved in providing such training are WAH! Programme
Institute of Health Management, Pachod and SEW A- Rural.
24
Addresses of the organisations referred to for the first time in this section are
PRERNA
IIHMR
CRHP
Kasturba Trust
19, Laxman Puri,
Faizabad Road
Lucknow-22'6016, Uttar Pradesh
Phone : 386715, 387884
Fax : 387884______________
Pachod
District - Aurangabad-431121
Mahrashtra
Phone : 02431-21419,21382
email : ihmp@giaspn01.vsnl.aet.in
Comprehensive Rural Health Project,
Jamkhed,
Dist- Ahmednagar,
Maharashtra -413201.
Phone(02421) 21322, 21323
Fax- (02421) 21034 _________ __
Kasturba Trust,
Indore,
Maharashtra
Booklet prepared hy:
Research and Text -Alka Agarwal, Abhijit Das, Jashodhara Dasgupta
AdditionaDtext and review - Dhanu Swadi, Bela Ganatra, Stddhi'Hirve
25
LJ H - H - E ;
*
ii
UNDERSTANDING
REPRODUCTIVE HEALTH
J
A Resource Pack
*-Z5
£-:^
. -.r-
Booklet - Jour
■■{’A
'.
—
»’>*•
.’
POPULATION AND DEMOGRAPHY
Understanding numbers
,
r ■’ '■
1*
-•. ■ •’*>■: •*■ »< '.-i ■<
SAHAYOG
W^;
INTRODUCTION
te leemmfr m.lhons. Hie population bomb, the serious overpopuktUon the problem
^Ih populaltott and similar expressions have now become very commonplace in the
media, at meetings and seminars and even during casual discussions over a cup often
■Sometimes this discussion is about poverty, sometimes about the environment or even
when there is a traffic jam or when railway reservations become difficult to obtain
When these words and expressions are being used we are unconsciously referrin- to
some theories and arguments put forward by some thinkers. And serious thinking
about the issue of population started some two hundred years ago Much of the
general discussion on population (especially with regard to over'population) is based
on an alarmist view where population is seen as a threat to middle class survival
While population is projected as a major problem in most spheres, there is an equally
strong view which does not do so. The only difference is that this point of view is not
so aggressively promoted and thus has not become popular. The logic here is that
people are a resource and the poor opt for larger families as a part of their survival
strategies. There is also a big debate about the role and position of women in the entire,
population related discussions, policies and programmes. For the not so well informed
person the entire issue becomes further clouded when statistics and stud.es are quoted
or dirrerent technical terms used.
In this section we will try to acquaint the reader with some of the debates, issues and
terminology associated with population and demography. An attempt will also be made
to contextualise the issue of population and demography in the present social reality in
the country . A separate section - Reproductive Health- Policy and Advocacy will deal
with the different population refated policies and how they evolved over time
CONTENTS
INTRODUCTION
Section One: Understanding Demography and Population
Definitions and Concepts
Demography and Population Studies
Mortality Measures
Measuring Fenility
Megration
Demographic Transition
Sex Ratio
Population Pyramid
Expectancy of Life
Growth Rate
Population Projection
Sources of Demographic information
Census
Registration of Vital events
Sample Registration System
National Family Health Survey
Section Two : Debates and Discussions
• Population is a problem
People are a resource
Population and Natural Resources
Family Planning or development9
Social Development and Population
Population and poverty
Population Control and Women
Population Control and Family Planning
Population discourse in India
Section Three : Working on Population related areas
Organisations working on population related areas
Resource section
Books for further reading
4
4
4
4
5
6
6
7
7
8
8
8
8
8
9
10
10
11
11
11
12
12
13
13
13
14
14
16
16
18
18
Section One
Understanding Demography And Population
Definitions and Concepts
’demP”P“';l,i°" .S,"d7 ’ The sl“‘'y "' I-™™ papula.,„„ is k„„„„ bv
e two terms - demography and population studies. In manv
t,
used interchangeably, but some scholars also try to distinguish between the two^’3
Broadly speaking populate studies is concerned with understanding what are the
kmds of changes tak.ng piace in the size and nature of human popu atiors ! I al o
concerned w.th why these changes are taking place. The distinction X t
made between the is usually along these lines- demography is said to refer mthThTd
affeT^th Ot nUm?erS Wh‘le P°puiati0n studies looks at
behavioural aspects "
th th 8 h
repr°duCt,Ve behaviour of people. Fertility, mortality and migration are
three bas.c aspects wh.ch considered influence the population of a particular place.
Mortality Measures - Information about mortality or how deaths take place within a
community ls very .mportant from the point of view of estimating the healthiness of a
commumty and understanding how it will grow. If the rate at whLh people dm is more
the' revVsewfll o^^ tT 7
"7^ °f Pe0P'e ^°Pulation) w'd decrease and
reverse will occur if the death rate is lower than the birth rate Some of the
common measures of measuring mortality in a community are given below
death rates can be calculated in a similar way by modifying the numerator and the
raTTh dr ‘7 eqUat'On By
deVel°ped nati0ns tend t0 have lower death
decades3"
el°Pin8 nat,°nS but the Sap has been raP'd|y losing over the last few
UCUdUcS.
Ih
f
T
dy,ng Under the age of one Vear t0 the total
number of hve births occunng in the year expressed per thousand live births The
tfZseDeT
'I" thC deVe'0Ped and deVel°pinS nati0ns can be to the order of
nH d
. DeVel°p,ns n“s having an IMR the region of 5-10per 1000 live births
and developing nations about 100.
fable 1 IMR of selected Indian states
( for a five year period preceeding 1992-92, NFHS - 1992-93)
State
Infant Mortality Rate
Kerala
___ _____________ _________ 23.8
_
Maharashtra
____________________ 50.5
~
J
4
Punjab
Pramil Nadu
53 7
67 L
UttarPradesh
| jDrissa
99 9
-itlZ
J
Monalily Rllte (MMR) . This is a very significant indicator efthe state of
a h services and well be.ng of women m a society. It is measured as a ratio of the
ta number ot deaths in women which are attributable to pregnancy and childbirth
divided by the total number of live-births ma community expressed in DO 000 In ’
PdPP^V’ '
t0 indiCate deathS Which aPemoteTattribPble to
ildbirth so all maternal deaths in pregnancy and up to 42 days after childbirth
for
purpose u„fon„„are!y aLrauinfo^aLu, “ re™,
mortality 1S often not available in many developing societies. The difference in MMR
indicators dLXdand deVe'°Pin8
tendS t0
hi«heSt
the three
Table-2 : Mortality and fertility figures of selected Indian states (SRS)
State_______
Crude Birth Rate (1996)
Kerala
17.8
23,2
23,5
34
Maharashtra
Punjab
Uttar Pradesh
Crude Death Rate
_ 62
[ 7.4
j 2-5
! 10.2
^easunng Fert.ftty - Fertility refers to the actutffbirfhs that women undergo
PcPthP 'V meaSUreS are
t0
‘h'e tOtal number of births Ibat tahe
has he J
c ‘yntmumty or at the level of an individual woman. Fertility behaviour
Some of Z
T 'y StUdi6d aSpeCtS in the field of PoP^ion studies.
Some of the commonly used measures of fertility are described below.
Xi'fc
Xia
•
™S ? a ""’leS’
Of“O “
“ «■=
r
* “mraun"y
by total mid-year
P pulation in a panicular year and expressed per thousand population It is not’
al.™™ 3 V7 1'7 ' I"’”!' °f aC,U’1 ferti,ity b““sc “ is
a large group which do not have the ability to give birth.
including
S
General Fertility Rate (GFR)- This is a more accurate measure of fertility in the
community and the denominator is restricted to women in the age bracket 15-44
dZemaS
™" SP“"1C
doe
r J'
' hlS ,S 3 Sllghtly different indlcator because here the rate
does not refer to a community as a whole but to individual women This rate is very
commonly used and refers to the total number of childbirths an individual woman '
undergoes in her entire reproductive life. The calculations involved are reasonably
s
complex, but it is a useful measure to compare the fertilitv of individi.nH
different periods of time or across ditTerent areas.
W°men aCr°SS
Tablc-3
Comparison ol FFR over time and place (SRS)
State^
Kerala_____
Maharashtra
Punjab
UP
J 992 (U) J992 (RQ lV93(U) J993(R)
1.7"
1.7
1.7
J_.7
2.3
' 2.6
3.3
'2.7
3.2
2.6
3.8
5T
5.4
tZI
Z2
1994(1)
1.8 _
26
2.6
4.0
I994(R) _ I
1.7
3.2
icT
5.4
Ne, Reproductive Rate (NRR)^ This rate refers to the potential reproductivity of a
popu auon by calculating the average number of daughters born to mothers The
assumption bemg that if there are more daughters born to the succeeding generation
he overall population is bound to increase- because there will be more rhilH h
.he
When .he NKK is ,ess ,ha„ one .hen .he
canTeXdT’
ecrease as there will be lesser numbers of child-bearers in the ftiture An NRR of 1 is
referred to as Replacement Level Fertility because at this rate total number of current
chi dbearersfmothers are being replaced by an equal number of future
cnildbearers/daughters. India has a goal of NRR 1 by 2000
Table-4. Desired Demographic Goals
Goal
NRR
CBR.
CDR
IMR
LEB
By 2000 (6 Plan
estimates)
1
21
9
60
64
By 2006-7 (8th
Plan estimates
1
•
21.77.4
48
66.1(M)67.1(F)
ActuaJ Situation1991
29.5
9.8
80
60
after biXL H tthe
h third
L important determ
'nant of the total population
determinant
population of
ofthe
the place
place
people move fro
?
dem°SraPhic studV is also concerned with how and why
people move from one place to another. Simply stated migration refers to the
movement of people from one place to another. The UN has added that the movement
or change in residence should be for a minimum period of one year and that some
administrative boundary should have been crossed. People usually migrate after
SmatZTT^
anTthe X °
I
'
the
h1’8™1 ‘S
°f livelih00d Ration is either internal
t0 aS an
or an out-migrant
on wh th
/h
Cr°SSeS 'nternaI,Ona, borders an immigrant or em.grant depending
on whether s/he is coming in or going out. In many cases migration has a significant
effect on the situation of both the place the person leaves or goes to.
o^aTaoiTl TranSiti°n- ThlS 1S a theory which tries explain how the population
social cond^reSA°n I"865 °T auPeri0d °f time W,th advances in t^ economic and
rates of b S h h h T '0 S
agranan life was characterised by high
Phase? i s
W;'h no “"sequent increase in the population (hiah stationary
phase), fhis was followed by the early expanding phase where due to advances in the
()
started declining- late expanding phase In the fourth or low stationery phase birth
ra es and death rates agam match each other but both the figures are ve^ low In the
fifth and Imai phase the birth rates reduce even further while death rates have reached
hur lowest possible level and are more than the birth rate. Here the population starts
dcclmmg. I his theory is based on the historical observations in developed countries
. lany countries today are not following this typical model which correlated
development with population growth.
It .s expressed the number of women for every thousand men. An invert rado
refers to the situation where the number of women for thousand men is less than one
thousand. Tins inverse sex ratio usually denotes a lower social position of women. In
India the sex ratio has always been inverse and this is also true of China and other
South Asian countries. In other, particularly non- Asian countries the number of
women 1S usually more. The sex ratio in India declining in every census except during
11 At present the sex ratio in India stands at 927 (1991).
Table. Sex Ratio of Selected Indian States ( Census-1991)
State
Kerala_____
Maharashtra
Punjab ■
UttarPradesh
Orissa
Sex Ratio
1036
879
934
882
971*
Population Pyramid ( Age -Sex stmeture)- When the population of a particular
region is arranged graphically according to age-groups and sex we get a graph which
resembles a pyramid. This population pyramid provides a lot information about the
composition of a particular society and its situation. In a typically developed nation,
where the birth rates have declined a considerably long time ago and the life
expectancy of the population is quite high the population pyramid is in the shape of a
column while in a different country where birth rates are high and fife expectancy is
lower the pyramid is shorter and more acute.
It IS clear from the Indian pyramid that the Indian population is much younger and
about 40% of India’s population is usually under the age of 15 and this has been steady
tor a long time. On the other hand the proportion of population above the age of 60 is
increasing, due to decrease in mortality. The dependency ratio refers to the
proportion of under I 5s and over 60s to the population between 15 and 59.The
dependency ratio in India is about 75%.
7
A
Population Pyramid of India
Aga
M i
w 74
»***•
•O4M
»»
WM
MaK
f •mala
«V4O
1^1
TO 74
10
io
Parcant
Population Pyramid of India (NHFS
1992-93)
Expectancy of Life - This is a measure of how many years a person is expected to
urv've in the prevalent situation. This measure can be calculated at any paXtr a.e
hough the common practice is to refer to life expectancy at birth In some situations
i e expectancy at one year of age is also considered and this figure is usually more than
he Life Expectancy at birth because the risks of dying in the first year are high India
abou™Phr°greSS 'n Ufe eXpeCtancy at birth and from a lowlv figure of
about 3 1 in 19M it has increase to around 60 years in 1991 Life expectancv at birth nf
= ,s usually
lha„ ,hat ofmen
of,
India this was not,
• cuciiiiy.
j
Growth Rate- This is a figure which is the nightmare of Indian planners and
demographers. It refers to the overall growth of the population and is calculated either
7r
te" yearS' The deCadal gr0Wth Fate m frdia is over
0 withle
abou. 25 ?"
A U P ' B""r' Madl,ya Prad“h to™= ’ ““•“al gro«b'a e „f
on the o.ht har7h dT"8!
\SO“,,,
S“'es llke K'ral« “d T«™> Win
n the other hand had decadal growth rates of about 14% in the same period Annual
f™”h,ra'“ ar' 'f ,h“ 10% “f^1 8ro«l> ra«s because the growth is
cumulative. Annual growth rate in our county is around 2%.
Population Projection - This is an estimation or forecasting of the population of a
particular region at some point in the future. In order to make this projection complex
mathematical calculations are made utilising the age-sex distribution, mortality fen'lity
and migration figures or the region. Different scholars use different assumptions about
groMh and it -s possible to come up with different figures using differenZthods
Population projection is an important tool for planning and policy formulation.
Sources of Demographic Information
Census - The enumerat.on of the entire population of a country or a region at a
ZhlT'5
3 C£nSUS USUally CenSUS is Conducted at de^lte intervals
H CenSUS
recorded and
d be donr^
r
-parately
the whole effort
should be done on one s.ngle day. Census is usually the primary source of basic
population data at the nat.onal or state level. This data is required for various
administrative, planning and research purposes
S
Census m India- The first comprehensive census in India t i i
then has taken place after every ten years The next cen
P 3Ce'n 188 1 and s,nce
census ,s .he eesP„„s,b,lily o,7he UnVn M.n's.ZrS Affa“ “k
' Th'
temporary census organisation would be set up for every censuslut
' 3
permanent oftlce of the Registrar General has been set ™ Anh
"
Directorates of Census Operations The Registrar Gen P| '
u ’eVel there arC
registration of birth and deaths, and for conducting other^l reSP°nS,b‘e tor census’
is conducted in accordance with the Census Act of India (1948)" SUrVeyS The CenSUS
enu3USe°fofthecount^.‘XZTuZer of
level
house is given a un.que number and mformaZ about h housemd
purpose, size, number of inhabitants and so on are‘ reco^
ltS
avauabihty of toilet was also included in the information gathered Thi^ -^on"5 ' A
the enumeration process which ideally should take place'^ ^stlP v'^Tbt
two types of enumeration - de facto - where all persons who spemthe m Jt 'n a are
certain house on the particular day are counted there or de jure where ai’nerson.
normally residing in a particular house are recorded together In India the
,
method has been in use since 1941. The Individual Slip is core of the Inf
in 199, ««
23 differe„t iKms „ere
77" “7“
hese are Demographic and Social, Educational, Migration and Fconom- Th
number and items under which information is obtained has varied from-census tT
How Census data may be obtained - J ~
Information gathered during the enumeration
process is compiled in to summaries which
dau isava.,^ „p o the vi„age,eve,
migration status is available m tables up to the tehsil level All this information and
H^andbooRs since 1951 IJ f rt
I '
l
Published in the District Census
andbooks since 1951. Unfortunately it takes quite some time after the census for
these to be released, but fortunately the information is now available in diskettes from
“e7b'tRegir GeT' " from ,he S“e Dire“ On<"ht to ay a
small fee ^hich depends upon the amount of space the information required occupies
m terms of the number of diskettes. There is a dififerential rate for information required
for commercial or non-profit purposes.
required
Events m den
TcU 969) .1
h
T
‘
S'
mamaKes and divorce are called vital
r f6' JCKCOrdinS t0 thC Re8istrat'on o^irths and Deaths
Act (1969) itjs compulsory for al! b.rths and deaths in the country to be recorded In
urban areas this ,s conducted by the Municipalities while in rural areas the
responsibilities has been given to gram pradhans. Based on these records the Registrar
General of India compiles the Vital Statistics of India. Unfortunately the recording
procedures are still not complete and these data can be inaccurate
<)
I
SRS' Sanipie surveys are a method of collecting information m whi-s ■ ..
obtammg information from the whole population it is obtained from =
set and the conclusions applied to the whole group The Sami
or SRS is a survey which has been ongoing since 1964 65 anH
country Under the SRS continuous eLtuer on
X”
r
a
°
raystem
done
a set of sample villages and a survey is also don ’ ‘ s x
'I
“
sample The results from the two different sources are mmche’d d pXhed m .he“
Ge„era'P
S
SRS BU“" (
•'»
c ild mortality and their reasons and determinants Information has hp-n
N..ional and State level reports which are .v.Hable X ta™ atio„an„
thePNrHSl,is^d'uerl^nS|999^u'rkeVeth>OPUla,'|On ^eSearC*'
7
' L
The
i j •
“f
999 Unl,ke Other P°Pulat'On related surveys this survev is
We^Irfo™'.,' IIPS “dhliS SPT°red
pra ie ofTaSr P
r.r
of th R t"
"" 'Jni“
ofH'al'h ’"d My
i" ' NFHS rePOr,S indu<,e st“s,i“ »"
avadable as posters, summa^ reports, state wise de.ai.ed reports a/d ZoXpert
10
Section Two
Debates and Discussions
Population is a Problem
This argument has roots in what is commonly called Mathusian thinking. Thomas
Kobert Malthus was an English clergyman and college professor. In 1 798 he wrote
a
essay in which pre proposed that the growth of human population will outstrip the
growth in food production , and thus population growth needs to be checked. He
argued that while food production increases in arithmetic progression (12 3 4 )
human population increases in geometric progression (1,2,4,8 ). In this’situation there
will not be rood for all. The checks that he had proposed, being a clergyman were
mostly restricted to moral restraint.
While Malthus’ original fear that food production will not be able to keep up with the
gro wth of human numbers has been unfounded due to rapid progresses in agricultural
technology, an extension of this logic is still being offered by a.group of thinkers who
are now called neo-Malthusian These writers have been looking at the natural
resources of the world as a whole and feel that the earth’s natural resources will not be
able to support the growth of population and call for public policies to restrict the
growth of population. National Family planning policies and programmes that different
countries have adopted were a result of this logic.
People are a Resource
This stream ot thought is diametrically opposed to the Malthusian arguments discussed
above. Marx and Engels had argued against Malthus that there can be no single law of
population increase and different modes of production tended to encourage different
situations They felt that capitalist societies would encourage large number of poor
people so that wages would be forced down. We can see a similar situation today
where countnes which provide most international aid for population control also shift
their production bases to the same countries because the labor rates are the cheapest
Many studies have also shown that the poor in different countries see greater
economicsense in the number of persons in their own family. Children provide solid
economic support either by taking care of household chores , thereby freeing adults to
seek other modes of income generation, or they even contribute labour in many
sectors- witness the carpet, bangle and firework industry in different parts of India.
Malthus had argued that such people who do not contribute as much to society as they
produced were a primary reason for the inadequacy of food supply. Marx and Engels '
had argued that each individual always produces more food than she or he can
consume. If we follow this logic than people are a resource , and poor people’s
behaviour all around the globe tends to prove this. But the problem of inadequate
resources still persists and we will examine this in the next argument.
I I
Population and Natural Resources
This is a very strong argument nowadays and has the sanction of environmentalists
around the globe. In a way it is an extension of Malthusian thinking and has been
receiving tremendous attention since Paul Ehrlich’s book “The Population Bomb” was
published. In this thinking the argument of food supply is extended to include all
natural resources and the argument correctly concludes that at todav ’s accelerated
rates of consumption, there is very little going to be left of the earth s natural resources
very soon. But what needs to be carefully thought out is that who consumes all the
resources. It has been conclusively shown with data from all sectors that the
consumption of natural resources is mainly a product of the extravagant Northern
countries ( the developed countries) and not the meager needs of the poorest nations.
The whole problem is more a question of distributive justice rather than that of larger
numbers of people per se. But even after such information has been available for a long
time now, these northern countries are extremely wary of cutting down on their own
consumption levels.
Turning a somewhat blind eye to their own consumption behaviour these countries and
thinkers have been involved in aggressively promoting Family Planning programmes in
the poorer nations of the world. The World Environment Conference at Rio in 1992
was supposed to be one platform where such issues were to be debated by all countries
but the final outcome has left much to be desired, in terms of commitments to reducing
levels of consumption in these countries.
Family Planning or Development?
It is often argued that the larger the density of population in a country the greater is its
population problem. It is also argued that the greater the density of people, the greater
the strain on the carrying capacity of the land. But then urban conglomerations have
the greatest density of people and they are also supposed to be the most developed. It
has now been accepted that just the reduction of numbers is not the goal but the
development of people. Family planning is supposed to assist in achieving this goal.
There is a great degree of disagreement as to what development implies, and we will
touch upon at some of these disagreements in the next debate. Even then there is some
agreement that life expectancy, mortality rates, literacy rates are some of the essential
indicators of development. And examination of figures across countries show that
there are many countries where the density of population is large but these are better
‘developed’ than others with much less density. Thus we need to look beyond absolute
numbers in terms of density to family sizes and fertility rates.
It is argued by some people that once social development (even in terms of the some
indicators mentioned above ) is promoted , people tend to regulate family sizes on
their own It is also true that the western world achieved population stabilisation much
before contraceptives were either available or aggressively promoted. Thus the state
should try to fulfil its obligations to health services ( prolong life and reduce death) and
education, especially for women and the population problem will take care of itself. It
is interesting to note that the leader of the Indian delegation to the 1974 conference on
12
Population in Bucharest had argued in a similar vein and the country started its
aggressive Family Planning programs very soon thereafter
Social Development and Population
Decline in population has long been held as major product of economic development
but increasing evidence gathered through the years is now challenging this opinion
According to evidences gathered in Kerala ( a favourite subject of scudy of
demograpners) and elsewhere it has been proposed that economic development is not
a necessary condttion lor population decline , but on the other hand the socio-cultural
milieu, education of women, position and status of women, increase in the quality of
life across age-groups, infrastructural facilities, efficient health services including
2ntraceptive senfvc^’hi8h cost
living etc are more essential factors in reducing the
desired number of children in families.
Since such a large number of factors affect the number of children in a family, the
study of population and fertility is increasingly becoming a multidisciplinary subject
with people with various interests becoming involved These include people from the
disciplmes economics, sociology, psychology, geography, public health, anthropology
women s studies and of course from mathematics and statistics. Social scientists
program managers and even activists from different fields who are interested in the
socio-economic-political development of people (especially the poor, have often got to
place their work in terms of the impact it makes in terms of the numbers of people or
me quality of their lives In such occasions a knowledge of demography comes in
Population and Poverty
In conventional development discourses population and poverty are seen as not only
interrelated but often as cause and effect. In this vision of things the only way to
economic growth is to control populations. And most population programs around the
world have started with this belief. But right from the time of Malthus it has been the
numbers of the poor that have mattered- it was never a problem of overpopulation of
the rich. Unfortunately this form of thinking makes the mistake of recognising the
symptom for the cause. That poverty is not the cause for overpopulation has to be
clearly recognised. In fact there are some countries which have successful population
control programs and continue to be very poor. In order to understand the reasons
behind the overpopulation of the poor one will have to understand why people are
poor and for this one will have to examine the structure of power- political power,
economic power, social power. One will also have to address the different structures
that keep these systems of power alive.
Population Control and Women
Population Control has been a major area of concern for women’s rights activists
around the globe. In fact much of the new understanding on population issues and
changes in population policies have been due to the concerted efforts of feminists
scholars and activists. PSome of the major debates and advocacy struggles will be
highlighted in the section
- 1 on Reproductive Health- Policy and Advocacy
13
Population Control affects the lives ot women very deeply because women are seen as
the mam party m procreation or adding to population Thus almost all population
control strategies have been focussed on women as targets of contraceptives- pills
injections, sterihsaUon operations and so on Women have also been long perceived as
1'Pi *
'
1
in different parts of the
world Thas attention that women have received as potential or actual mothers is in
mThewZZ tHe
Z W°men’S heahh haS reC‘eved in different ““"tries
X stZ
d a" rT3LV
t0 WOniCn’S health aCtivistS around the g|obe to ^ke
ery strong, and just.fied positions on population control ft has been argued by many
abZes a ZhT '
TT' P™"0"’ eCOn°miC conditi^, decision making
DO» . i™/r,
P
f'°rs
” ',“ber OfC“r“ she wi" »P'
n™
population control regimes focussing on temporary and permanent contraceptive
111 v-/11 Iv/Uo.
^cording to some authorities there are two main stands that women ususally take on
the subject of population control. These can be summarised as followsThe rad.cal viewpoint rejects all population control policies as being anti-people and
bemg promoted by western vested interests because they focus on the populatmn of
reZa^Z
f7PT “e °fthlS P°'nt °fview reJect the government’s role in
regulating the size of families, because it has often led to coercion and violence against
secomj1 nomtf685
r°le in welfare
people and of women.The
second potnt of view which may be called progress,ve calls for a feminist population
rights' ft cil 'f T
and f°CUSSeS °n W°men’S health' empowerment and
ghts. ft calls for framing of holistic population policies which include issues like
abortion, mfertihty, safe motherhood, free and informed choice in the number and
^spacing of children and access to contraceptives andI so
so on. This progressive view
point is the dominant voice in the international womeh’
-------- ’s health movement today.
Population Control and Family Planning
Very often these two words are considered synonymous The roots of this kind of
onto?^PneZPSF T
P'3™"8 iS
beSt
for PoPuiati°"
control. India s Family Planning programme explicitly and implicitly has long held this
view and whenever the words family planning are mentioned even in the latest
documents the idea of population control follows. It is true that if all families are
mvolved m planning their families then the population growth of the country (India for
example) will certainly start declining. But on the other hand what actually kis
happened is that with the objective of population control, coercive contraception has
often been practiced in the name of family planning. It must be clearlv understood that
res not d t T11 COntrO1,reVeals a H3110"31 concem while family planning is strictly
restricted to decision making at the family level. While family planning assists in '
population control the two are in no way synonymous
Population Discourse in India
14
,
'
country was too high was started in the 1930’s It was also concurrently argued that
India was the wealthiest country in the world with the poorest people, and the
Nationalise minded held that Independance would tilt the balance. At the same time
many organisations were founded on Malthusian lines and started working for family
planning and population control. Subhas Chandra Bose and Jawaharlal Nehru were
’
also strong advocates of family planning. The objective of most of these efforts were to
ensure greater socio-economic development. It must be noted that the initial impetus
to populatron control came entirely from Indian concerns for development. Later on
the programme and polices became influenced by foreign experts and donor
organisations which helped by introducing an extension based approach but also
introduced the much maligned target based monitoring system.
Much has been written about India’s Family Planning Programme - justifying its
successes as well as some of its major shortcomings, and the interested reader may
refer to some the excellent papers on the subject. But one thing that was becoming
increasingly clear that Family Planning and its targets was becoming an obsession with
the administration- right from Districts Magistrates/Collectors to lowly village level
functionaries. Under the pressure to obtain the right targets allforms of practices from
persuasion to pressure to blackmail was being used to get women under the surgeons
scalpel, while surgeon in many cases threw basic aseptic and surgical norms to the
wind to increase their tallies and records. In this hurry many women well past
menopause were sterilised, others underwent multiple sterilisations and unfold millions ?
underwent other major and minor complications. And almost all these were women. In
the madness of chasing family planning targets women’s health took a back seat
Despite some achievements in lowering birth rates India’s Family Planning programme
had begun to draw flak from within and outside the country, particularly from
women’s health activists who demanded greater attention to women's health needs and
a shift away from the method specific target fever which used to grip the nation
between January and March. The ICPD was a much needed boost to the concerned
citizens of the country because with it came many much needed changes in the
programme. These will be discussed in the section on Reproductive Health- Policy and
Advocacy .
No discussion on Population Programmes in India can be complete without a mention
of Kerala. Kerala’s performance in the population control front is seen as an oasis in
the other wise barren landscape in India. The various studies and articles on Kerala’s
remarkable demographic parameters have very clearly brought out the fact that these
were not due in any way to the National Family Planning Programme but to the socioeconomic-political conditions prevailing in the state. In fact comparing Kerala with the
program in China clearly outlines some of the shortcomings of a state sponsored family
planning programme for controlling birth rates and family sizes. Notably the position of
women in Kerala is far superior to that in China.
15
Section Three
Working On Population Related Areas
As has been mentioned earlier Population and Demography is essentially a
multidisciplinary subject and there are a large number of disciplines involved In India
the study of population has been particularly significant because of our large
population and in order to devise ways and means to control the growth in numbers as
well as finding development solutions There are many policy research and think tank
group engaged in working on the mynad of issues . Names and addresses of different
orgmsations working on the issue concerning population and demography from
different perspectives is given below. This list does not purport to be a complete list in
. any way.
Organisations working on Population related areas
Centre for Development Studies ,
Thiruvananthapuram
Centre for Operations Research
Training (CORT)
Centre for Social and Technical
Change (SOCTEC)
Foundation for Research in Health
Systems
Gujrat Institute of Development
Research
HEALTHWATCH
IIHMR
HM,Ahmedabad
Prashanthanagar, Ulloor,
Thiruvananthapuram,
Kerala-695011
405, Woodland Apartment,
Race Course Road,
Vadodra - 390007,
Gujarat
Ph-0265-326453/3260 3 4/336875
14, Bandstand Apartments,
B.J. Road,
Bandra (W),
. .
Mumbai-400050
Email- soctec-@giasbm01 .vsnl.net,in
6, Gurukripa, Apartments,
183, Azad Society,
Ahmedabad, 380015
Email-frhsad@adO 1. vsnl.net. in
Gota Char rasata,
Gota,
Ahmedabad-380481,
Ph-079-474809
________
C/o Vimala Ramachandran
10 B Vivekananda Marg,
Jaipur, 302001,
Ph-0141-360158
1, Prabhu Dayal Marg,
Sanganer Airport,
Jaipur-30201 1,
Rajasthan
Email- root@iihmr.sirdnetd.ernet.in
Public Systems Group,
I IM Vast rap ui\
16
Institute of Economic Growth
Institute of Health Systems
International Institute of Population
Sciences
Institute of Social Studies Trust
Minstry of Health and Family Welfare
Operations Research Group
Population Council
Population Foundation of India
Population Resource/Research Centres
of Different Universities and States
Tata Institute of Social Sciences
UNFPA
USAID
World Bank
Ahmedabad- 380015
Ph-079 407241
Delhi University Enclave,
Delhi- 1 100Q7
5-10-193, HACA Bhawan, Opp. Public _
Garden, Ground Floor,
Hyderabad- 500004
Email- his.ihsnet@axcess.net..in
in__________
Govandi Station Road,
Deonar,
Mumbai-400088
Ph-022-5563254-56 _____________ _
East Court,
Upper Ground Floor, Zone 6A,
India Habitat Centre,
Lodi Road, New Delhi 110003,
Ph- 011-4641083____________
Nirman Bhawan,'
New Delhi-110001
Rameshwar Estate,
Subhanpura,
Vadodra, Gujarat,
?
Ph-0265-381461/76 _________________
Zone 5A, Ground Floor,
India Habitat Centre,
Lodi Road, New Delhi -110003.
Ph-OJ 1-4642901/02
. ■_____________
B-28, Qutab Institutional Area,
Tara C resent.
New Delhi 110016.
Email-popfound@del2.vsnl.net. in
Sion - Trombay Road.
Deonar,
Mumbai 400088.
Ph 022-5563290_________
55 Lodi Estate,
New Delhi 110003,
Ph -011-4628877/4627702
Qutab Hotel Road,
New Delhi —110016,
Ph-011-6856301_________
New Delhi Office,
70 Lodi Estate,
New Delhi 1 10003,
Ph 011-4617241
17
RESOURCE SECTION
Books for Further Reading
As population studies and demography cuts across a large number of discilipes the
number and variety of books that one can read is consequently very large. Some of the
books we found useful were.
For understanding demography, particularly the technical side
fading Material for the Distant Learning Course for Master of Population Sciences of
tne UPS
For Perspective on Population related debates-
Desai Sonalde 1994,- Gender Inequalities and Demographic Behaviour India
New York , Population Council
**
• Dixon -Muller, Ruth-1993. Population Policy and Women’s Right. Transforming
Reproductive Choice . Westport, Connecticut: Praeger
Erlich, P R. and A.H. EInch. 1990. The Population Explosion. New York. Simon
and Schuster.
• Gaia Atlas of Planet Management , Pan.
• Heyser Noleen 1996- The Balancing Act- MacArthur International Lecture series
• Lappe, F.M. and Schurman, R. 1989. Taking Population Seriously. London:
Earthscan Publications Ltd.
*• Sen*Amartya - (Various books and papers)
.
• Sen, Germaine and Chen (eds), 1994 ^Population Policies Reconsidered: Health ,
Empowerment and Rights , Cambridge , Mass, Harvard University Press
•
Population situation in India -
•
•
•
Srinivasan K, 1995 ^Regulating Reproduction in India’s Population New Delhi
Sage Publications
Satia and Jeejeebhoy 1991. -The Demographic Challenge L A Study or Four Large
Indian States- Bombay, OUP
Anirudh Jain (ed) 1998-Do Population Policies Matt er - New York, Population
Council
Demographic Data about India
•
•
•
National Family Health Survey Reports (1992 -93) - UPS, Mumbai.
Health Monitor (Annual Publications) - Foundation for Research in Health
Systems.
District Census Handbooks and data on Floppy
18
JournalsThese are some of the Journals that carry articles about demography and population
studies.
• Economic and Political Weekly
• Reproductive Health Matters
• Population and Development Review
• Population Studies
• Studies in Family Planning
• International Family Planning Perspectives
• Demography
• Population Bulletin
• Demography India
• Population Reports
A
19
H " H • S
M
understanding
reproductive health
A Resource Pack
7'"
‘;‘f. .J.
•' • 'A
Booklet—' Three
V ••Ih'y'lL-'. ’
Y."
reproductive and sexual rights
1
'aAu
•v-.--xA:'U ;
SAHAYOG
•
y* ji-hJ
r.vA*,^.yir
o
o
i.UW
healthwatch
ACASH
AIDAN
Sama,
J-59, Saket,
New Delhi 10017,
Phone -011-696 8972
Email- magicLF@del.vsnl.net.in
C/o Vimala Rairiachandran.
10 Vivekananda Marg,
Jaipur -302001, Rajasthan
Pn 0141-360158
Email-vimalar@ip01.dot.net.in
Servants of India Society Building 2'nd
Floor,
Opp. Harkisandaas Hospital,
V P Road, Girgaum,
Mumbai-400004.
C/o Mira Shiva,
A-60 Hauz Khas,
New Delhi-110016.
International Organisations
There are a number of groups working on the Health and Rights Approach, outside the
country , contact information of some of these is given below:
HfRA
DAWN
WEDO
Catholics For A Free Choice
C/o IWHC, #
24, East 2'1 ’* Street, 5th Floor,
New York, NY 10010, USA.
Ph- 2112-979 8500
Email - hera@iwhc.org
C/o Vanita Nayak Mukherjee
429 Prasantha Nagar, Uloor
Trivandrum
Phone 0471- 442935
Fax 0471- 447137
E-mail - vanita@md2 vsnl.net.in
355 Lexington Avenue, 3rd Floor,
New York, NY 10017-6603,
USA.
Ph-212-973 0325
Email - wedo@igc.apc.org_____
1436, U Street NW, Suite 301,
Washington DC, 20009
Centre for Reproductive Law and
Policy, New York
USA.
Phone 202-332 7993
Email- cffc@igc apc.org
120 Wall Street,
New York NY 10005, USA.
Ph-
Stru^les against violations
Forum For Women’s Health, Mumbai
Sahdi, New Delhi
Jagori. New Delhi
Sakshi. New Delhi
c/o Swatija Manorama,
9. Sarvesh,
Govind Nagar,
Thane (East),
Maharashtra, 400 603
Tel.5423532_______________
Unit Above Shop 105-108,
Defence Colony Flyover Market
(Southside),
Defence Colony,
New Delhi 110 024
Tel. 4616485 (Wed & Sat)
C - 54, South Extension Part II,
New Delhi
Tel.- 01 1- 6257015
Email- system@jagori.unv.ernet.in
B-67 First Floor,
South Extension Pan I,
New Delhi- 110 049
Phone 011-462 3295
Fax-011 -4643946
Advocacy with Community, State, Legal System
Sahdi______________
Forum For Women’s Health
SAHAJ
CEHAT
WAH!
SHODHINI
See above_____
See above _______
1, Tejas Apartments
53, Haribhakti Colony, Old Parda Road
Baroda-390 018
Phone 0265-340223
Fax 0265-330430
Email - sahaj.wcost@m
l.sprintrpg.ems.vsnl.net.in___________
2nd Floor, BMC Maternity Home,
135 Military Road,
Bamandaya Pada,
Marol, Mumbai -400059
Phone -022-851 9420
C/o CHETNA,
Lilavatiben Lalbhai’s Bungalow,
Civil Camp Road,
Shahibaug, Ahmedabad -380004
PhEmail- chetna@icinet.emet.in(?)______
C/o N.B.Sarojini,
J
J
v
Kumar, R. Reproductive Rights As Human Rights' Studies in tM a •
Hamilton University of Waikato
es ln the Asian Context.
Kumar Radha.1997. The History of Doing: New Delhi Kali for w
Lindahl Katarina. 1995. Sexual and Reproductive Health and R J
ICPD 1994 Sweden. RFSU.
ouucuve Health and Rights in relation to
Petchesky, R.P. and K.J. 1998. Negotiating Reproductive Rights. London: Zed Books
Rehman Amka, Raghuram Shobha. 1995. Rethinking Ponulatinn t u- ,
Senes 1.4 Bangalore . HI VOS, and New York. CRLP
’
'Cal RepOrt
Tribune
1998 RlghtS ofWomen- New York: The Internationa] Women’s
SeXU^and
reproductive HeakhTogramm^nS
iXpTT"1 andHuman Rights- New York: UNFPA.
werment’ - lale
WOfnen ' A Pub,ic Health Priority: New
York: UNTPA
Whelan, D 1998 Recasting w7rn
'
,ss“K
St
H"^'h Association of India.
8hK ApprMch Wa!h^o":
Resource People and Organisations:
'hecommumty, with the government, and the legal systert
’
W
Some people and organisations include.
Support systems:
TARSHI, a telephone helpline in New
Delhi, on Reproductive and sexual helath
and rights.
Talking about Reproductive and Sexual
Health Isues (TARSHI),
49, Golf Links, 2nd Floor,
New Delhi 110003
Pnones-011-462-2221, 4624441
RAHI, a centre for survivors of CSA and _ Email-radhi@unv, ernet. in
Recovering and Healing from Incest
Incest
(RAHI),
M-79, Greater Kailash-II, 2nd Floor,
New Delhi 110048
Ph- 011-6238466,
LEmai^rahisupp@del2 ysnl net in
RESOURCE SECTION
Further Reading
The following books and reports were useful in preparing this booklet
----1995. Global Report on Women’s Human Rights. Washinston Human Rights
Watch
°
Akhter.F. et.al. 1991, Declaration ofCormlla. Dhaka: UBINIG
Anthony M.J. 1996 Women’s Rights : New Delhi Hind Pocket Books
•ARROW. 1994- Towards Women-Centred Reproductive Health - Part 1
KualaLumpur. ARROW,
Asian Forum for Human Rights and Development, The. 1997. Reports of a
Consultation on Reproductive Rights and Human Rights: A Challenge for Human
Rights Activists. Bangkok: The Asian Forum for Human Rights and Development.
Canadian Women’s Committee on Population and Development 1996.Bill of Rights
for Contraceptive Research, Development and Use. Canada: Canadian Women’s
Committee on Population and Development.
Capoor, I. Et.al. Realizing Gender Inequality and Empoerment for Meeting Women’s
Reproductive Rights. Ahmedabad”: CHETNA.
Centre for Reproductive Law and Policy, The. 1999. Silence and Complicity: Violence
Against Women in Peruvian Public Health Facilities. New York: The Centre for
Reproductive Law and Policy.
Centre for Reproductive Law and Policy, The. Reproductive Freedom Around the
• World: Reproductive Rights in the Refiigee Corftext. New York: The Centre for
Reproductive Law and Policy.
Coordination Unit. 1995. Indian NGOs Report on CEDAW. New Delhi. CU
Dutta, B. 1997. Advocacy for Reproductive Health and women’s Empowerment in
India. New Delhi: Ford Foundation.
East and South east Asian Women and Health Network. 1996. On Our Own terms:
Building Trust and Unity on Women's Health and Reproductive Rights from the
Perspective of Asian. Philippines: East and South east Asian Women and Health
Network.
Gomez, A. and D M. 1998. A Human Rights Perspectives: Women, Vulnerability and
HIV/AIDS. Chile: LACWHN.
Gupta Anuja . 1998. Voices From the Silent Zone New Delhi: RAHI
Gupte. M. et.al. 1997.We Shall Bring in the Dawn: Women Resisting Alcoholism
Pune: MASUM
Harden, A. and E. H. 1997. Reproductive Rights in Practiced Feminist Report on
Quality of Care. London: Zed Books Ltd.
Hardon.A. et.al. 1997. Monitoring Fammily Planning and Reproductive Rights: A
Manual for Empowerment. London: Zed Books Ltd.
Heise. L et al. 1995. Sexual Coercion and Reproductive Health: A Focus on Research.
New York: Population Council.
HERA. 1998. Women’s Sexual and Reproductive Rights and Health: HERA Action
Sheets New York; HERA
Jayawardena,K. and M. De A. 1996. Embodied Violence Communalising Women’s
Sexuality in South Asia. New Delhi. Kali for Women.
I
i'
Areas for Research
More information is needed on various forms of violations of RSR the
provST063 b°th PhySiCal
mentai’
tHe effectiVeness support services
safemoffierhoo^5 h'r?" violenCe agai^st women “d reproductive health, like
X— ofm,SCa™ge. comraceptlve „se.
•
Incorporate data on violations of women’s RSR in
health data and crime statistics
compilations .
Research on imale
’ contraceptives, women- controlled barrier methods, eapeciaily
for disease prevention., on contraceptive safety
Law and Policy Advocacy:
' mXOn„"geXROf ™"e"'S °rganiSa,iOnS ,0 Pro“”K
such as husband or male family members)
*
Reform existing laws to eliminate sexual violence, including rape within and out
fem“!ticid / mfSIt7t‘°nS °f anned °r communal conflict, CSA, trafficking and
remaie foeticide/ infanticide.
6
Enforce laws that regulate age at mamage and sexual activity to allow for informed
and consenting relationships.
mrormea
•
Remove reservations to human rights instruments such as CEDAW ( '
(the GOI
as a reservation on ‘interfering in marriage or other cultural institutions’).
Organisations working on Reproductive and Sexual Rights
A detailed list of organisation working on the issue along with their addresses is
provided in the Resource Section.
uuresses IS
•
Given women’s reluctance to report the abuse they have been suffering, it is up to
health service providers to be keenly alert to the possibility that their clients have
been abused. Many of the consequences of violations of RSR such as trauma,
unwanted pregnancy, abortion complications, miscarriages and STDs are likely to
ccme up before service providers. It is imperative that they understand these rights
and are motivated to monitor their violation by collecting leual evidence for
prosecution. It is also imperative that they ensure privacy, confidentiality and
sensitive treatment during examining and counseling. For this RSR should be
incorporated in the training courses.
•
Set up hotlines, crisis centres, shelters and rehabilitation homes which can be
accessed by women whose rights are being violated. It is imperative that these
provide a secure, non-judgemental, friendly atmosphere so that women start
healing from their emotional trauma.
Educational Interventions:
•
Adolescent boys must be taught that violations of women’s rights is not part of
male prerogative, and enabled to develop a concept of male- female relationships
that are not based on inequality and power imbalances, but are mutually respectful
and harmonious. It is also important to work with adult men on this through social
norm setting in communities.
•
Both boys and men should learn about their responsibilities in women’s
reproductive lives, especially about preventing unwanted pregnancy and disease
and also about when to seek out referral health Services.
•
Sexuality education has to be provided at ail age groups (no children are too
young, given the reality of CSA) that affirm the principles of gender equality and
bodily integrity, as well as inform about RSR. This has to be provided in both
formal and informal education, and through all possible youth groups. The positive
aspects of sexuality need to be highlighted, rather than projecting only the need for
preventing disease and pregnancy. Moreover, it should not be prescriptive: instead
it should encourage youth to develop a sense of responsibility about their bodies
and their partners .
•
Sexuality education should include aspects of reproductive and sexual health, the
tact that women s reproductive rights are human rights, the fact that the man’s
sperm determines the sex of the child, about where to access services, how women
can protect themselves from harm, women’s right to decide about sex, and what
to do if RSR are violated in any way.
•
Training and education on RSR is also urgently needed for health service
providers, educators, lawyers, police and judges.
•
Mediapersons also need to be sensitised to portray violations of women’s rights
responsibly, with full confidentiality, without sensationalisms them, but ensunns
that the public concern is aroused.
Section Three
Programmatic Implications For Working On RSR
Work for Reproductive and Sexual Rights may be done at several levels such as
thT'Xhts an03110^’6^^011' Ia'r/P°licy advocacy and so forth- is distinctive in that
health e rt I
.
s65 ; qUeStl°n °f WOmen’s entitlement - entitlement to
health, especially reproductive and sexual health, and the responsibility of social
mstitutions to ensure those entitlements, including the family, the community the state
“2" S ™ ery and ” “The
wro*ch' ™*"s ,l“
XX
SSESBSSSEi
amily. This is a protracted and exhausting struggle, for many of these wrongs have
as e^s th^ h°m
W°men
n§htS * a11’in fact theV are seen
as less tha. human, because they are not men. Addressing the legal svstem or the state
for redressal of wrongs is often futile, for these institutions do not have the ‘rights
perspective to begin with, and tend to offer paternalistic protection to women at the
wom116’^0^ ,mPTnt t0 W°rk t0WardS buiiding 3 wid^pread understanding of
women s rights as human rights, and this has to be done.not just with those who
^XTorT"’
WOmen themSe,VeS'
is because a "Cannot
beexercsed or demanded if the person is not aware of it to begin with However it
Xse a't h^1
'hat W7k WhiCh addreSS6S VCry perSOnal c’uestions of sexual’
buse home, domestic violence, sexuality, sexual relations and reproductive relations
like lackoT"? W d neV6r bVS aCCeptable as work which tables ‘external’ issues
hke lack ot water, education, housing, healthcare, and so on, which are problems in
the public sphere. Tins includes acceptability even with women, who are^he suffering
roserrc^ord"6 “h*
research or advocacy.
RSR thr°Ugh ServiceS’ educatl0^
Providing Services:
Ensure access for all women to high quality reproductive and sexual health
meTaet T
t 8e’
StatUS’
Or Sexual ^^tation. This would
mean actively reaching serv.ces to currently underserved groups such as
adolescents, single women, sex workers, women who/whose partners have
undergone stenhsat.on, post menopausal women and survivors of abuse.
‘
^7„h0,U“‘ ” ,he ‘T5'inClUde Ski"ed
d“rin« P"W-«very and post
p rtum, contraceptive choices including user-controlled and barrier methods ?
prevention, diagnosis and management of infertility/ reproductive tract problems/
b I Ds/reproductive system cancers and safe abortion services
However, these are more like prisons, and inmates are treated as ‘bad’ women who
ha. e pursued a socially unacceptable profession. As such, there is very little scope for
humane psychological and economic rehabilitation.
If we look at domestic violence in India, one horrific form that has attracted public
attent.on since the seventies is violence related to demands for dowry from the girl’s
foaily, even to the point of murder. Despite the Dowry Prohibition Act (1961) and the
Cr.me (Women) Cell which had been set up in 1985 (as the Anti- Dowry Cell) the
omv improvement .s that more crimes are being reported, which does not say much
for the actual decrease in the incidence of such violence. Apan from these is general
routine inter-spousal violence. It is prevalent to the point that it is accepted by all
concerned as something the husband definitely has the right to do. In several areas it is
connected to alcohol abuse by the men. The Criminal Law (amendment) Act of 1983
maxes cruelty to a wfre a cognisable, non- bailable offence, and includes mental as well
as physical harassment. However, since women usually cannot visualise any other
options besides living with their husbands, this law is not used as often as it could
have.
Rape is one of the most common and frequent crimes against women in India It
includes the categories of landlord rape, police/custodial rape, caste rape, army rape,
communal rape, marital rape, rape of sex workers, of children and family members
There are mcidents of mass rape, of an entire community of women, and of course
individual rape. However, rape remains an extremely under-reported crime Since
most, if not all rape is an assertion of power and rights over the women concerned
aiming to hit at their most vulnerable sense of‘honour’, it is not surprising that
women and their families often attempt to cover Uf5 the incident to avert the stigma.
Moreover, rape law in India insists that only p'enile penetration constitutes rape and
demands proof of guilt; all other forms of sexual violation are termed as assault, which
is a lighter offence. It is only in custodial rape that the onus of proof is on the accused
Then again sex with minors of 16 years or below is taken as rape, but the law
contradicts itself in that if a man has mamed a girl of 15 years or more, he can legally
hax e sex with her (although the legal age at marriage is 18!). Another serious issue is
of women in situations of armed conflict such as in the North East and in Kashmir
Civil rights have been suspended: the army has the authority to enter people’s homes
to flush out insurgents, and has raped and assaulted women with impunity
undergo foetal sex testing and abort any number of female foetuses because of social
pressure to give birth to sons. And yet, if she undertakes an abortion for contraceptive
Ssa^prov^erCed
She 'S unable t0 speak °Penly about 4 for fear of social
The .ncdence of ch.ld sexual abuse (CSA) and incest has remained shrouded in secrecy
and silence for long, but a recent study of 600 English speaking, upper or middle class
Th
'n ; metr°P01lses of India’ revealed that 76% had been sexually
abused m chddhood or adolescence. 82% of the abusers were either family members
Person^ known to the girl. Male cousins and uncles account for 84% of the abusers
45 /o of the abuse took place between the ages of 4 and 12 years. All this when 60% of
the mothers were housewives (RAHI, 1998). These chilling statistics about a
pnvilegec class of women leave questions hanging about what may be happening in
sTnce6 a S hOmeSwh"re PerhaPS ,eSS attention is
to the girl child. However
since a high premium is placed on virgmity in Indian society, no on would want to
publicly admit that they have been. At present, the Indian legal framework only
recognises penile penetration of children under the law for ‘Rape of Minors’ Other
torms of sexual violation are not recognised .
Amo
haS been PreVent6d by the 13W Called Chlld Marriage Restraint
Act (1978) that sets the minimum age at marriage for women at 18 Four states in
India have the average age at -effective’ marriage either below or at 18, and all the
eTPLKera a
19 or 20 (Re8,strar General of India, 1994). This actually
r
hOu sc c)f t h c i ti I h r n
. i
|
ft'*
displacement
to
the
house of the in-laws is counted
as the
age of‘effective
marriage’ (While
it mav be
argued that tins protects the girl ch.ld from early sexual activity and pregnancy 7t sti1
means ,ha. mam.ge ,s taking place al an age when she is unable to s JU™ed
“ ?w 1 7" ,°f S” ““ be'Ween '5 “ ' ’ ar' gained Xs.
992-93) It we look al ctaldbranng, 17"/. of total fertility is accounted for by birth
ar.^h8'0''1’,1.,5 '0
°f,he gi'IS h"”"" ,3'19
marneu, ^8/0 are either mothers or pregnant.
Trafficking in girls and young women continues to flourish in the poverty- stricken
zones of the country ( 86% of the sex workers are from UP, AP, Tamil Nadu
W.Bengal. Karnataka and Maharashtra) and there is also influx of girls sold into
Proat‘tutlon from Nepal and Bangladesh, who end up in the established red-light areas
of metropolises. According to a Government of India survey done in 1991 there are
around 70.000 to 100,000 girls and women engaged in prostitution. Younger virgins
are espectahytn demand because of a popular belief that sex with a virgin can cure
s I Ds. 15 o of the sample surveyed (500) were below 15 years, and another ?5%
between 16 and 18. Also interesting is that 60% were from scheduled castes and tribes
or backward classes. The current legal provision for this is called the Immoral Traffic
Prevention ) Act, 1986, which does not seek to abolish prostitution or even puZ
client who asks for commercial sex services, but certainly penalises a sex worker
for soliciting m a public place. It does make procuring and brothel keeping an offence
but protecuon money is pa.d by brothel keepers to local ‘toughs’, police personnel ’
d to politicians creating an .mportant source of income for the underworld As far
as the question ot rehabilitation goes, girls and women rescued or arrested are the
responsibihty of protective homes, correction institutions or rehabilitation homes
"d
n?,dS Th're haS b'en aa resurgence
resurse“e ot
orinteio®
diseases
infectious diseases
Uhicn reflects this. A major dilemma is how to address women's reproductive health
----j women s reproductive health
needs when the primary health infrastructure i*s ’n this appalling state, and budgets for
health have been cut back (Sen, op cit.)
HSsSSiirSSSxS
(18/,.), haemorrhage(16/o), and unsafe abortions (12%) (Id). Maternal morbidity is
projected to be 15 to 16 times higher than the number of maternal deaths All this in a
country which has had a programme for maternal and child health for a long time and
where abortion has been legal from 1972, apart from the fact that contraceptive
provision has started as early as 1952.
11 bK, °TeS °iV1OUS that mere launching Of wropnate-soundmg nrogrammes will not
enable the millions of poor women in India to ‘attain the highest standard of
reproductive health’. In fact, given the current scenario, women’s right to life itself is
being violated, for they are unable to access life-saving healthcare / referral services.
There are many reasons for this, one being state apathy, echoed in the indifference of
government service providers. But there is also women’s lack of newer to make
decisions concerning their reproductive health care, their lack of economic decision
making, their inability to negotiate contraceptive use in a patriarchal society and low
literacy and mobility which prevent their access to information which could have
protected their health and lives.
At present, the government has announced the ‘-Reproductive and Child Health (RCH)
Programme’, which is supposed to ensure a certain standard of reproductive health for
women by providing services for safe motherhood and child survival, family plannning
safe aoortion, management and prevention of RTIs, STDs, and prevention of AIDS : ’
all this for the ultimate goal of‘population stabilisation’! (MoHFW 1997) Two years
down the line, it is difficult to assess impact as there has not been very much progress
in implementation, or even in service provider training, for that matter. The programme
has possibilities, but in the absence of political will to address women’s health needs,
may not be able to bring about much change.
Violarions of women \ sexual and reproductive rights
Looking at violations through the life-cycle approach, the practice of aborting female
foetuses by determining the sex of the foetus through amniocentesis or ultrasound
scanning reflects strong son preference in a highly patriarchal society. Although it is
against the law, there are enough unscrupulous clinincs flourishing throughout the
country to ensure this ‘service’ to all who desire and can pay. Iromcally, while people
cannot access basic primary health care, and public health related information is unable
to reach large sections of our society, this ‘knowledge’ has percolated deeply even
into the rural areas. Doctors are profiting enormously from people’s anxiety to know
the sex of the foetus, and willingness to pay for late abortions. The same religion that
extols the virtues and necessity of having sons, also preaches about the ‘right to life’ of
the foetus (that is, against abortion). As such, a woman is always at fault: if she does
not produce sons, she is pitied, scorned, even abandoned. She may be forced to
on the experiences of other women, and nothing is known regarding contraindications
One ot the most detrimental factors in service provision has been the Hmited choice of
methods available. Women are expected to be mute recepients of whatever the
programme makes available to them. What is available is. decided on the basis of
programme efficacy, not on women’s needs and preferences. Those who have no
children can have the oral pill, those with one child may have the IUD inserted, and
those who have two or more children are given no choice other than sterilisation. In
fact, health facilities have been known to pressurise women seeking abortion into
accepting sierilisation (Sundari Ravindran, 1993).
Women’s health activists in India have been struggling against the government donors
and research msitutions that seek to introduce unsafe and heavily provider-controlled
contraceptives for Indian women, such as new hormonal technologies, transplants and
even the anti-malanal, Quinacrine! At the same time, non-invasive user-controlled
barrier contraceptives like the diaphragm or female condom are unavailable in the
country. Whatever testing has been done has often violated the right to informed
consent of the test subject, and has usually excluded women who are undernourished
or anaemic, although this is the charactenstic of most of the population of women in
this country Moreover, given the lack of adequate pre-examination and follow up by
the service providers, any invasive provider-controlled method is unsuitable
Resistance movements over several years have finally prohibited the promotion of
insufficiently tested contraceptives, but they are still being offered to women privately.
Despite the latest policies on the contraception programme, which declare that there
will be no more method-specific targets imposed from above, and announce a
community needs assessment approach’(GOI, MoHFW, 1998), there is no evidence
on the ground to support the assertions of a ‘client centred, quality of care, people
driven programme’ which goes beyond provision of mere contraceptive services to
providing care for reproductive health as a whole. The mindset of programme
managers and service providers has not been changed from their view that poor
women are incapable of making rational reproductive decisions
As such, while India supports RSR in providing free contraceptive and abortion
services to women and men, the interest has always been ‘population stabilisation’
rather than the health of poor women, and as such the quality and purpose of these
services remains questionable.
Healthcare services for safe pregnancy and childbirth.... the right to the highest
standard of reproductive health :
Illness and death from reproduction related causes are particularly significant for
women, but have been recognised only very recently in India. Estimates of the
percentage of Disability Adjusted Life Years (DALYs) lost by Indian women due to
reproduction related causes (maternity, cervical cancer, STDs, HIV) were as high as
10% in 1990. This does not include losses in the postnatal stage, or due to unsafe
abortion, or anaem.a, or malnutrition. Yet, public health and primary health services
are also in a poor shape, with large numbers of people unable to access clean water.
Section Two
Issues And Debates In India
When we look at the situation regarding RSR in India, we find on the one hand some
progressive legislation and policies, like
• the law permitting Abortion (something that women of many ’developed’ countries
are still struggling for ),
• laws prohibiting sex pre-selection and female infanticide,
• provision of free contraceptive services and free abortion services,
• government programmes for safe motherhood and reproductive health (including
RTIs, STD, HIV/ AIDS),
• shelter homes/ women’s police cells/family counseling units/National Commission
for Women,
• laws prohibiting child marriage and immoral trafficking
• and a secular state that does not persecute women on religious grounds
On the other hand, we also see several violations of reproductive and sexual rights ,
both by the state and society. This includes legislation against homosexuality, rape
laws that are inadequate in dealing with the problem or ensuring justice, lacunae in
dealing with domestic violence/ state-sponsored violence, and health policies that do
not provide for safeguarding RSR. A discussion on the actual situation of the ground
with respect to some of the crucial aspects of RSR is provided below.
Access to safe methods offtfmily planning... information and means.
reproductive decisions free of coercion, discrimination and violence:
to make
Right from the early beginnings of Family Planning programmes in the early 1950’s,
the main objective of population policy has been demographic control. The principal
victims of this of this approach have been women’s health and women’s rights. Acts of
commission such as the coercive use of sterilisation targets, incentives and
disincentives, and the introduction of contraceptive technologies without adequate
safeguards, and of omission such as ignoring the wide prevalence of RTIs and STDs,
the high incidence of cervical cancer, and the risks of unsafe abortions, have been all
too prevalent (Gita Sen, 1996).
Although a concern with reducing fertility has led to a national ‘family planning
programme that has provided some women with access to contraceptives, the
government does not adequately address the underlying socio-economic conditions
within which its women citizens live, and as such, its policies possess the potential to
aggravate the continued violations of Indian women’s rights.
Despite the millions spent on information, education and communication (IEC),
detailed information on the different contraceptive methods and their pros and cons is
still unavailable to the majority of women. What they get instead is a lot of propaganda
on why they should have fewer children. Knowledge of adverse effects is based solely
to unaont'''OlledUblee^ding.eHoodepeoisoniligSandndemh1aCpanefniP'eiheTltS
lead
Another harmful traditional practice involving girls is chilrt
l ures that set a premium on virginity or have a wpII d irnage'' Prevalen‘ >n
child would need less dowry) The child usuallv m ' entrencfled dc"wry system ( a
-pe with the pain and trauma of eady exu^J aS
°,der has *
and has to undergo pregnancy and childbirth S h
6 t0 neSOtiate safe se^
!ead to prolonged labour, obstructed birth tearing and lo^f '
Which COuld
bladder or rectum.
’
& and 'oss °f control over the
fape, and often faced
before marriage. Another vicious practice invnl 8
att‘tUde demands virginity
»,th acid when she refuses to recipZte“ b™8 theV
been happening in South Asian countries for some tim
trafficking in girls from poor families who are oft
-kers (CSWs), at an ag’e whe^
fr°m 3 man' This has
Hen again’ there is
—al sex
Physical abuse XhZ^Xn’d p^iyXXtb'"* w''"'""’
because they have been conditioned to think that this rs*?5'6'
also because they are dependent on their husbands ir X
X^ed prXciZ "
and
J
g° thTOUgh this
re'ations’ and
Xf”
—- -
used 10 -leaei, me„ a |e '„„ s „ee'
C''y lnd 50 °"- W‘™"’»
family, epan from a display of power e„rwomerX ’
“ 'h' 'l’OnOur' of her
severe ,„)u„es. including reproductive tZtta'X
'a
"™vors face
S-onr sexually transmitted diseases as well as seZi d"7"‘ pre>‘"s"'-'-'. infection
suicidal tendency.
dysfijnction, depression and
baXoSectives, the
RSR, like caste/ class/ religion based
police or armed forces, etc.
■d/iy act of gender based violence that results in, or is likelv to result in. physical
sexual or psychological harm or suffering to women, including threats of such acts
liZ^'t
dePrivatio"s ^f^erty. whether occurring in public or private
The international community also recognises the following forms of VAW:
physical, sexual or psychological violence occurring in the family and in the
community, including battering, sexual abuse of female children dowry related
violence, marital rape
’
J
• female genital mutilation and other traditional practices harmful to women
• nonspousal violence
• violence related to exploitation, sexual harassment and intimidation at work and in
educational institutions
• forced pregnancy, forced abortion, and forced sterilisation
• trafficking in women and forced prostitution
• and violence perpetrated or condoned by the state
I cannot be demed.that sexual violence is also faced by men, for child sexual abuse
also extends to male children, and adult males are raped in situations of vulnerability
such as the workplace, and educational or corrective institutions. But girls and women
face systematic discrimination from entrenched power relations that perpetuate the
almost universal subordination of females. This'leaves them constantly and highly
vulnerable to being harmed physically, sexually or psychologically by the men in their
families and communities. Unfortunately, while gender-based violence has been
estabhshed as a human nghts concern, much less headway has been made in addressing
VAvv as a public health issue.
If we look at the forms of gender-based violence from a life-cycle perspective and
their consequences in terms of women’s reproductive and sexual health we find that
women s nghts are violated nght from before birth until their post-menopausal years
A widely prevalent son- preference has led to selective abortion of female foetuses
and female infanticide, especially in Asia and North Africa. Girls in the 1 - 4 age
group have higher mortality rate than boys, reflecting neglect and denial of adequate
nutntion and healthcare. Child Sexual Abuse is another widespread phenomenon that
is rarely discussed, and little documented. One reason is that the abusers are frequently
known to the child and her family. Studies confirm that apart from physical trauma, '
children suffer from long term psychological effects that lead to low self-esteem
depression, poor ability to delay or even negotiate safe sex, or enjoy intimate ’
relationships.
Harmful traditional practices such as female genital mutilation ( FGM) involves
cutting off of the clitoris and the labia , sometimes even sewing the two sides of the
vulva together, so as to prove to the marriage partner that the girl is a virgin, and
needs. The right to informed consent has also been violated, with researchers and
service providers conducting invasive procedures on women’s bodies without
bothering to ask.
Further, w omen’s health advocates have viewed RSR in the context of present gender
dispanties according to them, ‘ a definition of RR must include women’s economic
political, legal, educational, and general health rights. It is only when these rights are
recogmsea as
having a focal role in their reproductive choices that population
and demographic patterns can be properly understood...’ (Shirkat Gah 1994) This is
because one of the key obstacles to women exercising rights over their own bodies is
their disempowered status in family and community decision making processes
RSR also stem from the philosophy and struggle of the feminist movement. As
Rosalind Petchesky said in a pre-Cairo women’s conference
“Four basic ethical principles lie at the heart of RSR: bodily integrity, personhood
equality and diversity. All four have both negative and positive applications - that is
ey involve both protection against coercion and abuse, whether by state officials ’
needs 3 PerS°nne ’ k'n’ °r SeXUal Partnersi as weil as the fulfillment of basic
Bodily integrity involves people’s rights not only to be free from physical abuse
coercion or violence but also to be enabled to enjoy their body’s foil potential for
health, procreation and (safe) sexual pleasure.
™
10
“ P"K'Pal «"• “d d“isio"
makers matters of reprodeetton and sexuality; as subjects not objects, of medical
social and family planning policies.
Reproduce and sexual quality - both between women and.men and among women
' t d°J10K °n 7 W'th Pr°hlbltlng dlscnmination but also with providing social
justice and the conditions of development..
g
Finally, the diversity principle, requires respecting the differing values needs and
n^ZZTf
W°men '
i" CU*tUre’
’religi0n’Sexuai orientation, and
abonahty - but as women themselves, not male kin, politicians, or religious leaders
who define those values, needs and priorities.(Petchesky, 1994)
^Zknow^-aSS^
‘3
§
iS n° ngh‘if th0Se for whom * is meant
i "foe resnoand lf services
not Prided to ensure its enjoyment.
t is the responsibfoty of governments and organisations.... to ensure that individuals
and couples are given access to both information and services. In addition to this
ocieties should make all effort to free their citizens of practices, taboos and
constraints which deny them other reproductive rights and freedoms’. When
governments seek to deal with some of the most private and intimate aspects of
people s lives by not ensuring informed consent and by providing women with
inadequate and inaccess.ble services, they are infringing women’s reproductive rights.
Violations of Reproductive and Sexual Rights
nfo.XClUSiVe?nUS
CUlpab’lity °f the St3te f°r inadequate reproductive health
r attehntl°nkfrOm S°Cietal resPon^dity for pervasive violations of
en s RSR. Yet perhaps the most consistent violators of women’s rights can be
individuals and family members. There are also deep-rooted cultural practices that are
sy“ns,,, ,o ,iberty and
»t,“
~ <>f
Perspectives and Struggles of the Women’s Health Movement
The women’s health movement has had to struggle against several fronts On the one
hand were the demographers and planners? who felt the goal of reducing population
growtn justified coercive, and sometimes downright dangerous means On the other
hand were religious fiindamentalists, who opposed contraception, abortion sex
education, and promote practices that restrict women’s education and mobility. Then
t ere v. ere countries that brutally sought to restrict women’s sexuality through
customs like Female Genital Mutilation. Besides these were the usual biases' against
single women, against including men’s responsibility, against providing services and
information to adolescents, and so on. The challenge was to negotiate differences
about morality ; of separating sexual behaviour from reproduction; and ‘freeing’ sexual
activity to the extent of ‘promiscuity’. Then there was also the school of thought
which held that given widespread poverty and lack of the very basic amenities, it was a
western’ luxury to talk of reproductive rights!
Stated simply, reproductive rights provide women with the freedom to control their
bodies and obtain needed health services. But reproductive health occupies the crux of
women s subordination and is really a ‘political question of choices and the right to
- choose', rather than a medical question of providing care for infections of the
reproductive tract or the urinary tract or through-sexual transmission. The key
challenge in the whole quest for reproductive rights is to address issues of power and
gender relations.
Women’s health advocates have viewed RSR as ‘constellations of legal and ethical
principles that relate to an individual woman’s ability to control what happens to her
body and her person by protecting and respecting her ability to make
decisions
about her reproduction and sexuality (Freedman, 1995). Yet respect for these rights
has profound consequences. All women would then maximise their chances of enjoying
good health, accessing quality reproductive health care, entering only into consensual
sexual relationships and deciding the number and spacing of their children by using safe
and acceptable contraception. But the right to control reproduction remains elusive for
most women. Their bodies are often pawns in the struggles among individuals,
families, religions and states. Women continue struggling to reclaim their bodies,
given the context of denial of some of the basic rights: to liberty, to security, and to
decide whether, when and with whom to found a family.
Moreover, when we talk of the freedom to access services, such services must be
provided in a context that respects women’s moral agency and that treats women as
principal decision makers in matters of reproduction and sexuality. Unfortunately, the
opposite has often been the case, and women have also been denied the right to access
contraceptive services or other healthcare, the right to quality of care, (including
counseling), apart from not being provided with appropriate healthcare for women’s
reproductive and sexual health and rights, and stressed the need to empower women
while increasing men’s responsibility.
Some definitions of Reproductive and Sexual Rights
A definition of RSR has been comprehensively set out in thelCPD Programme of
H^kh (RH^SH)"011 dr3WS fr°m thC eXp,anat'On ab0ut ReProductive and Sexual
(Art. 7.2) Reproductive Health is a state of complete physical, mental and social
well- being and not merely the absence of disease or infirmity , in all matters
Z ic ‘l the/epr°dUCtive SyStem and tO its factions and processes. Reproductive
Health therefore implies that people are able to have a satisfying and safe sex life
and that they have the capability to reproduce and the freedom to decide if, when and
how often to do so. Implicit m this last condition are the right of men and women to
be inftrmed and to have access to safe, effective, affordable and acceptable methods
offamily planning of their choice
and the right of access to appropriate
hea thcare services that will enable women to go safely through pregnancy and
childbirth..
Reproductive health also includes sexual health, the purpose of
which is the enhancement of life and personal relations, and not merely counseling
and care related to reproduction and sexually transmitted diseases.
(Art. 7 3) RR embrace certain human rights that are already recognised.
These
rights rest, on the recognition of the basic right of all couples and individuals to
ecide freely and responsibly the number, spacing and timing of their children and to
have the information and means to do so , and the right-to attain the highest
standard of sexual and reproductive health. It also includes their right to make
decisions concerning reproduction free of discrimination, coercion, and
°fthe responsible exercise of these rights for all people
should be the fundamental basisfor... policies and programmes in the area of
(Para 7.3 y Human sexuality and gender relations are closely interrelated and
together affect the ability of men and women to achieve and maintain sexual health
and manage their sexual lives. Equal relationships between women and men in
matters of sexual relationships and reproduction, includingfull respect for the
integrity of the human body, require mutual respect and willingess to accept
responsibility for the consequences of sexual behaviour.
SexuaJ RightsfSR) were firrther described in the Platform for Action of the Fourth
World Conference on Women (1995), which said:
(Para ^96) The human rights of women include their right to have control over and
decide freely and responsibly on matters related to their sexuality, including sexual
a,'d^Pr^duc,'ve hea,,h' free °f coercion, discrimination and violence. (After this, is
the K I D language from Para. 7.37 again, with the significant inclusion of the word
Section One
Understanding Reproductive And Sexual Rights
The History of RSR
The first statement of rights with regard to reproduction was at the UN organised
International Human Rights Conference at Teheran in 1968 which said that‘parents
have a basic human right to decide/ree/y and responsibly on the number and spacing
of thecr children and a right to adequate education and information in this respect’ The
catchword here .s responsibly', which left ample room for international organisations
and governments to carry out coerc.ve measures with the excuse that citizens had not
been responsible i This was veiy much on the agenda, since the dominant western
thinking in those days was influenced by Paul Ehrlich’s The Population Bomb which
presented a gnm picture of the global devastation resulting from unchecked population
growth (especially in Third World countries).
In 19 4, at the World Population Conference at Bucharest, there was a new element
introduced into the debate by developing countries, saying that development affected
population , rather than the other way around The Plan of Action adopted there once
again reaffirmed the earlier language with some changes: the word ‘parents’ was
changed to ‘all couples and individuals’, and to ‘education and information’ was added
the word means . Moreover, the element of‘responsibility’ was defined in some more
detail.
On tire other hand, by 1975, the international women’s health movement had
articulated its philosophy that every woman must have the right of control over her
body, ner sexuality and her reproductive life. This was in opposition to the movement
to control population growth (especially through focussing on women) in the Third
Worlo. At the International Women’s Year Conference in Mexico City, the earlier
language of the right to reproductive choice was firmly grounded on a notion of bodily
integrity and control: “The human body , whether that of a woman or a man is
inviolable and respect for it is a fundamental element of human dignity and
freedom”(Art. 11, UN, 1976). The Convention on the Elimination of all forms of
Discnmmation Against Women (CEDAW) codified the right of reproductive choice on the basis of equality between men and women”(UN, 1979)
By 1984, however, a strong Anti- Abortion movement had taken root, especially in the
US, and was calling itself the Tight to life’ movement, although women’s health
advocates saw it as ‘anti-choice’. This changed the attitude and funding of the US
Government towards population growth. Nonetheless , the recommendations of the
1984 International Population Conference at Mexico City urged that “governments
can do more to assist people in making their reproductive decisions in a responsible
way”(UN, 1984).
This was the context of the Cairo ICPD in 1994. Given the inequities between
countnes, different view on human rights, and strong pressure from the women’s
health movement, the conference was yet able to negotiate a document that
recognised the central role of gender relations in women’s health and rights, defined
INTRODUCTION
The term Reproductive and Sexual Rights (RSR) gained popularity after the
International Conference on Population and Development (ICPD 1994) althoueh ngnts’ language with regard to reproduction had already been used all’the way back
>n 1968 at the Intemat.onal Human Rights Conference in Teheran In order to
unaerstand the term Reproductive and Sexual Rights, we need to explore the meaning
of me expression
It conveys a sense of entitlement, airhough it cannot always
be taken for granted Th.s particularly so in the case of women's rights, which need to
be constantly defined and even struggledfor. The process of defining rights more often
than not stems from a perception of ongoing injustice. Yet, even when rights are
encoded, they cannot be assumed as a prerogative, and violations are more often the
rule than the exception.
When we reflect on the exercise of rights, some questions arise such as: do people
have rights before they are aware of them? Or is it imperative that rights have to be
known and exerased if they are to exist? Further, can rights be ‘given’? Or is it always
necessary for those deprived to struggle for them? Does society have any
responsibility in this matter? Moreover, can we understand rights if there have been no
wrongs 9 That is, must violations always precede acknowledaements of rights? These
are some of the fundamental questions that have to be answered if we are to work on’
any sort of rights, including reproductive and sexual rights.
.
Sexual and Reproductive Rights have been encoded in several international documents
, some of which are legally binding and some more in the nature of an agreement
between states. However, the ICPD document -was an explicit statement that brought
the term Reproductive and Sexual Rights into popular parlance. It marked a watershed
through which the women’s health and rights movement was able to generate great
impetus for its advocacy work.
This booklet provides some definitions and the histoiy of reproductive and sexual
rights. It also highlights their importance and deals with the aspect of their violation.
Further , this booklet also raises some issues and debates about Reproductive and
Sexual Rights in India, and suggests programmatic implications. At the end is a
resource section, giving a reading lists and some other information which may be
useful.
CONTENTS
INTRODUCTION
Section 1- Understanding reproductive and sexual rights
The history of RSR
6
Some definitions of reproductive and sexual rights
Perspectives and struggles of the women’s health movement
Violations of reproductive and sexual rights
Section 2- Issues and debates in India
Access to safe methods of family planning, information and means to make
reproductive dec.sions free of coercion, discrimination and violence
Healthcare services for safe pregnancy and childbirth, the right to the highest
standard of reproductive health
&
Violations of women’s sexual and reproductive rights
Section 3- Programmatic Implications for Working on RSR
Providing services
Educational interventions
*
Areas for research
Law and policy advocacy
Organizations Working on Reproductive and Sexual Rights
Resource Section
Further Reading
Resource People and Resource Organisations
Support Systems
Struggles against violations
Advocacy with Community, State and Legal systems
International organisations
2
4
4
5
6
7
10
10
11
12
15
15
16
17
17
17
18
18
19
19
20
20
21
3
?
International Women’s Health
Coalition, New York (IWHC)
^XRROW
IRRRAG
http://www.crip.orQ
24, East 21’' Street. S* Floor,
New York, NY 10010, USA
Ph-2112-979 8500
Email-___________
2nd Floor, Block F,
Anjung Felda,
Jalan, Maktab,
Kuala Lumpur, Malaysia
Ph- 603-292 9913
5 Email-arrow@po.iari ng. my
Hunter College,
695, Park Avenue, 1726W,
New York NY 10021,USA,
Ph-212-772 5682
J Enrail-irrrag@igc.aDac.org
Booklet prepared by
Research and text - Jashodhara Dasgupta
Review- Kranti, A bhijit Das
Understanding
Reproductive Health
A Resource Pack
Booklet - Two
REPRODUCTIVE HEALTH POLICY AND ADVOCACY
Changing Paradigms
SAHAYOG
1I
Engaging and Confronting
Saheli, Women’s Resource Centre
HEALTHWATCH
Forum for Women and Health
WAH!
Unit above Shop Nos 105-108,
Defence Colony Flyover Market,
New Delhi-110024.
.
C/o Vimala Ramachandran
10 B Vivekananda Marg,
Jaipur. 302001,
Ph-0 M1-36Q158______________
C/o Swatija Manorama,
9, Sarvesh,
Govind Nagar,
Thane (East),
Maharshtra- 400603,
Ph- 542 3532
C/o CHETNA
For address see above
Booklet prepared by:
Text: A bhijit Das
Review : Jashodhara Dasgupta
31
E - mail - sahayo^@ysnl.
SARTHI - Gujarat
SEARCH, Gadchiroli
C/o Dr Giriraj Singh
P.O. Godhar (W), Via Lunawada,
TA. Santrampur
Panchmahal-389 230 ( Gujarat)
Phone 02674-39306
C/o Dr Rani Bang,
SEARCH,
Gadchiroli Post,
Maha.rashtra-442 605.
Phone 0712-2403,2404
Training and Resource Support
AIKYA - Bangalore
CEHAT- Mumbai
CHETNA- Gujarat
SAHAJ- Vadodra
See above_______
__________ _____
2nd Floor, BMC Building,
135 Military Road, Bamandayapada, Maro ,
Andhri East Mumbai- 400059
Phone : 91-22-851 9420, Fax : 850 5255,
Email- cehat@vsnlxom
Lilavatiben Lalbhai’s Bungalow
Civil Camp Road, Shahibaug,
.Ahmed abad
380004, Gujrat
Phone : (079) 786 8856, 786 5636
email: chetna@adineternetin
^C/o Renu Khanna
J, Tejas Apartments
53, Haribhakti Colony, Old Parda Road
Baroda-390 018
Phone 0265-340223
Fax 0265-330430
Email - sahaj.wcost@m
1, sprintrpg.ems.vsnl.net. in
SAHAYOG - Uttar Pradesh
Sakhi- Kerala
VHAI - New Delhi
See above______
________
TC 27/2323,
Convent Road,
Trivandrum- 695001.
Ph- 0471-462251
Email Sakhi@md2.vsnl.net. in
Tong Swasthya Bhawan,
40 Institutional Area, South of IIT
NewDelhi-UO 016
Phone 0116618071,6965871,696295j
Fax 0116853708
33
Addresses of organisations involved in Reproductive Health and Rights Advocacy
Community Based Advocacy
ACTION INDIA- Delhi
AIKYA - Bangalore
ARTH- Udaipur
CINI- Calcutta
MASUM,
* - Pune
Kansari nu Vadavno (KnV)
RUWSEC - Tamil Nadu
SAHAYOG - Uttar Pradesh
C/o Gouri Choudhary
5/24 Jangpura
New Delhi- 110 014
Phone 01 1-4314785
Fax 01 1-4327470
C/o Philomena Vincent
377 Jayanagar, 42nd Cross, 8th Block
Bangalore-560 082(Karnataka)
Phone 080-6645930,8432363
Fax 080-6631565, attn. Aikya________
C/o Dr. Sharad Iyengar
67, Adinath Nagar, Fatehpura
Udaipur-313 004
Phone 0294-561150
Fax 0294-561150__________________
C/o Dr. K. Pappu
P O. Box- 16742
Calcutta-700 027
Phone 033-4678192. 4671206
Fax 033-4670241
E-mail- cini@cal.vsnl.net.in__________
C/o Manisha Gupte,
1 T, Archana Apartments,
163 Solapur Road,
Hadapsar, Pune -28.
Ph-0212-675058
Fax 0212-611749
E-mail- admin@masum.ilbom.emet.in
C/o Rahul and Subhadra
497 Sudama Nagar
Indore-452 009_______ ___________
C/o Dr. Sundari Ravindran
Nehru Nagar, Thiruporur Junction Raod
Vallam Post,
Chengalpattu-603 002_____ __________
C/o Jashodhara Dasgupta
SAHAYOG
Premkuti, Pokharkhali,
Almora-263 601
Phone 05962-32919, 33029
Fax 05962-32919,33029
2?
•
•
•
United Nations. 1995. Summary of the Programme of Action of the International
Conference on Population and Development. New York: United Nations.
VHAI. 1997. Report of the Independent Commission on Health in India. New Delhi
VHAI
World Bank. 1996 Improving Women’s Health ::n India. Washington. The World
Bank.
28
Isis International. Women's Perspectives on Population Issues ( Information kit)
Phillipines. Isis international.
• Jain, A. 1998. Do Population Policies Matter9 New York:
’' ‘ Population
~
• Council
• Kissling, F. 1997. The Vatican and Politics of Reproductive Health. London
Catholics for a Free choice
• Lombardi, K. and C.S 1999. Cairo+5. Telling th-ie Stories. Washington: The Centre
for Development and Population Activities.
• Ministry of H&FW. Reproductive and Child Healih Programme. India. Deptt. Of
Family Welfare.
• Ministry of H&FW 1997. Reproductive and Child Health Programme Schemes for
Implementation. India ; Deptt. Of Family Welfare
• Ministry of H&FW. 1998. Manual on Community Needs Assessment Approach. India
Deptt . Of Family Welfare.
• Mukhopadhyaya, S. 1998. Women’s Health, Public Policy and Community Action.
New Delhi: Manohar Pub.
• National Commission for Women. 1996. Development of Health facilities Among
Women Belonging to Scheduled Tribe Communities. New Delhi: NCW.
• Pachauri, S 1995 South and East Asia: Defining a Reproductive Health Package for
India a Proposed Framework. New Delhi: The population Council.
• SAlHAYOG. 1999. Voices From the Ground Almora: SAHA YOG.
• Saheli Women’s Resource Centre. New Delhi : Saheli Women’s Resource Centre
• Saheli Women’s Resource Centre. 1997. Quinacnne: The Sordid Story of Chemical
Sterlization. New Delhi: Saheli Women’s Resource Centre.
• Saheli Women’s Resource Centre. 1999. Enough is Enough. New Delhi: Saheli
Women’s Resource Centre.
• Sen'.G. et.al. 1994. Population Policies Reconsidered Health Empowerment and
Rights. SIDA.
• Sethi, G and M.C. 1996. The Reproductive Health Approach. New Delhi: Population
Council.
• Sharma, R.R. An Introduction to Advocacy Training Guide. Africa: SARA.
• Shiva, V. 1993. Minding Ourselves. New Delhi: Kali for Women.
• Subhadra and Rahul. Felicitating KANSARI: Bhil Tribal Women Battle Diverse
Patriarchies. Madhya Pradesh : KNV.
• UNFPA. Advocating Change Population Empowerment Development New York
UNFPA.
• UNFPA. Coming up Short: Struggling to Implement the Cairo Programme of Action.
New York: UNFPA.
• UNFPA. Population and Sustainable Development Five Years After Rio New york
UNFPA.
• UNFPA. 1998. Population Issues Briefing Kit 1998. New York: UNFPA.
• UNFPA. 1999. Partnership with Civil Society to Implement the Programme of Action,
ICPD, New York. UNFPA.
• United Nations. Report of the Ad Hoc Committee of the Whole of the Twenty First
Special Session of the general Assembly.
•
27
RESOURCE SECTION
Books for further reading
This is a selection of books and reports we found useful while making this booklet
Alcala, M. J. 1995. Commitments to Sexual and Reproductive Health and Rights for
All. New York: Family Care International.
• ARROW. Changes in Population Policies and Programme Post ICPD Cairo. A
Regional Research Project. Kualalumpur: ARROW
• ARROW. Gender and Women’s Health Kit. Kualalumpur: ARROW.
• ARROW. Towards Women Centred Reproductive Health. Kualalumpur: ARROW.
• ARROW. 1996. Women -Centered and Gender Sensitive Experiences Changing our
Perspectives, Policies and Programmes on Women's Health in Asia and the Pacific(
Health Resource kit). Kualalumpur: ARROW.
• ARROW. 1999. Taking up the cairo Challenge- Country Studies in Asia pacific.
Kualalumpur. ARROW.
• Ashford, R. and C.M. 1999. Reproductive Health in Policy and Practices. Washingtor
: Population Reference Bureau.
• Bharati, S. (ed). 1999. Risk, Rights and Reforms. New York. Women’s Environment
and Development Organizatuion.
• CEDPA. 1995. Cairo, Beijing and Beyond. Washington . CEDPA.
• Centre for Reproductive Law and Policy. Cairo+5 ( Kit). New York: The Centre for
Reproductive Law and Policy
Cenjre for Reproductive Law and Policy. 1995. Women of the World: Formal Laws
and policies Affecting their Reproductive Lives. New York: The Centre for
Reproductive Law and Policy.
• Chayanika et. al. 1999. We and Our Fertility. Mumbai: Comet Media Foundation.
• Correa, S. 1994. Population and Reproductive Rights. New Delhi: kali for Women.
• Correa, S.1999. Implementing ICPD: Moving Forward in the Eye of the Storm. Suva
Fiji: Development Alternatives with Women for New Era.
• Family Care International. 1994. Action for the 21st Century Reproductive Health and
Rights for All. New York . Family Care International.
• Family Care International. 1999. Sexual and Reproductive Health Briefing Cards.
Netherlands: Family Care International.
• Ford Foundation. 1997. Advocacy for Reproductive Health and Women’s
Empowerment in India. New Delhi. Ford Foundation.
• Germaine, A. and R. K. 1995. The cairo Consensus the Right Agenda for the Right
Time. New York: International Women’s Health Coalition.
• Hardon, A. et.al. 1997 Monitoring Family Planning and Reproductive Rights: A
Manual for Empowerment. London: Zed Books Ltd.
• HERA. 1998. Confounding the Critics: Cairo Five Years On . New York. HERA.
• HERA. Women’s Sexual and Reproductive Rights and Health. New York: HERA.
•
25
Campaign against Injectable Contraceptives
Women s groups in India have been very vocal against the introduction of Injectable
Contraceptives in the country The campaign started in December 1984 and is still
ongoing which illustrates the very dynamic and sustained nature of this campaign. During
this extended period the campaign has included dhamas, sit-ins at the Ministry of Health'’
and Family Welfare and ICMR, gherao of the Drug Controller, public interest litigation
reaching out to the public through posters, booklets songs and skits and even video The
success of this campaign can be measured by the fact that these contraceptives have not
yet been made part of the Family Planning programme For more information about the
campaign please get in touch with Saheli, Women’s Resource Centre
25
Confronting and Engaging -1 he third strategic option for advocates is to engage or to
confront the policy makers and implementors. For engaging the process one needs a
through understanding of policy making processes and the ability to interact with
bureacrats and ministers at the crucial time. For confrontation the advocates need the
strength of conviction and courage to stand up to even third degree measures. The m$dia
can be used as a use collaborator in such advocacv efforts.
In order to sustain an advocacy camapign there needs to be a coordination of all these
three approaches which is only possible through a shared goal, mutual trust between
actors and active collaboration.
Advocating for Change-Some Experiences
As has been listed out in an earlier section of this booklet there have been a number of
advocacy efforts for reproductive health and rights. In this section we will introduce four
different efforts which exemplify four different kinds of efforts at advocacy. Addresses of
all these organisations are provided in the Resource Section.
Kansarinu Vadavno (Kn V), Khargone District, Madhya Pradesh.
KnV is an organisation of Bhil women, which is named after the Goddess of Kansari. This
organisation has been involved in initiatives in the field of health, education, micro-credit
etc. But the women have also started taking their demands for better health through
campaigns up to the District and State Authorities. On the other hand they are also
negotiating with their own men for social control of alcoholism as well as the excessive
sexual demands of the men, especially under the influence of alcohol.
HEALTH WATCH
This was a national network started immediately'after the Cairo Conference by a group of
individuals who had attended the conference and wanted to assist in the process of
actualising the PoA in India. Today HEATHWATCH is very broad based and includes in
its core-group activists, researchers, established service deliver and training NGOs,
demographers and academics. The network has been involved in the last four years in
creating an understanding and awareness both about the TEA and RCH as well as the post
ICPD programme implementation around the country through series of consultations.
Women and Health (WAH) Network
Thw WAH! network has been active in first developing a clear Iperspective on women and
health and once that perspective was developed has been actively involved in
disseminating this understanding through training and advocacy. These training
programmes which have been conducted in South and West India have now helped in
creating a large number of organisations who are committed to this framework. Now the
network is involved in advocating for a comprehensive women's health policy for the
country.
24
organising communit.es and creating a widespread understanding and consensus on
sensitive issues like women’s position in society her nghts and entitlements, male
responsibility and participation and so on. Engaging in all these activities is not possible
lor any one actor and so ot us essential that interested parties themselves in engage
inbroad-based coalition building so that different people can focus on activities they are
best skilled at. Wh.le advocating and lobbying with the Government authorities for both
programme implementation and policy formulation has been visible, the other important
task of mobilising communities for demanding their nghts has not received much attention
in the sphere of Reproductive Health and rights. Some of the important areas around
which advocacy is important are :
• Broad based alliance building within activists, NGOs and other concerned actors
• Community based research and wide dissemination of the results
• Changing mindset ot the bureaucrats and health care service providers
• Open avenues for dialogue and partnership between GO and NGOs and with the
community
• Increase in botton-up planning, ensure accountability and transparency; involve
panchayats, especially the women representatives
• Increased investment in training, involve social sector experts in training; skill
upgradation of health personnel;
• Improving working conditions of ANMs and rationalising her workload
• Developing a strategy for involving men
• Generating a demand from women and the community for reproductive health services
and rights
Community based advocacy The challenge for community based advocates is to help
Mthe community especially the women articulate their own reproductive health needs and
demand their rights - from their families and communities as well as from service
providers and the Government. This as has been pointed out earlier , is easier said than
done, but a number of experiences all over the country prove that this is possible ( see list
provided earlier). These community based efforts need to incorporate many of the aspects
outlined above like transparency, bottom-up planning, involving men and so on. At the
same time these efforts need to be linked to other similar efforts and with national
campaigns and movements in the same direction.
Providing the background for change - That the situation of women in our country is
bad is well documented, but there are many aspects of women’s health and the denial of
their reproductive health which has not been adequately documented and many false
notions about the status of women’s reproductive health and rights persist. Similarly
people in the community accept their situation unquestioningly. The challenge for research
for advocacy is to bring to light these situations through throrough documentation to
policy makers and implementors as well to the community at large so that they make take
stock of their own situation and act accordingly. The other task of intermediary
organisations is to develop alternate modules for training to prepare new advocates at all
levels. I hese training modules may also be strategically used with Government
functionaries. This possiblity may sound attractive but may not be very feasible.
23
• Sakhi- Kerala
• VIIAI - New Delhi
( addresses are provided in the resource section)
Advocating for policy change with the Government - Besides creating an informed
community awareness on the issues of Reproductive Health and Rights an agenda which
has slowly emerged is that of advocating for policy changes or for effective
implementation of Government Programmes On this count there are three different kinds
of efforts which are currently being tried within the country. These three efforts are
characterised by different approaches but all three are spearheaded by activists and NGOs
There are some NGOs which are involved in all three efforts.
The first effort could be broadly termed as active conformation and litigation. This has
included successfully resisting the introduction of long-term hormonal contraceptives like
Depo Provera and Norplant or for Quinacrine. On the other hand the same groups have
also actively lobbied for introduction of legislation for banning sex-selective abortions in
which they were successful. Many of the activists involved in these efforts belong to wha
is loosely called the autonomous women’s health movement in India.
The second effort could broadly be called engagement and is being spearheaded by a
network of academics, activists, NGOs, demographers called HEALTHWATCH This
network was formed immediately following the Cairo conference and has the fulfillment of
the Cairo PoA as its main objective. Towards this end it has been involved in consultative
processes and conductive nationwide studies. The results of these consolations and studies
have been regularly shared with the Government. While there has been no explicit
acknowledgment of the contribution of HEALTHWATCH in the farming of the new
-“Target Free Approach, Reproductive and Child Healffi Programme of the CommunityNeeds Assessment Approach, members of the network have been involved in influencing
some of the changes in their independent capacities.
The third effort mentioned above is that of the Women and Health (WAH!) network. This
is a network of NGOs which are concerned about women's health. Its activities have
included consensus building among NGOs around the issue of a gender sensitive women
and health approach, training of community level NGOs in this approach and thereafter
lobby with the Government for a Women’s Health Policy. The WAH! Network is veryactive in the southern and western states of India. The success of WAH! lies in the fact
that a large number of NGOs are now pursuing a holistic women’s health approach in the:r
community based programmes and from that position of strength are willing to proposes a
framework for a Women’s Health Policy.
Stategies for Successful Reproductive Health Advocacy
Advocating for Women centred Reproductive Health is not just a matter of getting the
Government to formulate the right sounding programmes. It is a complicated issue of
building bridges with the Government, service providers, media, community leaders
9?
reforms. In recent tunes dowry deaths have g.ven rise to strong voices with.n the women'.,
movements decrvmg tins inhuman praet.ee In the case of contraceptives there have been
struggles agatnst the mtroduct.on of long-acting hormonal contracept.ves But m the case
of reproductive heal,. m general there have been no large scale or vehement demands In
the pertod before K PD, NGOs and women's groups organised a ser.es of parallel
consultations across the countr.es try,ng to take on board concerns of activist and grass
toots workers But at the same time organisations all around the country have in there
own way tried to dehne newer ways of addressing the reproductive health concerns of
women in the communities. A review of these efforts is given below
so strong and
been often more in terms of legal provisions rather than change in people's mindset In
such a situationthe importance of advocacy is two fold- raising consciousness among the
community to the issue and practice of inequity as well as with state systems to enaefand
implement new po icy. Where consciousness raising efforts are concerned in the sphere of
Reproductive Health these are primarily p.oneered by different community based NGOs
workmg on this issue. Their numbers are few, and they are far outnumbered by those
NGOs which are working primarily with either a very- Family Planning/Population Contro
oriented approach or a maternal and child health perspective. Some of the more prominent
organisations working on a reproductive health and rights perspective at the community
• AIKYA - Bangalore
• AR.TH- Udaipur
• ClNJI- Calcutta
• RU.WSEC - Tamil Nadu
• SAHAYOG - Uttar Pradesh
• SARTHI - Gujarat
• ACTION INDIA- Delhi
• MASUM, Pune
• SEARCH, Gadchiroli
Jh6S! °r^atl0ns f addresses g.ven in the resource section) are assisted in their efforts
by other NGOs which have developed their core competencies in traininu/documentation
tor community based workers and organisations in implementing effective Reproductive
Health and Rights programmes. Some of the more prominent NGOs providing training
and Resource Support are
°
•
•
•
•
AIK YA - Bangalore
CEHAT- Mumbai
CHETNA- Gujarat
SAHAJ- Vadodra
•
SAHAYOG - Uttar Pradesh
21
Section Three
Advocating for Reproductive Health and Rights in India
Reproductive Health and ( ultural and Political Challenges to advocacy in India
In the recent past lot of success has been gained in getting gender, empowerment of
women and reproductive health and rights incorporated at the policy and programme level
of the government and that of international development organisation but in reality many
of these changes remain restricted to paper and poor rural women continue to suffere
multiple oppressions, lhe International changes have been successful in changing the
language of the discourse but as far as the state is concerned, a lot of doubt remains abou
its intentions. 1 here is the fear that the state has adopted the rhetoric without adopting the
substance and this is even worse. The experiences over the last couple of years with
regard to the implementation of programmes by the different authorities strengthens this
doubt.
The other challenge in enabling women to achieve their potential reproductive health doe^
not lie in not having effective policies or programmes, but in their implementation. It is
with regard to this hurdle one has to consider the cultural traditions and biases existing in
different parts of our country. Patriarchy is by and large practised in most parts of the
country (except some notable exceptions), reproductive organs and functions of the
women’s body are considered polluted and shameful, there is a great degree of hypocrisy
surrounding matters relating to sexual behaviour. Added to this there are numerous
beliefs and practises concerning the smallest aspect of women’s lives, especially menarche,
< pregnancy, childbirth, childrearing, infertility, and^women’s health (especially reproductive
health problems). In such a situation enabling women achieve a state of health is not just c
simple matter of providing services and designing IEC programmes. The challenge is to
somehow change the deep-rooted centuries’ old traditions and unless we realise this most
efforts will not be very successful.
The problem of cultural biases is prevalent not only within communities at large, within
the women themselves, but also within the service providers who are supposed to provide
different social sector and health services to the community. In such a situation, just
assuming that a change in programmes will affect their behaviour is being very naive.
There are enough evidences in the last three years to show much of changes that have
been brought about by programmes are not being implemented in the spirit intended.
Advocacy efforts at the community level to change community attitudes and perceptions
becomes very important in this context.
A Review Current Advocacy Effort for Reproductive Health
There is a long history of social movements in seeking a better social status for women in
our country. Close on the heels of social movements has also been a history' of legislative
23
The ANM is the worker loaded with the maximum number of tasks, yet she is under
trained, hardly supervised or supported in the community, under-equipped with equipment
and supplies, and has to function often in very poor living and working conditions. Yet
the she is expected to provide the entire gamut of health services under the RH
programme Yet, there is also a Male Multipurpose Worker, who is not accountable for
much beyond condom distribution and promotion ot vasectomy Obviously, a resource is
under-utilised here, especially if we take into consideration how most RH decisions in a
family are taken by men, including decisions to seek referral care: This reflects an
underlying gender-blindness in the entire programme, despite the lip service; perhaps
following from basic lack of clarity as to 'why RH?’
I?
A second major anomaly is the definition of Rd I P >r|,
. .□
■strong, and the voice of women's health activists let? i P‘S le donor nudg'ng" was too
gomg ahead with a very limited definition and cal m.- Hrch ' a"'
?°' ‘S determ'ncdl'
exposition in the TEA manual puts it
'
C
As a rather mathcni‘itica!
KCH = IT t CSSM+prevention ofRTl/STD and AIDS
chent approach' to providing FW and Healthcare services.
This reductionism might be understandable in terms
,■ r •■
it omits several significant aspects of RH such as / ’
8 ear 'er tami,iar concepts, but
disorders, childlessness, prolapse uterus and so fortr^T^T 31
post’nlenoPau-s‘i|
ignores women's lack of reproductive rights male I TT' th'S approacb completely
access and gender. The underlying assumption
behavior, issues of violence,
married and m the reproduct.ve^age group wdl beT 'T '
W°men who are
dealing with unmarried or childles^ women old
8
There 'S 00 prov,sion for
widespread gender bias which depriX wOmer^of a T"' ad°,eSCentS "
Tht
» nol clearly addressed anywhere even as a factor affeeZg
In’heZ"
Se’‘U‘"
POli“'
°P™«satic„
and mid-course correction are absent All m
001 Clear’ f°r systems of feedback
community participation, rematns “ p "i,™™"'"8 'S ‘“y top-down Thus
services, not as active agents for empowerment in i'lff wT"”"
actors in the community in a consultative nmr
terms, is the paramedic worked Xto .e p
re“pien,s of
strateSies t0 involve key
SPeIt °Ut H°W’ in COncrete
extent that the 'Felt Need" actually gets alesseVtanT"""7 TT
s6™65 t0 the
Centre Action Plan?
tangib.x enough to feed.into the Sub
stakeholders. The earlier government attitude
service delivery contractorsteZl f
PPr°aCta Involvement of NGOs and other
t0
NGOs as cost effec^e
NGO identity in India has changed toward"1NG° r°leS
charitable work. Bui
development. NGOs have done nitneerinu ^7“^ training^ ^search and alternative
understanding RH HIV/AIDs gender and
forth, which L governmt^
V" ratIOnal d™s use’ alte™tive therapies,
-ual health and
only call in NGOs for programme imnlementadn
The government continues to
to avoid sharing information at the planning sta " aCr?OrdlnS t0 Pre-designed norms, and
women's health movement in India fs evin^ d
DeSp,te the existence of a strong
networks, thts valuable re ource has h
Y
°f dedicated NGOs and
A look at the RGHTh
" extremeIy underutilised
iook at tne KCH Schemes seems to belie this for
■
innovations, and resource provision for smaller NCn
0pp0rtunity t0 be ^ded for
Yet a closer scrutiny shows that the fi.nd
mG°S
tramed by 'mOther' NGOs
missing. NGOs are not invited to any platform for dill °f S°Ve',nment accountab.lity is
participate anywhere in framing the Sub-centre ActionX ""
S°Vernment'
d° the'
1s
An Assessment of the post-ICTD Policy Changes in India
Positives Signs India has undeniable taken its commitment to the ICPD POA quite
seriously I he combined effects of some nudgings from donors, and internal .voices
demanding change has resulted in a fairly dramatic shift from a policy position held for
thirty years There has been substantial documentation of the shift, with Manuals,
including I raining Guidelines, detailing the changes and new components. This does
provide a basis for common understanding nationwide. The intentions are laudable’
Quality of Care, Bottom-up Planning Community- Need based service provision, very
much in line with the ICPD outcome, as well as genuinely addressing the existing lacunae
in the FWP 1 he components of the programme also address some of the most pressing
RC H problems in the country, where women actually die of lack of these health services.
Anomalies While granting that the Cairo document presents an ideal to be attained only
after considerable struggle, there remain several anomalies in India's policy changes after
ICPD. Regarding India s policy shift even from even from the viewpoint of community RH
needs leaves a lot to be desired.
First and foremost the global swing away from 'demographic imperative' language was
achieved at ICPD by pressure from women's groups who demanded that women's health
concerns be given centrality. This resulted in accommodation of women's and adolescents
reproductive and sexual health, empowerment and rights on the global agenda. However,
this seems to have been left unstated in all the GOI documents. There is on the contrary, <
feeling that by ensuring healthy mothers and healthy children. 'RCH is even more relevant
for obtaining the objective of stable population for the country". Moreover, using of
<spacing.and terminal methods means “populationjs controlled in the short term". The TEA
Manual Introduction states clearly that' the success of the (Family Welfare)
programme
can be judged only on the basis of the reduction in the birth rate'.
While talking of a client centred demand driven approach, no clear roles is given to local
women for planning or monitoring at community level. Neither is the ANM or any other
worker accountable to local women. The only local women's group mentioned in the
Manual is the Mahila Swasthya Sangh, which seems primarily a recipient of health and
population education. The LHV is supposed to ask the opinion of community women but
in absence of an active group, this may not work. Despite mainly targeting women for
most activities, no systematic feedback is taken from them. As before women remain
"object" of the RH programme rather than partners.
This brings up the deeper issue of whether such a radical policy shift can be instantly
accommodated by such a large administrative structure as the government. Since the
government was not part of the women's health movement in the build-up to ICPD, the
policy announcement was fairly abrupt for the mass of medical, political and administrative
leaders, service providers and members of the medical professions all of whom have the
earlier 'population control' mindset deeply ingrained into them.
I7
that there will be no more top-down .mposition of method-specific contraceptive targets
for health and non-health government functionaries, and all incentives for motivators or
providers will be withdrawn, neither will there be assessment of any functionaries solely on
the bas.s of contraceptive targets,. What there will be instead are bottom-up planning '
processes, quality of care, and generation of community demand for services to make it a
people's programme
The components of the programme include mother care (including ante-, intra- and post
natal care), care ot newborns, immunisation, prophylactics for anaemia and Vitamin A
deficiency, contraceptive and abortion services, curative care from diarrhoea and Acute
Respiratory Tract Infections (ARI), and nutrition counselling and prevention of RTI/STD
and AIDs. While several components already existed earlier in the Family Welfare
the new prograrnme lnterventions include management of ARI, prevention of
KTI/STD/AIDS, and attention to emergency obstetric care
Manual And Training : The TFA Manual (1996) goes into a fair amount of detail to
spell out services and activities, outcomes and indicators, and procedures for planning ant
monitoring. The need for training and effective IEC are highlighted and there are formats
for monitoring and record keeping within the new approach. The concept of "Quality of
Care" is also examined in fairly minute detail.
The TFA Manual was followed by the "Training Plan Guidelines" to prepare in- service
district training plans(MoHFW, 1996). The Guidelines-stress the need for a ’change’ in
mindset of the health (care) providers, and that 'it is not only necessary for health(care)
providers to be technically sound but they will also~have to acquire necessary
communication skill
to satisfy the clients. There is an assessment of what went wront
in earlier programs, and suggestions for a 'Continuing Education’ approach utilising even
monthly meetings.
NGOs There is a significant difference between the TFA Manual and the Training Plan
Guidelines. In that the latter acknowledges the existence of NGOs are seen as potential
sites for skill training of ANMs, and as participants of community level trainings. The role
of NGOs within the new scheme of things is spelt out in detail in the third major postICPD document, the manual on 'RCH Programme - Schemes for Implementation'. This
document, in its chapter on NGOs, clarifies that the role of NGOs in RCH will be '
complementary in nature vis a vis the government and sets out three kinds of activities fo ’
NGOs.
• Community level advocacy and counselling for RCH.
• Screening, Funding, Monitoring and training's of smaller NGOs for RCH programme.
• Innovative programme under RCH (Baby-friendly hospitals. Mobile RCH services,
surveillance for Sex Detection Clinics etc )
Gandhi during the emergency As everyone know. ,h r
sterilisations were one of the main reason, k- u L " ,'nlcrgency excesses m (lie field of
'
'»«■> .... ..... ,h?amcnm'
ai,“
low-key activity but soon after Mrs. Indira CanHh ' mcd aS dmiiy Welfare) became a
sterilisation camps re-started with the new technofoT™^t0 P°Wer
volu,,tary
Women now were the mam targets for contm^
laParoscoPic sterilisation
vasectomy figures became negligible. Method snec’f?eSpeC'a ly ster,,|sations and
s
temporary methods but there were incidences of '
Were alS° lntroduced for th<'
were difficult to follow-up. Performance in Famihfpk miS'reportln« because tfl«e figures
key indicator of ranking States and districts and it u. anni"s pr^rammes also became a
the twenty- point programme.
included as an important feature of
scrutiny for its coerc.ve mefoods'Tnd n^n-aXtemenTof d^"35
'nCreasing
achievement of targets. Following the ICPD thp c .
demographic goals despite
of experts from the World Bank) started a process ofl"dl" (™‘l1 lhe “sistanct
expenmen,s in remoemp ,arge,s had startJ i„ T
N ^i'
**
removed targets in one or two districts in park
t • a
"2’ th Government
Government declared the entire Family Planning p
' "5 In Apnl 1996 the
that centrally determmed targets were no Ion. p
target free’ indicatmg thereby
which these changes had beeXogh, aboZXd mt,™" T?«h
years the name of the programme was nnrp a
u
°me con^JS,ons and within two
Assessment Approach to Family Planning ColcurrentTth t°CommUnity Needs
World Bank advice reonented the entire Fa^lv WPlf
Government followmg the
“ Md in O',ote
policy from the begfnn'ng theTndiangovem 0*"3 Separate P°Pulation
business of framing one. In 1991 it wts felt thaHhe^ T”7
expert comm.ttee was set up with Prof M 8 \
t
d°Wn t0
aCtUaI
t0
°ne and an
Chair. The Swammathan Committee submitted hs™"31
a8nculturaJ scientist as
While it is claimed that the Government has drafted^0*
GoVernment in May 1994
period by refering to this reoort th^m
d A ?
ProSrammes in the post ICPD
of a Population Policy
that five years Iater
still have no sing;
Features of the New Approaches - TFA, CNAA and RCH
announced in quick succession between 1996-1998
CNAA being essentially a new ternt for the conls ns TF^
new approaches are discussed below.
8 ?FA' S
FamiIy Planning were all
°f the features of the
c«o,The cssenda. fea.uce of ,he Tacgc, Free Approach (TFA) an<J
CNAA
15
Section 2
family I lanning and Reproductive Health Policy in India
Evolution of Population related Policy and its changes in India
In the Pre Independence period - A concern for the countries growing population was
articulated by Indian leaders well before Independence. Till 1921 India's growth rate
negligible and started rising after 1921. Immediatelv afterwards there were many local
initiatives for arresting this growth In Pune the firsi Family Planning clinic was started in
1923 In 192S, a neo-Malthusian league was formed in Madras, and in 1930 the Congress
Government run family planning clinic was started in Mysore, in 1938 the Congress party
started its National Planning Council and it had a special subcommittee looking into
various aspects of India s population problem. In 19-49 the Family Planning Association
was started. It is but natural that with such a growing concern in all parts and sections of
the country' Family Planning become part of the national agenda soon after independence.
Family Planning - Early \ ears - The Bhore Committee recommended in 1946 that
population growth would be a problem and that the Government should promote birth
control. The Planning Commission soon after it was set up recognised the need for a
population policy. In the draft of its first five year plan it recommended that a population
policy was essential for planning, and family planning was necessary for improvement of
health of mothers and children. It also accepted that the state should provide facilities for
sterilisations. Clinics were considered the main vehicle for providing services
Sterilisations were accepted as a method in 1959, and in the same year incentives were
given for the first time in Madras. Vasectomy was the method promoted. During the
second and third five year plans suggestions were also made in include sex education,
family life education, child guidance to promote welfare of the family. By-the late fifties it
was becoming clear that the clinic based approach was not able to reach most of the
countries families and in 196j the Government proposed that Family Planning should be
promoted using the extension approach- or visiting women at their homes. Auxilliary
Nurse Midwives(ANMs) were now trained to do this. In 1966-67 time bound targets wer?
first introduced to enhance the decline in birth rates. These targets were set by the central
Government and in turn passed on to lower levels- state, districts, primary health centres
subcentres and functionaries.
Tyranny of Targets - The Fourth Plan (1966-74) period marked the intensification of the
Family Planing efforts. On one hand the Ministry of Health was renamed into the Ministry
of Health and Family Welfare, and a separate department of Family Welfare with a
Secretary in charge was set up. On the other the 'cafetaria' approach started broadening
the range or contraceptives offered (pills and IUD), mass sterilisation camps started and
the MTP Act was passed. However the ambitious target of reducing birth rates was not
achieved. In the Fifth Plan the Minimum Needs Programme was integrated with the Family
Planning Programme but this was also the period of apparent anomalies. While the Indian
Health Minister raised the slogan of "'Development is the best contraceptive” at the
Bucharest conference, forced sterilisation camps were conducted at the behest of Sanjay
I4
- Lack of proper health services
- Lack of decision making and financial autonomy for health care seeking
- Domestic violence
- Sexual violence
reproductive and sexual health and rights be alien9
Going beyond Reproductive Health - Developing a women's health policy
are^hZ
f ’ea'th' Women's He^h - What do these terms mean, how
PrimaZ Heal h
'
T
inference which talked of Universalisation of
Pnma^ Health and ra.sed the slogan of "Health for all by 2000". Obviously there was
somethmg m.ssrng and now the Ca.ro conference has firmly established Reproductive
Health and the goals this time have been placed for the year 2015. Now what is missing
that we need to discuss Women's Health separately- Many activists agree that while the
Camo and Beijing conferences have put the issue of Gender as a determinant of health
fill h ha d 7 h'pJUSt d'SCUSS'nS reProductive health is not enough. Also reproductive
health has developed from the population perspective and not from the health side In
order to enable women enjoy the best possible health (physical, mental social ) it is
essential to discuss a separate women's health perspective which while including
reproductive health will not be restricted to it. There are many other health problems of
and nollls "d
hT
"3
feender roles and Oology)
and pohe^s need to be framed m order to address these. There are a few countries in the
world which have already framed such policies - Brazil, Columbia, Australia and South
^rocTs'3 '"h h6 P?CeSS
S° ACtiviStS in
3re aIso
t0 Put together a
process wh.ch calls upon the Government to do so. But it is not going to be an easy task
and wil need the concerted efforts of a dynamic women's movement together with a
favorable political climate in order to do so.
1 5
I ramers ol population policies also need to seriously question the assumption that
populations growth is not the only or most impotent determinant of poverty and
environmental or resource depletion Reduction of fertility rated cannot take place without
concommitant improvement in other social development indicators like education and
general health and gender relations And it must be also remembered that Reproductive
I lealth in its true essence goes much beyond just adding some additional services to
existing Family Planing and MCH programmes
Is Reproductive and Sexual Health and Rights an idea which has been imported?
There is often a tendency to label the reproductive and sexual health and ights related
discussions as alien to our own culture and as being imported by feminists from the west
1 he reason given is that where people do not have enough to eat this kind of discussion
draws attention from the many other immediate needs for survival. Unfortunately
reproductive health is at the core of survival and so this argument does not hold much
water. The other thing that needs to be kept in mind that while survival may be important
the right to life also qualifies the quality of life that rhe surviving person is entitled to.
Reproductive health and rights of women is a significant aspect of that quality of life. And
thus in no way is a discussioni on this subject less important than one on food security
While it is true that Western ideas have played a role in drawing attention to what should
be women s entitlements in terms of health and on her body at large, women from the
developing countries have contributed equally with their own ideas and analyses and
played their own roles in the entire struggle. The most important "western" idea is the ide i
of or the primacy of self or the individual identity which is central to the debate of rights
^(bodily mtegrity). In cultures like our, women are socialised from early on about self
denial, and this way tend to accept all forms of prTvatfons as fail accompli. Women’s
activists from the developing countries have developed the concept of'self or individual
entitlements further to include the notion of social and economic needs and conditions
which enable individual poor women to access their health, and rights to decision making.
The entire debate of reproductive health and rights becomes extremely relevant in India
when you consider the following situation of women as it prevails in our country - Sex selective abortion for aborting female foetus
- Lack of proper nutrition or education for the girl child
- Early marriage and child bearing
- Shame and pollution around reproductive organs and processes like menstruation
- Frequent pregnancies and childbirth
- Harmful customs and practices around pregnancy, childbirth and peurperium
Lack of quality antenatal, intra-natal and post natal services
- Lack of safe abortion services
- High incidence of maternal mortality
- Lack negotiating power in sexual relationships
- Pressure to contracept, unwanted sterilistions
- Lack of information or choice in contraception
12
informed
5. Underlying
assumptions
Population size/growth is the
main determinant of poverty
under-development and
environmental sustainability
Population control will reduce
fertility
Poverty is due to the economic
growth model of development.
Focus is on meeting basic needs and
not on population control
Improving women's status and
providing quality reproductive healt i
programmes will help to reduce
fertility
(From ARROW 1996 Women centred and gender sensitive Experiences- Changing out
reXCeVKit)P
S
Pr°SrammeS °n Women’s ^alth in Asia and the Pacific. °
Population Policies and Reproductive Health
The concept of
or Reproductive
ivcp.uuucuve Health
neaitn emerged
emerged as a reaction against the narrowness of the
Population control mindset and its operationalisation. Now that reproductive Health has
established itself as an idea whose time has
come one needs to define the relevance of
Population Policies. These two concepts seem
fundamentally opposed to each other in
some ways - population control is defined
---- ini terms of social significance while
reproductive health is concerned with
”±'7:F"? p,ar8 wUch
poM
important idea m Reproductive Health. The difference being in how it is viewed
Population control is concerned with family planning from reducing fertility and'
and'he' ith" Th^f 1
is c6"«fned with individual and their choices
and heakh. Thu for this point of v.ew the challenge for population pol.cies is thus to
enable individuals to achieve the reproductive intentions.
1 there another point of view which sees population policies in an entirely different
fight m the new reproductive health and nghts framework. Here population policies are
not concerned with the reduction or augmentation of numbers but in the quafity of life of
segments of populations - especially the ignored sections of the population.
'"‘T thTint °fViCW iS thC Cha"enge Of PoP^ation policies is to ensure that
certain principles and incorporated, some of which are given below• the principle of equity and social justice
• the principle of autonmy and self determination of the individual - women and men
• that individual have individual rights and social responsibilities
- women and men
towards each other and children's health and well being.
The pnnciple of participatory democracy - engage the most marginalised in the
decision making process.
• The pnnciple of accountability and transparency.
1I
increase of fertility and
population
Improve women's and
children's health and family
welfare (secondary goal)
4. Ethics/values
Reproduction is primarily a
social function
Demographic goals of a
country are more important
than the human rights of
individuals
Increase women's control ever their
bodies and ultimately their lives
Change socio-economic conditions
which are barriers to the exercise of
reproductive rights (e g. women's
legal status, education, poverty Icve
Decision making power in the
household, choice of whether and
when to marry)
Women have the individual rights
and the social responsibility to
decide whether, and how and when
to have children and how many to
have: no woman can be compelled
to bear a child nor be prevented from
doing so against her will
Women have the right to choice
within a human rights framework
Men also have a personal and social
-responsibility for their own sexual
behavior and fertility, and for the
•effects of that behavior on their
partners and their children's health
and well-being
The fundamental sexual and
reproductive rights of women cannct
be subordinated against a women’s
will, to the interests of partners,
family members, policy makers, the
state of any other actor
Due to biology and gender role and
responsibilities, women have a
greater right to make fertility relatec
choices
Women can be trusted and must be
respected to make their own
reproductive decisions when fully
1 )
I lealth Programme which was designed with the assistance of the World Bank
Political Parties and Leaders - The role of national political parties and leaders in the
framing of national policies are obvious. Very often political will decides the kind of
population policies are in place within a country For examples within India one has to
consider the Emergency period forced sterilisation and the target-oriented regime of
India's Twenty Point Programme. Lven today the tack of political will makes mockery of
the provisions ol the new ( ommunity Needs Assessment Approach and the Reproductive
and Child Health Programme.
Women Centred Reproductive Health and Population Control/Family Planning
Approaches Compared
I he change that the two LN conferences recommend has to be operationalised in terms of
an effective approach. The table below gives a comparison between the conventional
Population Control mindset and the newer Reproductive Health approach in terms of the
conceptual understanding and assumptions.
Area
I - Rationale
Population Control/FP
Approach
The most important aspect of
women's health is pregnancy,
childbearing and fertility.
Women's health is very
imponant as it affects the
health of children
When women have fewer
children who are better
spaced, women's health and
status will improve
2- Definition of
women's
reproductive
health
A narrow biomedical
meaningvas maternal health or
the health of women of
reproductive age, focusing on
birth child bearing without
death of disease, and on
contraception
3- Goals
Demographic reduction of
Women-Centred RH Approach
Women's health has not
automatically improved by focusing
on contraception and maternal
health- maternal mortality rates can
still be high even though use of
-contraceptives has risen
•With a narrow family planning and
maternal and child health care focus
women's other health problems are
neglected (e g. unsafe abortions,
RTIs, STDs, cancer and health
effects of violence against women.
A broad understanding which is
centred on the right of women to
make their own autonomous choices
about reproduction and sexuality,
and the right to provision of services
of a high standard which are womencentred (based on women's
experiences and needs)
Improve women's health including
their reproductive health
maternal mortality rate below 125 per 100,000 live births and below 75 per 100,000
live births by 2015
Alongside the UN conferences on Population were the conferences on women- Mexico
City 1975, Nairobi 1985 and Beijing 1995. These conferences too have made important
recommendations about the status of women including their health. Some of the important
principles which these two conferences (Cairo 19<M and Beijing 1995) upheld were•
•
•
•
•
•
•
•
Gender equality and equity and women’s empowerment are essential
National strategies have to be developed to ensure universal access to all individuals a
full range of reproductive and sexual health services
Sexual and Reproductive health has to be considered within a primary health care
context
All barriers to women’s access to health services have to be removed
Reproductive health interventions have to be redesigned taking into consideration
women’s multiples roles
Male responsibility and equal partnership has to be promoted
Efforts to increase women’s awareness of their rights - including sexual and
repriductive rights has to be supported
Transparency and accountability has to be ensured
The interested reader will find details of the recommendations of the two relevant
conferences - Cairo and Beijing in many interesting documents some of which are
mentioned later.
Other Actors Influencing Reproductive Health Population Policies
Religions - Religious doctrines and religions leaders are often serious critics of many
population or reproductive health policies. On the one hand religions are often adverse to
artificial forms of contraception, while on the other they also try to stall any form of
deviation from their accepted codes of reproductive and sexual behavior. The position of
women is also very clearly delineated in most religions and attempts at changing this status
is sometimes scene as a attempt to undermine the religion. Most religions tend to take a
natalist, anti abortion stance and this seriously hinders policy formulation and
implementation in many countries. The Roman Catholic Church has played a particularly
reactionary role in the entire ICPD and its follow-up process. The Vatican has an
observers status in the UN and using this official position it often stalls debates and
discussions which it perceives as being against its teachings. Other religions play
significant roles within individual countries.
International Agencies and Donors - UN agencies usually follow the agenda that has
been outlined at the different UN conferences and this dictates the funding they provide tc<
countries. Other International agencies/donors like World Bank, USAID and even
Population Council are also known to influence reproductive health and population
policies in our own country. Examples from India include the Reproductive and Child
8
• Successful campaigns against sex selective abortions
hitcrnadonal Conferences, Population policies and Reproductive health
I he UN has held a senes ot conferences which has e had an important bearing on the
evolution of ideas ol reproductive and sexual health and rights. The first one, which was
not stiicily on the issue was the.International Human Rights Conference held in Teheran i i
l()68, which introduced the. concept of the rights into the realm of contraception and
family planning. I he first conference devoted exclusively to the issue of population was
the World Population Conference in Bucharest in 1974. In this conference the dominant
view was that development was the best contraceptive and importance was given to socio
economic development as a major force in reducing population growth. The next
population conference was held ten years later in Mexico City. By this time women’s
health activists managed to include some women's issues within the World Population
Plan of Action - emphasising linkages between high fertility and lack of education, health
care and employment opportunities for women and their low status. But this document
also stated that government should make family planning measures widely available,
shifting the focus to family planning programmes. The period between 1984 and 1994
when the ICPD was held, was a period of great challenges to the traditional thinking on
population. Women’s health activists all over the globe drew attention to the effect of
these programmes on women’s health and their presence in large numbers in Cairo
ensured that the Cairo Programme of Action reflected many of their concerns. The
changes in thinking that the Cairo process has brought about is being hailed as a "paradigm
shift The shift from population control to individual well being which has been outlined
earlier.
These International conferences have played a major role in the way countries’ populatior
4?olicies^re framed. While the discussions and debates in these conferences reflect those
which are ongoing within official circles within different countries, the parallel NGO
meetings are increasingly providing spaces to activists to react and interact with official
delegates and get their concerns heard. Once the official document/recommendations gets
ratified, individual countries are expected to change own policies in lines with the
principles of this agreement. In case of the ICPD the document is known as the
Programme of Action (PoA) and it is to form the guidelines for countries for the next
twenty years. Some of the major goals from the ICPD PoA are as follows:
•
•
•
•
•
By 2015, the PoA advocates for a universally available family planning programme foi
everyone in the world
By 2005, all countries should attain life expectancy at birth greater than 70 and by
2015 all countries should attain life expectancy at birth greater that 75
By 2015, all countries should achieve infant mortality rate below 35 per 1000 live
births
By 2005 those countries with intermediate levels of maternal mortality should achieve
a maternal mortality rate below 100 per 100,000 live births and below 60 per 100,000
live births by 2015
By 2005 those countries with the highest levels of maternal mortality should achieve a
7
of Discriminations Against Women(CEDAW) was also ratified
The initial impetus for a separate movement for women’s health started in Europe and
North America in the 7()’s. In different places women had started feminist information
centres, women’s health centres, publication of specialised women’s health related books
and materials, campaigns against sterilisation abuse and abortion rights, and against baby
food producers and so on The first International Women and Health Meeting was
convened by European and North American women but subsequent meetings have all bee i
attended by women from developing nations in great numbers.
These meetings allowed women from all over the world to debate on a wide variety of
issues and also to join together into a united political force. Women from the developing
nations have been playing an increasingly important role in all the deliberations regarding
women’s health and rights. DAWN ( Development Alternatives with Women for a New
Era), a network of women researchers and activists from the developing nations has been
at the forefront of the international women’s health movement for a long time. Other
influential networks included the International Women’s Health Coalition( IWHC),
WGNRR ( subsequently disbanded), WEDO, LACHWHN and so on. Today there are a
large number of organisations and networks at the national ( in many countries), regional
and international levels and they are working in synergy to enable women around the
globe achieve their health potentials and rights.
While the actual situation of women’s health is different in different countries , the
common thread that unites their different situations is the lack of control women have over
their health, their sexual lives , their own bodies and this external control takes many
forms. Thus in India women had to face forced sterilisations, in other countries it is the
pressure of pro-natalist (against contraception or abortion) policies , while in still others
* forced marriages and honor killings make a mockery of women’s rights.- The basic
message of the women’s health movement is the same every where and includes- access to
quality health care services, particularly reproductive health services; safe and effective
contraception and abortion services; respect for women’s reproductive rights. The final
demand is that the design and implementation of all services should be done keeping in
mind the women’s health needs and demographic objectives. Women’s health activists
have raised these issues persistently at various international fora including UN
conferences. It may be argued that as a result of these persistent advocacy efforts a large
number of these demands have been met through the Programme of Action adopted at the
International Conference on Population and Development at Cairo in 1994.
Box - Some important gains made by / achievements of women’s health activists around
the world
•
•
•
•
•
ICPD PoA
Women’s Health Policies in Brazil, Columbia and Australia
Visibilising the morbidity from Reproductive Tract Infections in women
Abortion law reform in many countries
Successful campaiagns against harmful contraceptives - injectables and vaccines
difficult this can be. This simple advice does not take into consideration essential factors
like availability of vegetables, women s social position, economic condition of the family,
and the prevalent myths and beliefs around women s diet and so on. Among the different
cultural factors one of the most important one is gender roles and relationships (and power
distribution) between men and women.
This understanding that heath is determined by socio-cultural factors as well has slowly
emerged over the years. Reproductive health is one area where socio-cultural factors are
even more predominant, and gender roles and power relationships very clearly defined. In
such a situation a population control and maternal health approach becomes very
inadequate to address the actual health concerns of women.
Box - Adverse effects
Some of the consequences of having a population control oriented policy and
programmes:
•
•
•
•
•
Pressure for undergoing sterilisation - denial of human rights
Health repercussions of hastily done sterilisation operations in makeshift camps —
infections, intestinal adhesions, high failure rates, even death
Inadequate attention to contraceptive safety- inadequate screening and follow-up
Health services do not have provisions to deal with women’s genuine health problems
Poor quality of curative services
The International Women’s Health Movement
The changes in the population control mindset to a broader Reproductive Health
framework was to a large extent, due to the continuous critique of established policies by
the International women s health movement. The International women’s health movemeni
started in the late 1970 s challenging the basic premise of population control. The central
logic of the challenge was that individual women’s health and rights of concern rather
than population control in the so-called greater interest of society. While there was no one
international women’s health movement, it developed in differing regions of the world
differently, there were ( and still are) many common platforms where women’s health
activists join together in expressing their common concerns.
The development of the International women s health movement has to be seen in
conjunction with the larger women’s movement . The UN declaration of Human Rights
(1948) unequivocally affirmed the equality of the sexes. In 1968 the International Human
Rights Conference in Teheran the concept of human rights was applied to the issue of
family planning. Women s situation and condition became a central issue of international
debate after the launching of the women’s decade in 1975. All the while feminsists were
critical of the narrow population control mindset and policies. The International Women’;5
Year Conference at Mexico City ( in 1975) was an opportunity for women to place their
reservations on the international stage In 1979 the Convention for Elimination of all forms
Section 1
Understanding The Evolution Of Reproductive Health Related Policies
The need for the change from Population control and Maternal Health
If one considers the situation in India, programmes and policies for population control and
maternal health have been in place for over fifty years. Even if these did lead to some
decline in population growth rates their impact on women’s health was negligible In tact
it can be successfully argued that these have adversely affected the health and status ot
women. In India, despite such programmes the Maternal Mortality Ratios (MMR) remain
as high as over 400 per 100,000 live births. In countries like Indonesia, MMR was as high
as 450 despite the fact that contraceptive prevalence was over 50% of all married women
Besides this, these narrow programmes failed to address the many reproductive health
problems of women. Table one provides a summary of the principal health concerns of
women.
Table 1
Category of health problem
Unwanted pregnancies
Unsafe Abortions
Severe maternal morbidity
Maternal deaths
Women with invasive cancers
STDs .
Maternal anaemia
.Beating by male partner
Depression
Numbers world wide/year_________
80 million
25 million
20 million
585 thousand
2 million
50 million
58 million
20 - 30% of women
2 to 3 times more frequent in women
( Source : Sen, Germain, Chen eds - Population Policies Reconsidered and ARROW
Resource Kit, 1996)
It is clear from this table how little can actually be addressed by programmes focussing on
population control and the limitations only having a maternal health focus. In addition to
ignoring some of the most important women’s health problems the earlier approach had
another major limitation. This limitation is related to how the system views women’s
health problems. The conventional approach had ( and to a great extent this is the order of
the day even now) a very bio-medical understanding of health- meaning health was viewed
as a result of factors like nutrition, susceptibility to diseases, physical, chemical or
biological factors and so on. Having understood health in bio-medical terms the solutions
consisted of bio-medical interventions as well. Thus anaemia was considered a result of
iron -folic acid deficiency and iron-folic acids and green leafy vegetables were considered
the answer. This approach totally misses out on the number of economic, social and
cultural factors which influence health. Any one who has tried to tackle anaemia in the
village by dispensing advice on green leafy vegetables and iron tablets will appreciate how
4
INTRODUCTION
Reproductive health policies are a follow-up on Population and Family Planning policies
India is well known as the first country to have started a state sponsored Family Planning
programme in 1951. Since the beginning the programme had a strong concern for
controlling India’s rapidly growing population. Side by side there evolved the Maternal
and Child Health (MCH) programme which was concerned with the health of mothers and
their children. While in the initial years of the Family Planning Programme men were the
main acceptors of permanent methods, the programme slowly changed its nature to one
that more or less exclusively targeted women for sterilisations. In this situation women
were important as long as they were pregnant or had delivered recently or as potential
cases for family planning. And this state of affairs was not unique to India. In many
countries around the world women’s health issues were largely ignored while many of
their reproductive health functions were controlled by different policies pertaining to
Family Planning or to abortion.
Women all over the world were slowly realising how state policies were against the
interests of the health of women and a movement was slowly built up to challenge this
neglect of women’s health, especially their reproductive health. The culminating point of
this dialogue between the women’s health activists and states took place at the UN
sponsored International Conference on Population and Development at Cairo in
September 1994. The resultant Programme of Action is the commitment for all signatories
on the document (states) to slowly change their countries policies relating to reproductive
health. Changes in Indian polices are also the result of this process.
Changes that have taken place in our country in terms of policy have not always been a
result of a benign and concerned government. People have for a long time expressed their
‘own concerns and put pressure on the government for initiating policy and legislative
reforms. The low socio-economic condition of women in the country has always been a
major reason for social movements in the country. Some of the first successful advocacy
efforts for securing women some rights had been the ones to sati ( burning widows on the
funeral pyres of their husbands) or for widow remarriage which took place through
legislation over a hundred and fifty years ago. Other successful efforts in more recent
times have related to legislation concerning the minimum age at marriage and for dowry
related violence. Unfortunately, the social forces which perpetuate many of these
inequitous systems within society are very strongly entrenched, and even legal measures
have often not been very successful. Advocacy efforts towards reproductive health and
rights also need to be seen in this context.
This section of the Resource Pack will present the changes that have taken place in the
evolution of policies concerning reproductive health as well as how advocacy efforts both
at the international sphere as well as within India have affected these processes.
CONTENTS
INTRODUCTION
Section I - Understanding The Evolution of Reproductive HeaitiTRelated
Policy_______________
-The need for the change from population control and maternal health
The international women’s health movement
international conferences, population policies and reproductive health
_Other actors influencing reproductive health population policies
Women centered reproductive health and population control/family
planning approaches compared
Population policies and reproductive health
Is reproductive and sexual health and rights an idea which has been
imported?_____________
_Going beyond reproductive health-developing a women’s health policy
Jection 2- Family Planning and Reproductive Health Policy in India
Evolution of population related policy and its change in India_________
Features of the new approaches-TFA, CNAA and RCH
_An assessment of the post ICPD policy changes in India _____________
Section 3- Advocating for Reproductive Health and Rights in India
Reproductive health and cultural and political challenges to advocacy in
India__________
A review of current advocacy effort for reproductive health____________
Strategies for successful reproductive health advocacy
Advocating for change some experiences
Resource Section
Books for further reading
Addresses of organisations involved in RH and R advocacy
4
4
5_
2
8
2
2
2
_2
_2
_£
5
21
JLL
J’2
2^
]!6
29
2
pH - n-gpi
1
I
UNDERSTANDING
;4-
REPRODUCTIVE HEALTH
i-:,:'
A Resource Pack
-'•.-A*.*-
I
f
;r«r»
Booklet - One
INTRODUCTORY BOOKLET
l-r.r
SAHAYOG
i«Sj
sO
4i'^
CONTENTS
Foreword
Acknowledgements
Introduction
How the idea of this Resource Pack was born
• Objectives of the Resource Pack
• How the Resource Pack was put together
• Structure of the Resource Pack
Introduction to Reproductive Health
• What is Reproductive Health
• What are the factors affecting reproductive health
• Whose reproductive health is of concern
• What are the appropriate health care services included within RH
• Reproductive health in India
Organisations involved in working on Reproductive Health
• Research organisation
* • Organisations providing training and other kirfds of resource support
• Organisations working with the media
• Implementing organisations
• Network organisations
• Funding organisations
Books and Materials on Reproductive Health
• .Annotated bibliographies
• Books
• Journal
Information Kits
• Books on Research
List of topics covered in the different booklets of the Resource Pack
List of Contributors and Reviewers
3
4
5
5
6
6
7
8
8
5
9
9
10
11
11
12
16
17
17
18
22
22
22
22
23
23
24
2
FOREWORD
( to request Poonam)
3
ACKNOWLEDGEMENTS
This Resource Pack was conceived as a kind of ready reckonner for those who wish to
earn about the different facets ot Reproductive Health and as such it was estimated that it
w°ula be a simple task to produce. Instead it has taken over a year to produce and has
needed inputs from over twenty people from different parts of the country Mana«in<>
correspondence and contributions from so many different sources was a difficult process
pa icularly so, because the editors were based in a remote area. This is where the^reat ’
communication revolution was indeed a great boon. Over the oce year m Zh we^Xe
'"7 ®d 10 Producing thls pack we graduated from a tenuous email link via Delhi to a full
conn^ed
C°nneCtlOn’ which haS «iven new waning to the concept of being
e^thus^ and no
P P
al' We had was an idea and lots of
enthustasm, and no expenence m prepanng anything remotely similar A few steps into the
actual preparation we realised how difficult the task would be Firstly having been
'"vo'ved in some aspects of Reproductive health at an operational level we had started out
w! confidence that we had an idea of the ground that the idea of Reproductive health =
covered. Working on the different aspects with which we were a little Uc f r
a
US realise bow ii,,,.
k„e» This inhere o.her THeo/s
PaelVed “.T'"""8 suppon f™” wtom we “Sksd Without their support this Resource
P X tr' ‘X
* “fW' ”“ld
«ke to X Saroj
Paehaun. .S.gn Singh. Saraswathy Raju of the Population Council for providing advice as
as agreeing to pitch in with contributions and fof reviewine All nnr m r^ii
Mac^hur Foundation who agreed to go along with this idea and seeing it through °
eserve all our gratitude for readily responding to our continuous requels Thank you
strhT’ 0nUJa’ BDhanU’ Geeta’ G0P'’
Kirtl’ Rah“t R-anjan Siddhi
scherin 3’jTAn^
f°r providing ali the suPPOrt despite your own busy
schedules. Alok, Alka and Amitrajit deserve our gratitude for allowing us to rone them
into this project. We would also like to thank members of the SAHAYOC
uallowances for,he .wo us. and for providing ah the sZpoX^
thank you Io Diya tor putting up with our long absences and to Ma for bolding the fort
Jashodhara Dasgupta
Abhijit Das
4
INTRODUCTION
How the idea of this Resource Pack was born
Reproductive Health 1S one of the new ideas that has caught our country by storm
Populauon has long been a bugbear for politicians, planners and pundits in India Over the
w h'TnH t° Tr repr°dUCtivhe hea‘th is a,so bei"g cautiously mentioned in relation
Xd Bank hTs m ! G7emni7t ha® re-chri^ed its family planning programme and the
y',en 1 a very large loan in the name of reproductive health NGOs all
over the country are prepanng proposals for becoming Mother NGOs or for different
projects related to reproductive health. For many reproductive health is a new name for
Family Planning, for others it is a reincarnation of Mother and Child Health (MCH)
awarding
D
Cathenne T MacArthur Foundatio"
been
awarding a number of fellowsh.ps to Indians from different backgrounds to work on the
issue or Population Innovations. Much of these innovations have^had to do with
reproductive health and a qu.ck glance at the profile of fellows over these five years mves
heafthVT Pe°hP
77Se backgrounds are getting interested in reproductive °
heal h. Fellows have included activists, grassroots workers, doctors, media persons
theatre persons, film makers researchers, trainers, psychologists, psychiatrists and so on
the sublet PS 3 refleCt’On °f the dlfferent kinds of People who are getting interested in
LllC oUUICC/i.
enrnt aJOt X
th/ COrnpiexity of Reproductive Health during the period of their
tellowshjp. Newer fellows were confused with the same complexities. An idea was then
mooted .hat a kind of Resource Pack be prepared by the people who felt that they had
learnt something about subject. Since most of the fellows were involved in work which
was directly concerned with the subject - it was felt that this resource pack would be
grounded in reality and not just deal with concepts. Two of us took the challenge of
coordinating the effort while the others promised to chip in. It has taken a little over a year
to put this pack together, and in putting this together we learnt how far more complex the
subject is than what we had originally thought. Reproductive health is a vast subject as the
reader of this pack will soon realise; with vanous perspectives, different specialities
contentious policies and complex operational details. This resource pack tries to provide
just a glimpse of all this. It is not a definitive work, nor a theoretical masterpiece It has
been put together primarily by practitioners and thus may lack the technical finesse that
academics might insist upon. It also lacks dispassionate objectivity which is often the hall
mark of a good text-book. Instead it is loaded with the writers own perspectives which is
born out of struggling with the different issues in the workplace. This resource pack is
clearly wntten keeping the interests of women, especially marginalised women in mind
5
Objectives of the Resource Pack
fins resource pack is pnmanly meant for all those who may be interested in the subiect of
Reproductive Health As has been mentioned earlier, today a large number of individuals
are gettmg interested in the subject. Any way the concept hself veiy new ani d ; pSie
“'Ve,y ’'l’ea"h' SUbj“ ln ”S
L,aHe-e ”
hus ? could be a matter of interest to any one in any of these specialities Also
intere^in the he^h’of
t0 NG° WOrkerS beCauSe of their inherent
interest in the health of women but also because of the potential of diverse funding
opportunities that exist today in the name of reproductive health . We also hope that the
many oureaucrats and the doctors who are involved in designing and implementing
Zh0roUuXts
,n“i0nS for the miIIions in
country”can take some time out to
feo through its pages. Thus the resource pack could be of interest to a wide range of
people with different interests and specialities.
This resource pack has been deliberately designed in booklets so that the interested reader
may stra.ght away refer to the issue of her/his interest. We would like to
i you choose to look up the subject in which you have experience and expertise you will
‘nd Veiy bas,c’ because the entire resource pack has been kept simple for the first time
JhaTth?15 reS°UrCe Tk-ii 'n many W3yS 3 Primer’ and not a rePerence book It is assumed
the resource pack will pnmanly be used for those who wish to work on the subiect
thus we have included many operational ideas as well as a small resource section
wfiich is intended to help the practitioner.
•
How the Resource Pack was put together
This resource pack is the collective effort of a large number of individuals As has been
mentioned earher the lead for putting this Resource Pack together was taken up by a few
Ma'Ari'h S Zh°
56611 aWarded 3 fellowshiP in Population Innovations by the
MacArthur Foundation. The task of editing was taken up two of them while others took
upon the task of sending in their contributions. The first draft of the different booklets
h
tlme t0 PUt together because the fellows live all through the length and
breadth of the country. While some have access to ema.l or courier others who are
vvorking with communities in remote areas often do not get mail regularly Once the first
ough draft was ready, it was sent to for review to other practitioners in the same
speciality as the subject matter of the booklet. Some of the reviewers were fellows while
rp ■
respect4ed Practltl0ners in the discipline. We tried to get each booklet ’
review^ J?0 '"dep^dent reviewers, but this was not always possible Finally when the
into the booktrF 'll b COmmentS their COmmentS 3nd suggest'O"* -ere incorporated
into the booklet. Finally the entire Resource Pack was reviewed bv - independent
reviewers^ All reviewers and contributors are essentially practitioners as has been
dXerBooS“'‘‘1°f “n,r,l’“,OrS and
ls P'™" -
““ of
6
Structure of the Resource Pack
•Xe
k°T“S °r“e,v= b‘>°kta»
a c eXerebff"' u
'0
are covered in the pack. These different themes are:
<he imroductory bookta E.ch
Thus eleven .hemes
Booklet Number Theme
—.
-------------- - ----Two
Policy and Advocacy :Ch~
Three
Reproductive and Sexual Rjghts : Exploring new frontiers
Four
Population and Demography Understanding Numbers
Five
Women’s Health -1: Maternal health is still important
Six
Women’s Health -2: The Promise of better health
Seven
Contraception Going beyond Family Planning
Eight
Adolescents : The Emerging Agenda
Nine
^eaith and ResP°nsibiiity: Forging new partnerships
Ten
HIV/AIDS & STD : Coming to terms with reality
Eleven
Sex and Sexuality . Acknowledging ourselves
Twelve
Women have Minds Too! Exploring the interface between RH and
Mental health
Contents of the different Booklets- Each of these'elevdn booklets is basically divided
into four sections The first section deals with ideas; concepts and definitions which are
associated with the subject of the booklet The second section deals with perspectives and
includes discussions and debates around the subject, especially with regard to India. The
ird section deals with operational aspects and includes both tips and guidelines for
working on the issue as well as brief introductions to some organisations which are
currently mvolved in working on it. We have tried to include three or four orgnisations in
each booklet, and this has meant that we have had to choose some and the choice has
a ways been difficult, with many excellent organisations pioneering work in many of these
relatively new and unexplored fields The final section is ambitiously referred to as the
Resource section and has a select bibliography ( primarily of books which we found usefill
ini preparing this Resource Pack) This reading list is not exhaustive. There are also names
ot Journals, or docomentation centres or training centres or resource organisations
wherever relevant.
is Introductory booklet is also a kind of summary for the whole pack and includes a list
of organisations involved in different aspects related to Reproductive Health It also
includes an index of the different topics that have been discussed in the different booklets
INTRODUCTION TO REPRODUCTIVE HEALTH
What is Reproductive Health
The dea of reproduct.ve health has emerged from a discourse between the twin ideas of
family .plann.ng/populat.on control and women’s health needs. It was developed ihrotmh a
process of dialogue and cnt.que between the population control/family planning onenfed
plann^s on one side and the women’s health activists on the other. It was also the result
of the clear failure of population control/family planning policies and programmes to
deliver the promised results and in improving the quality of women’s lives. The
International Conference of Population and Development ( ICPD) at Cairo in 1994
orm ised the acceptance of Reproductive Health as an imperative for the states of the
wortd. A very comprehensive definition of Reproductive Health was developed at the
ICPD and runs as followshealth ‘r ? S,a,e <,fcomP'ete Physical’social well-being and not
the^Se'™ Ofd,SeaXe
a" »s relating to the reprodtL e
system and to itsfunctions and processes. Reproductive health therefore, implies that
renr^ t
sex
^ey have the capabil.tv to
h
°f,en 'O d° SO- ImPlicil in
P"'
condi non are the right of men and women to be informed and to have access to safe
effecnve. affordable and acceptable methods offamily planning of their choice as well
as other methods of their choice for regulation offertility which are not against the lose
and the right of access to appropriate health-care services that will enable women to go
safely throughpregnancy and childbirth and provide couples with the best chance of
having a healthy infant. In line with the above definition of reproductive health
hea"h^are ,S defi^das the constellation of methods. Techniques and
services that contribute to reproductive health and well- being through preventing and
solving reproductive health problems. It also includes sexual health, the purpose of
Which IS the enhancement of life and personal relations, and not merely counselling and
care related m reproduction and sexually transmitted diseases. ( UN 1994)
Drawing from this it means that reproductive health includes.
• the ability to have a satisfying and safe sex life
the freedom to decide if, when and how often to reproduce
’
•
t0
inf0™edka"d have access t0 safe- effective and affordable methods of
family planning and methods for fertility regulation
the right to have access to appropriate health care services
Another aspect which is stressed in this definition is that reproductive health has to be
and^unf
These rights include the right of individuals
nd couples to decide freely and responsibly about the number and spacing of children the
means to do so the right to make reproductive decisions and in short the right to attain
that mumal
Ti
repr°duCtive health' The definition goes on to emphasise
mutually respectful and equitable gender relations are essential for the promotion of
8
these rights.
Some of the issues covered under reproductive health include
Sate motherhood. Unsafe abortion. Women’s health , Child survival and health Family
plannmg and contraception, HIV and AIDS, infertility, reprodeuctive tract infection
cancers of the reproductive tract and so on.
What are the factors affecting reproductive health
Reproductive health is thus not just a simple matter of ensuring adequate family plannmg
eduction and services, nor is it just a matter of providing appropriate health care services
I
reC°gniti0n Ofthe different Actors which stand in the
touche "non m tL'fcZS tfiheir repr°duCtive health P^ential. These factors are briefly
touched upon in the ICPD definition as reproductive health eludes many of the world’s
people because ofsuchfactors as: inadequate levels of knowledge about human
sexuality and prevalence of high-risk sexual behaviour; discriminatory social practicescgatt ve attitudes towards women and girls; and the limited powers many girls have over
l
,exuai' andreproductive lives’. Thus reproductive health is affected by a large
number or factors like.
°
• level of knowledge about the body and its functions
social discriminations, especially discriminations towards women and girls
• gender and power relations in society
• access to and quality of health care services
• access to information and services about health ccare and contraception
In order to secure reproductive health and rights for all individuals it is necessary to take
action on social and economic fronts like - poverty, empowerment of women, gender
equality and equity, education, situation of children sustainable development interventions
as well as m health related areas.
Whose reproductive health is of concern
In the times before reproductive health was acceptable as an idea. Family Planning (FP)
and Maternal and Child Health (MCH) programmes focussed exclusively on women and at
the most on coup es where the woman was in the reproductive age group. This led to the
total neglect of other women. Reproductive health has a much broader framework and
includes chtldren, adolescents as well as older women. Reproductive health is equally
concerned with men s health, and is also interested in men as essential partners and
supporters of women's health. The-reproductive health and rights of neglected populations
like mdegenous people, m.grants and refugees as well as persons with disabilities has also
to be taken into account.
What are the appropriate health-care services included within reproductive health
The range of services include the whole range of prevent we, promotive and curative
9
curative services which includes information, education and c
communication (IEC),
counselling as well as curative sevices. The different conditionsfor
—
which such services
mus<. be made available include - ante-natal, <* "
de 1T!7.and P0St’nataJ period, infertility,
abomon, reproductive tract infections, STDs and HIV/AIDs'
, Family planning, cancers of
the reproductive tract and so on.
Reproductive Health in India
India was one on the signatones of the Programme of Action
~™
programme with the assitance of the Worfd Bank and ri
needs and implements a RCH programme.
emerging out of the ICPD,
^rTlic,esr
”s
Fam
I
’511"®
'ly Plann,nS
deIerm,ninS communities
10
ORGANISATIONS INVOLVED IN WORKING ON REPRODUCTIVE HEALTH
Wh, e Reproductive Health ,s a relatively new idea in India, there are a large number of
excellent organisation primarily in the Non-Governmental sector who have been involved
pioneering work Many of these organisations have been enaaged in creating new
undXood1”8 t fh
hb°UndanekS’ in many of the hitherto unexplored and little
understood aspects of human behaviour which come under Reproductive health Others
have been evolving new paradigms of providing services for conditions which have long
been neglected or even unknown. Some of the contributors have been involved in these
Ph115 7
bavedrawn lnsP'rat>on from them. While a small number of
orgamsa ions have been referred to in each booklet, this section will primarily deal with
organisations which work m cross-cutting areas like Training, Research, Resource
Support and so on. These organisation are being referred to here for their generic
expertise while speciahsed expertise finds mention in the relevant booklet" The editors
have tried to include organisations from all around the countiy . but they are aware that
some regions may be under represented.
Research organisations- Some of the organisations involved in field based behavioral and
operauons research are mentioned below. Many of these organisations also provide
traimngs in conducting research. The Ford Foundation has recently commisioned an
extensive review of literature of Reproductive and Sexual Health and this review is being
coordinated by Sundan Ravindran of RUWSEC. There are five teams working on five =
topics which are Abortion, Women’s Health, HIV and women. Sexuality and Health
Systems Research It is expected that an extensive literature review will soon be available
as a result of work of this team.
Centre for Enquiry into Health And
Themes (CEHAT)
This group is involved in research and
documentation of rational health systems,
and also runs a documentation centre of
Reproductive Health
Centre for Operations Research and
Training (CORT),
Conducts operations research as well as
training programmes in qualitative research
Christian Medical College, Vellore
The Community Health and Development
Depanment (CHAD) runs one of the best
training courses in epidemiology and
biostatistics, as well as conducts research
from a community health angle.
Foundation for Research in Health
Systems
2nd Floor, BMC Building,
135 Military Road, Bamandayapada, Marol,
Andhri East Mumbai- 400059
Phone : 91-22-851 9420, Fax : 850 5255,
Email- cehat@vsnl.coni
405, Woodland Apartment,
Race Course,
Vadodra-390007
Tel - 0265-326453, 326034, 336875
Department of Community Health and
Development (CHAD),
Christian Medical College,
Bagayam, Vellore.
Dist. N Arcott, Tamil Nadu
6, Gurukripa, Apartments,
183, Azad Society,
11
This organisation is involved in conducting
Ahmedabad, 380015
research in Health systems as well as
E^Qllsad^adO 1 .vsnl.net. in
Jgnduct trainings in quantitative methods
KEM Hospital Research Centre
1 Sardar Mudaliar Road,
This Centre is active in conducting different
Rasta Peth,
kinds of clinical as well as social research in
Pune 411001, India
Reproductive Health
Tel-0212-625600
j™il-kem.pune@sm4sprintrpg. sprint, com
Operations Research Group
Rameshwar Estate,
As the name implies this organisation is
Subhanpura,
involved in operations research. It also
Vadodra, Gujarat,
conducts on qualitative research on
Ph-0265-381461/76
Reproductive Health
Population Council
Zone 5 A, Ground Floor,
Population Council is involved in
India Habitat Centre,
supporting and conducting different kinds
Lodi Road, New Delhi -110003.
of research on the issues related to
Ph-011-4642901/02
Reproductive Health. They also have a
number of very useful publications which
jnclude reports, papers as well as books
SYNTHESIS :
B-322, Clover Gardens,
This group is involved in providing training
4 Naylor Road, Bund Gardens,
support foforganisations interested in
Pune<ri0*01, India,
upgrading their research skills
Telefax- 020-627716,
Email- sidbela@vsnl. com
Training in different kinds of research is available in many schools of Public
ith '
many universities outside the country Most of these arJYnZf
c 5
course and run during the summer Some of the schools wh' h °T S Ort summer
course include the London School of Heahh Zt r
7?
may be contacted for such
Health , Johns Hopkins SivelSX
about ,hese courses ’ also
health care functionaries in the NGO sector Training for C
reProductlve hea,ttl t0
languages for health workers, trammg kits and manuals or s7m 1
H
where essential information is easily available Some of the
3 d.OCUmekntat,on centre
posmon to provide this kmd of support are mentioned below 8an'
a"" 3
12
Catholic Health Association of India
PB No. 2126,
(CHAI)
157/6, Staff Road,
This network of Catholic organisations
Gunrock Enclave,
working for health provides a variety of
Secunderabad - 500003,
training programmes in health. They also
Andhra Pradesh.
publish a mothly journal called Health
Ph-040-7848293,7848457,7841610,
Action. One important training is concerned Email- chai@hdI .vsnl.net.in
wi th the use of herbal medicines in primary
health care .
Centre for Health Education Training
Lilavatiben Lalbhai’s Bungalow
and Nutrition Awareness (CHETNA)
Civil Camp Road, Shahibaug,
CHETNA runs a training and resource
Ahmedabad
centre for women’s health and provides
380004, Gujrat
different kinds of trainings, as well as
Phone . (079) 786 8856, 786 5636
produces excellent material on the subject.
Email: chetna@adinet.ernet.in
CHETNA primarily works with
organisations in Gujarat and Rajasthan_____
CENT- Chetana
Village - Daulatpur,
This training centre is affiliated with the
P.O. Pailan via Joka,
community based health project of CINI,
Dist. 24 Paraganas South,
and is involved in providing training in RH I West Bengal. 743512
in West Bengal and other states in the east. ! Ph-033-467 8192,467 1206.
-
Indian Institute for Health Management
and Research (HHMR)
This organisation provides training for
managers of Reproductve Health
programmes. It is affiliated to the
University of North Carolina for a MPH
programme...
Institute of Health Management Pachod
(IH.MP)
This institute is invoved in providing
training to health personnel of different
categories, especially from the middle and
senior management. Many of the trainings
are not specific to Reproductive Health
Jamkhed Institute of Training and
Research in Community Based Health
and Population
This is affiliated to one of the pioneering
institutions for community health in the
country, if not the world It is involved in
conducting different kinds of training
I programmes. Trainings related to RH
I
Email- cirii@cal2.vsnLnet.in______
1, Prabhu Dayal Marg,
Sanganer Airport
Jaipur
Phone : 0141-550770,551685
Email - root@iihmrj.simetd.ernet.in
Pachod
District - Aurangabad-43 1121
Mahrashtra
Phone : 02431-21419,21382
Email ihmp@giaspnOI.vsnl.net.in
Comprehensive Rural Health Project,
Jamkhed,
Dist- Ahmednagar,
Maharashtra-4 13201.
Phone (02421) 21322, 21323
Fax- (02421) 21034
13
include MCH related trainings.__________
PRERNA Population Resource Centre
19, Laxman Puri,
This Centre is affiliated to CEDPA and is
Faizabad Road
primarily involved in providing RH related
Lucknow-226*016, Uttar Pradesh
training to the projects supported by the
Phone : 386715, 387884
USAID sponsored SIFPSA programme.
Fax , 387884 ______
SAHAYOG
Premkuti,
SAHA YOG is involved in conducting field
Pokharkhali,
based studies as well as providing training
Almora- 263601, Uttar Pradesh
and producing material in Hindi on the issue Phone & Fax : (05962) 32919, 33029
ot women s health. SAHA YOG primarily
Email : sahavog@vsnLc^ri
works with NGOs in Uttar Pradesh and in
Bihar._____
Voluntary Health Association of India
40, Institutation Area
and state VHAs.
South of I. I T Behind Kutab hotel
While VHAI is involved in conducting
New Delhi-110016
trainings in the management of community
Phone : 6518071-726962953
health programmes its state units provide
Fax : 011-6853708
specific trainings in the local language.
Email : VHAI@del2.vsnl.net.in
Popular training provided by state VHAs is
IS
the training of TBAs, and training i________
UNFPA bnngs out a Directory of Training Courses in
in Reproductive
Reproductive Health
Health which
which
catalogues cou^e from aroound the world. This director^ may be obtained either from
tneir country office or from their headquarters
Delhi Office •
55, Lodi Estate,
New Delhi 110003,
India
—Headquarters
220 East 42nd Street,
New York N.Y. 10017,
USA
There are a number of organisations which run documentation centres. Some of these
organisations are mentioned below:
AKSHARA,
Neelambari 5th Floor Road 86
Opposite Portugese Church
H Gokhale Road
Dadar (W), Bombay 400 028
Phone 022-4309676
Fax 022-4319143
E-mail lakshmi@ilbom.ernet.in
JAGORI
C - 54, South Extension Part II,
New Delhi
ISST
East Court, Upper Ground Floor,
Zone 6,India Habitat Centre,
Lodhi Road,
New Delhi -1 10003
Ph- 011 464 1083
E-mail- isstdel@giasdlO 1 .vsnl.net.in
SAKHI
TC 27/2323,
Convent Road,
14
"Tel. 6257015
:
“
Email system@jagori unv.emet.in
Trivandrum- 695001.
Ph- 0471-462251
Email Sakhi ^).md2.vsnl net.in
SANHITA
IwiD
V~HAI (see above)
CH ETNA (see above)
E2, B Block 4th Floor
Parsh paradise Aparts.
109 G.N.Chetty Road
Madras- 600 017
Phone 044-8260689
Fax 044-8264728
_ i~mail- martha@iwid.ilmas.emet.in
SAHA YOG (see above)______
| CEHAT (see above)
1
Organisations working with media
15
i
Comet Media Foundation
This group is involved in material
prepartion and actively disseminating it .
Drishti Media Group
Is involved in highlighting the situation of
| women and involved in promoting
awareness about women's empowerment
and reproductive health through film and
theatre._____
•Jana Sanskrit!
This group is involved in promoting
women’s empowerment and reproductive
health using a unique form of theatre.
Topiwala Lane School
Lamington Road
Mumbai-400 007
Phone 0223869052
Fax-022-3870901
E^rnaul - admin@comet.ilbom.emet.in
B-l Divya Aparts.
Near Carnival Restaurant, Bokadev
Ahmedabad-380 054
Phone 078-674137
Sanjay Ganguly,
65 A Kalyani Road,
vill. Prasadpur P O. Hridayapur
Dist 24 paraganas N West Bengal
Tel: 033 552 1499 Fax- 033 5523162
Entail - theatre@cal2.vsnl.net.in
I Madhyam Communication
Sucharita Eswar,
Madhaym is mvoved in producing material j Post Box 4610
59 Miller Road
as well as providing communication training
Benson Town
on^Reproductive Health issues. It publishes
Bangalqre;56O046
.. •
a journal called VOICES.
Phone : 080-5546564
Magic Lantern Foundation
Gargi Sen and Ranjan De,
This organisation is involved making short
J-1881, Chittaranjan Park
films as well as publishing a newsletter on
New Delhi-110019
development related media issues
Phone: 011-6221405
Jmail: rnagicLF@giasdlO2.vsnl.in
UNNATI Features
S-20 Greater Kailash II,
Unnati features is involved in producing
New Delhi 110048,
features related to health and development,
Tel -011 623 7509;647 4144
particularly reproductive health and placing
Fax-011 647 4144
them in both National dailies as well as
Email unnati@nde.vsnl.net.in
regional Hindi language dailies
Women's Feature Service
Anita Anand,
, This feature service is involved in
Director,
promoting articles related to women in both
I Nizamuddin East
the press and electronic media.
New Delhi -110 013
Phone 01 1 462886, 4632546
Media Advocacy Centre ( New Name)
I his centre is involved in media research
and advocacy and reproductive health is
i one of its core areas.
E-mail- wfs@unv. ernet. in
Akhila Sivadas,
R-l, Press Enclave,
Saket,
New Delhi
]Tel-0l 1-686 5921:623 1360
16
A list of three of four organisations, according to the kind of work they are involved in has
. een provided in each of the booklets. The interested reader will find an exhaustive list of
organisations working on the issue in two excellent directories. Details of these directories
•■S as Follows.
I Reproductive Health Database- Compiled by Department for International
Development(DFID), December 1998.
This Data base includes thematic collection of organisations with a brief descnption of
•-hem work in the particular theme as well as a matrix at the end which provides the range
of activities each organisation described in the database is involved in. The database
includes research, training as well implementation organisations. Contact information of
each organsiation . including names of contact persons and phone and fax number and
email are also provided. A copy of this book may be obtained from the office of DFID.
Community based programmes addressing Women’s Reproductive Health Needs in
India, - Compiled and edited by Masuma Mamdani 1998
This document includes details of the work of 72 organisations which have community
based programmes tor womens health. The organisations are arranged alphabetically and
the documentation is veiy detailed as it has been substantiated by field visits Contact
information of each organsiation , including names of contact persons and phone and fax
number and email are also provided. A copy of this book may be obtained from the office
or the Ford Foundation.
-
Besides these two booklets the Voluntary Health Association of India brings out penodic
documentation of different organisations involved in community Healath related activities
in a senes called the ANUBHAV senes. Organisations involved in working of women’s
health are also coveren m this series. A list of all the organisation covered may be obtained
from the office of VHA1.
N etworks of organisations- There are a ffew networks of organisations working on the
issue of women’s health or reproductive health.
There
----- ---e are some more which are more
broad based. Some of these networks are:
Women and Health Network (WAH!)
This is a network of voluntary organisations
and activists on the issue of Women’s
Health. Important activities of the network
have been conducting trainings and in
advocacy for a women's health policy
WAH! Secretariat
CHETNA
Lilavatiben Lalbhai’s Bungalow
Civil Camp Road, Shahibaug,
Ahmedabad
380004, Gujrat
Phone (079) 786 8856, 786 5636
17
Email: chetTia@adinet.ernet.in
A-5 Institute of Economic Growth
University Enclave
Delhi -110Q07
Phone : 7256134
JEmail: visana@sidev. Delhi, nic.in
2015, C Block,
First Floor,
Indira Nagar,
Lucknow -226016
Email- sahayog@vsnl.com
HEALTHWATCH
This network of NGOs, academics,
activists and researchers is primarily
tocussed on implementation of the ICPD
agenda in India.___________
Healthwatch, U.P.-Bihar
This network of NGOs and activists and
organisations in the two north Indian states
is involved in advocacy for promoting a
gender and reproductive health based
programmes ._____
Forum for Women’s Health
This is a campaign group working on
women’s health. They have been involved
in the campaign against hazardous
contraception and against coercive
population control
C/o Swatija Manorama,
9, Sarvesh,
Govind Nagar,
Thane (East),
Maharshtra- 400603,
Ph- 542 3532
Shodhini Network
The Shodhini Network was involved in a
latge multicentre study on the efficacy of
herbal medicines in treating women’s
illnesses.
C/o N.B. Sarojini
J-1881. Chittaranjan Park
New Delhi-11QQ19
Phone: 011-6221405
Fax : 011-6223894/6231801
Voluntary Health Association of India
(VHAI)
VHAI is a federation of state level networks
of NGOs involved in health.
40, Institutation Area
Behind Kutab Hotel
New Delhi-110016
Phone .011-6518071
Fax : 011-6853708
Email vhai@del2.vsnlnetin
50, L1C Quarter,
University Road,
Pune - 411016.
Medico Friends Circle (MFC)
The MFC is a loose network of Health
Activists , doctors and researchers,who
meet once a year. They also produce a
L monthly bulletin.
Fund ng organisatwns -Much of the innovative work in the non-governmental sphere is
ept alive through grants from different Rinding organisations Infact organisations like the
I ord Foundation and the MacArthur Foundation have made special efforts to support
innovative work related to Reproductive Health. The Department of Family Welfare has
nmaJ°r S°UrCe °f SUPP0rt f0r communi'y based projects through its
Mother NGO scheme m the Reproductive and Child Health Programme Some of the
funders who support work in Reproductive health and related areas include
18
The John D and Catherine T MacArthur
Foundation - The Foundation supports
innovative individuals through its annual
Fellowship programme, as well as provides
grants to institutions.
Zone 5A, First Floor,
India Habitat Centre,
Lodhi Road,
New Delhi - 120003,
Ph -011-464 4006, 4007
^jnaikmacarth^^iasdlOl.vsnl.net.in
Ford Foundation - The Foundation has
55 Lodhi Estate,
been very active in supporting organisations New Delhi,
who have been pioneering work in different 110003,
speheres of Reproductive Health, both in
Tel-011 461 9441.
the spheres of research and in interventions
Mother NGO scheme - This scheme of
C/o Joint Secretay,
the Department of Family Welfare is
Department of Family Welfare,
supporting NGOs in different states to
Ministry of Health and Family Welfare,
become conduits for providing funds and
Nirman Bhawan,
opther kinds of support to grassroots NGOs New Delhi 110001.
tor implementing RCH projects
Rockefeller Foundation - Provides grants
1133 Avenue of Americas,
primarily for research related projects in the New York
sphere of Reproductive Health
NY 10036, -
World Health Organisation - the WHO
provides support to research on
Reproductive Health through its special unit
called Special Programme of Research,
Development and Research Training in
Human Reproduction_________
Programme for Appropriate Technology
in Health (PATH)
Is involved in supportin research and
development, technology transfer and allied
activities. Reproductive health is one of
their key issues of concern
USA.
______________
World Health Organisation,
1211, Geneva 29
Switzerland.
Fax-41-22-791 4171
4, Nickerson Street,
Seattle, WA 98109
USA.
Ph: 206-285 3500
USAID
--------------- Qutab Hotel Road,
This is the official development agency of
Tara Cresent,
the US government Population, Health,
New Delhi 011-685 6301.
and Nutrition is one of the key areas of
support for USAID The Innovations in
I Family Planning Services (IFPS) is involved
in a large project in UP PACT/CCRH and
APAC are two other projects concerning
Reproductive Health_____________
International Centre for Research on
1717 Massachusetts Avenue, Suite 302
J
19
Women (ICRW)
Provides technical and financial support for
research projects on women's health
| CEDPA
While CEDPA is primarily involved in
, providing technical support it also provides
financial support to some NCOS
Department for International
Development (DFID)
Originally known as the British ODA, this
organisation supports reproductive and
sexual health and AIDS related work in
India
Danish International Development
Agency (DANIDA)
DANIDA supports social sector activities,
which include health and women’s
development.
DSE
-«*
•.
The DSE has been instrumental in
supporting the entire WAH! initiaitve
Washaington, DC 20036, USA
Phone : 202-7970007
Fax . 202-790020___________
Liason Office,
42 Shanti niketan,
New Delhi 1100
Pho The British High Commission
50 M Shantipath ( Gate 4),
Niti Marg,
Chanakyapuri,
New Delhi 110021,
Ph: 011-687 1647, 687 1655
Technical Advisor in Development,
Royal Danish Embassy,
11 Aurangzeb Road,
New Delhi 110001.
Ph-011 301 0900
Deutsciie §tiftung fur Internationale
Entwicklung (DSE)
German Foundation For International
Development
Breite StraBe 11. D -10178 Berlin (Mitte)
Germany
Phone 49-030-23-11-92-20
Fax 49-030-23-11-92-22, 23-1 1-91-11
Foreign Aid and NGOs
Edited by : Manoranjan Mohanty and Anil K Singh
Published by and available from : VANI, B-52 Shivalik, New Delhi 110017.
20
BOOKS AND MATERIALS ON REPRODUCTIVE HEALTH
Subject specific reading lists have been provided at the end of each booklet The following
c found usefiji arran8ed
•»
»
Annotated Bibliographies
' SSw tZ:
X; "d se"al,,y “ “
NewOeK WaJ”0'08''’1 ASPe“S°f“ A Se,“‘
2.
3
4
ARROW. 1997. Gender and Women's Health: Annotated Bibliography No
Kualalumpur: ARROW.
5 p
ARROW. 1996 Women Centred and Gender Sensitive Experiences: Annotated
Bibliography. Kualalumpur: ARROW.
ARROW. 1994. Towards Women Centred reproductive Health: Annotated
Bibliography, No. 1. Kualalumpur: ARROW.
WHO 1995: Women's Health and Development' An
annotated Bibliography: Geneva,
WHO
Books
1 Pachauri Saroj 1995: Defining a Reproductive Health Package for India - A proposed
framework. Population Council, New Delhi
•
Das Gupta Monica, Chen Lincoln, Krishnan T N* 1998: Women’s Health in India
Risks and Vulnerabilities: OUP, Delhi
3. Lingam Lakshmi 199 : Understanding Women’s Health Issues: A Reader- Kali for
Women, Delhi
4 Pachauri Saroj 1999: Implementing a Reproductive Health Agenda in India' The
Beginning: Population Council, New Delhi
? Burns Augusta, Lovich Ronnie, Maxwell Jane, Shapiro Katherine 1997- Where
Women have no Doctor: The Hesperian Foundation, Berkeley
6. United Nations 1994. The Programme of Action of the International Conference on
Population and Development: New York
/ Gittelsohn, J et.al. 1994. Listening to Women Talk About Their Health: Issues and
Evidence from India. New Delhi. Ford Foundation.
8 MoHFW. 1997. Reproductive and Child Health Programme Schemes for
Implementation. India. Deptt. of Family Welfare
Journal
Reproductive Health Matters - This journal is publish biannually and in each of its issues
lakes up a diHerent theme related to Reproductive Health, which
-.1 it covers
comprehensively The journal is publsihed from
Reproductive Health Matters,
29-35, Farringdon Road,
London EC 1M3JB, England.
21
a
<
Tel (44-171) 2428656
Information Kits
'W S““’' “d R«prod«tive Health Bnef.ng Cards
.Netherlands Family Care International
2. Germaine A and R.K 1995. The Cairo Consent
,
New York International Women's Health Coalition
§ 386,1 a a“ e nsht ,lme
" ^rk’HEM"’"’3 S“'J3' “d ReprOduc'i''e
Kights-Aetton Sheets New
'
4.
. H*
<^PrOd“'™
' *-
-Y UNFPA. 1998. Population Issues Briefing kit 1998. New York; UNFPA
Books on conducting Research in Reproductive and Sexual Health
mov'w" J°el'
u M6110’ Bentley Margaret E’ Bhattacharya Karabi Russ Joan
1995. Women s Health Network Protocal for Using Ethnographic methods to
^^H^Untve^ SdFoTdX
'
Roberts He en 1990. Women s Health Counts. Routledge, London
3. Roberts Helen 1992: Women’s Health Matters: Routledge, London
4.
.
1996 Gu'd"”K fOT
5
Miller Robert et al 1997 The situational Analysis Approaoh to Assess™ F.milv
Planning and Reproductive Health Services: A Handbook: Populate cou„™ New
6
Graham Wendy et al 1995 : Asking Questions abou, Women's Reproductive Health in
Community Based Surveys: Guidelines on scope and content: London sXolo?
Hygiene and Tropical .Medicine, London
CONTENTS OF THE DIFFERENT BOOKLETS
Booklet Two
Reproductive Health Policy and Advocacy : Changing Paradigms
INTRODUCTION
Section 1- Understanding The Evolution of Reproductive Health Related
Policy
The need for the change from population control and maternal health
The international women’s health movement
International conferences, population policies and reproductive health
Other actors influencing reproductive health popuiation policies
Women centered reproductive health and population control/family
planning approaches compared
Population policies and reproductive health
Is reproductive and sexual health and rights an idea which has been
imported9
Going beyond reproductive health-developing a women’s health policy
Section 2- Family Planning and Reproductive Health Policy in India
Evolution of population related policy and its change in India
Features of the new approaches-TFA, CNAA and RCH
An assessment of the post ICPD policy changes in India
Section 3- Advocating for Reproductive Health and Rights in India
Reproductive health and cultural and political challenges to advocacy in
India
A review of current advocacy effort for reproductive health
Strategres for successful reproductive health advocacy
Advocating for change some experiences
Resource Section
Books for funher reading
Addresses of organisations involved in RH and R advocacy
3
4
4
5
7
8
9
11
12
13
14
14
15
17
20
21
21
22
24
26
26
29
Booklet Three
Reproductive and Sexual Rights : Exploring new frontiers
INTRODUCTION
Section 1- Understanding reproductive and sexual rights
The history of RSR
Some definitions of reproductive and sexual rights
Perspectives and struggles of the women’s health movement
Violations of reproductive and sexual rights
Section 2- Issues and debates in India
Access to sate methods of family planning, information and means to make
reproductive decisions free of coercion, discrimination and violence
3
4
4
5
6
7
10
10
23
i
Healthcare services for safe pregnancy and childbirth, the right to the
highest standard of reproductive health
Violations of women’s sexual and reproductive right s
Section 3- Programmatic Implications for Working on RSR
Providing services
Educational interventions
Areas for research
Law and policy advocacy
Organizations Working on Reproductive and Sexual Rights
Resource Section
Further Reading
Resource People and Resource Organisations
Support Systems
Struggles against violations
Advocacy with Community, State and Legal systems
International organisations
11
12
15
15
16
17
17
17
18
18
19
19
20
20
21
Booklet Four
Population and Demography : Understanding numbers
INTRODUCTION
Section One. Understanding Demography and Pobufatioh ’
Definitions and Concepts
Demography and Population Studies
Mortality Measures
Measuring Fertility
Megration
Demographic Transition
Sex Ratio
Population Pyramid
Expectancy of Life
Growth Rate
Population Projection
Sources of Demographic information
Census
Registration of Vital events
Sample Registration System
National Family Health Survey
Section Two Debates and Discussions
Population is a problem
People are a resource
I opulation and Natural Resources
Family Planning or development9
Social Development and Population
4
4
4
4
6
6
7
7
8
8
8
8
8
9
10
10
11
I1
I1
12
12
13
24
Population and poverty
Population Control and Women
Population Control and Family Planning
Population discourse in India
Section Three : Working on Population related areas
Organisations working on population related areas
Resource section
Books for further reading
13
13
14
14
16
16
18
18
Booklet Five
Women’s Health -1: Maternal Health i;is still important
INTRODUCTION
Section One: Understanding Women's Health
What is women’s health
Women’s health and the socio cultural context
Gender and women's health
Women’s health and the health care delivery system
Women’s perception of their bodies
Menarche, menstruation and menopause
Menstrual problems
•
Section 2- Maternal Health and Safe Motherhood *
The importance of safe motherhood
Reasons behind unsafe motherhood
Ensuring safe motherhood
Antenatal care
Supplementary programmes of the government
Care during childbirth
Post partum care
Section 3-Implementing a Maternal Health Programme
Understanding the community
Strengthening community capacities
Preparing for referral
Dealing with traditional practices
Health education and communication strategies
Some Innovative Projects In The NGO Sector
Resource Section
Further Reading
Resource Organisations
J
4
4
6
6
7
8
9
9
9
10
11
11
12
13
15
15
16
16
16
17
18
20
20
23
^5
4
1
Booklet Six
Women’s Health-2 : The Promise of Better Health
INTRODUCTION
Section I: Understanding Women's health problems
Determinants of women's health
Socio-cultural determinants
Bio-medical determinants
Economic determinants
Environmental degradation and women's health
Violence as a determinant of women's health
Domestic violence
Violence in displacement and conflict situations
Common gynaecological morbidities in India
Common women's health problems
RTIs
Abortion
Infertility
Some other health problems
Women's health in later years
Menopause
Health problems of the elderly
Section Two Important issues ffor operationalising
_
women's health
Role of traditional and home remedies in women's halth
Women's access to health care
Understanding the language of women
Women health care givers
Empowering women for health
Section Three. Working on women's health
Different approaches of working on women's health
Strategies for change
Training for women's health
Some Innovative community based women’s health programmes
Resource Section
Further reading
Resource Organisations
4
4
4
5
S
5
6
6
6
7
7
8
9
10
11
12
12
13
15
15
16
16
17
18
19
19
19
20
21
22
22
22
Booklet Seven
Contraception: Going beyond Family Planning
INTRODUCTION
Section One Contraceptive Options
What is contraception
Efficacy of Contraception
3
S
5
6
26
Brief description of different contraceptives
Natural Methods
Barrier Methods
Methods that prevent fertilisation
Abortion
Hormonal Methods
Permanent methods
Emergency Contraception
Section Two : Issues and Debates in India
Contraception or Family Planning
Male Responsibility for Contraception
Reproductive Rights and Contraception
Government services for contraception - a review
Violence Gender and contraception
Provider control vs user control
Clinical Trials, Human rights and contraceptives
Section Three Implementing a Contraceptive Programme
Contraceptive Research
Advocacy
Organisations working <on Contraception and Family Planning
Resource Section
Books and Reports
Videos
Resource Organisations
6
6
9
12
13
15
19
21
22
22
23
23
24
25
25
25
27
28
28
29
32
32
33
34
Booklet Eight
Adolescents: The emerging Agenda
INTRODUCTION
Section One : Understanding Adolescence
Some Definitions
Adolescent Sexuality
Patterns of sexual behaviour in adolescents
Anxiety around pubertal changes
The generation gap
Peer pressure
Sex education for adolescents
Section Two Adolescent reproductive and sexual health in India
Minimum age at marriage
Consequences of early marriage
Adolescents and abortion
Adolescents and reproductive morbidities
Adolescents and STD/HIV/AIDS
Adolescents and young people in Inda some facts and figures
3
4
4
4
5
5
6
6
7
9
9
9
10
10
10
10
27
Section Three : Working with adolescents
Issues to be kept in mind while devising programmes
Recommendations for action
Some Innovative Projects
Resource Section
Resource List of Materials
Resource Organisations
Booklet Nine
Men's Health and Responsibility : Forging
12
12
13
15
17
17
22
new Partnerships
INTRODUCTION
Section One: Establishing Men’s Role in Reproductive Health
Evolution of the idea of men’s involvement
Men’s responsibility in Reproductive Health
ICPD and men
The need for increasing men’s role and responsibility in RH
Men s knowledge and involvement in Family Planning
Increasing men’s responisbility
The health system in India and men’s involvement *
Section Two . Men’s Health
Men’s health as distinct from men’s responsibility *
Men s halth and its social determinants
What needs to be done
Men’s socialisation and their health
Masculinity
Men’s Reproductive Health
Reproductive Health problems of men
Health seeking behaviour and service providers for male RH problems
Some important Reproductive health problems of men
Section Three. Starting a programme for men and RH
Important Imperatives
Some organisations working on men’s health and involvement
Resource Section
Further Reading
Resource Organisations
4
4
4
5
5
6
7
9
10
10
10
11
11
12
13
14
14
15
17
17
19
21
21
22
Booklet Ten
HIV/A1DS & STDs: Coming to Terms with Reality
INTRODUCTION
Section One . AIDS and STDs Some Basic Information
History
4
4
28
The Origin of the HIV
What is AIDS?
What is HIV9
The HIV Continuum
Diagnosis of HIV and AIDS
HIV Transmission
Prevention of HIV
STDs
Safer Sex
Treatment of HIV related Infections
Section Two . AIDS and Society in India
AIDS in India
Women and AIDS
Human Rights , AIDS and the Indian legal system
Living with AIDS - living positively
Section Three: Working on AIDS
Working on Preventing the spread of HIV
Working on HIV/AIDS care and support
Some Innovative Projects
Resource Section
Further Reading
Resource Organisations
4
4
5
6
7
9
10
11
12
13
15
15
16
19
21
23
23
24
26
28
28
29
' Booklet Eleven
Sex and Sexuality; Acknowledging Ourselves
INTRODUCTION
Section One : Understanding Sex and Sexuality
Sexuality
Sexual Health
Sexual Anatomy
Puberty
4
4
4
5
5
Social Construction of Sexuality
Sexuality and Reproductive Health
Common Sexual Problems: Sexual disorders and dysfunctions
1. Sexual dysfunctions in men
2. Sexual dysfunctions in women
Preventive and curative aspects of sexual health
Different forms of sexuality and gender
A. Heterosexuality, homosexuality and bisexuality
B Transvestitism, cross-dressing and Transexualism
C Hijras
D Paraphilias
Section Two: Issues and Debates in India
Human Rights and sexuality
6
7
7
7
8
8
9
<)
10
10
11
I I
29
Indian history and sexuality
Sexuality and sexual behaviour in India
Heterosexuality the only acceptable form of sexuality
Homosexuality
Male Homosexuality
Female Homosexuality
Crime and sexuality
Child Sexual Abuse
Rape
Eve Teasing and Sexual Harassment
Section Three: Working on Sexual Health Issues
Research
Education
Services
Media
Law and Policy
Organisations working on Sexual Health and Sexuality
Resource Section
Further Reading
Other Resources
Resource Organisations
11
11
13
14
15
15
15
15
16
17
17
17
17
18
18
18
21
21
22
23
I
Booklet Twelve^ .
•
Women have Minds Too! Exploring the interface between RH and Mental
Health
Introduction
Section One- Understanding Mental Health and Mental Illness
What are Mental Health and mental Illness
Linkages between Reproductive Health and Mental Health
Reproductive Symptoms and Psychological Disorder
Childbirth and Mental Health
Family Violence and Mental Health
Rape and mental health
Child Abuse and Mental Health
Reproductive Tract Surgery and Mental Health
Abortion and Pregnancy loss
Adolescent and Mental Health
PMS, Menopause and Mental Health
H1V/A1DS and Women's Mental Health
Section Two - Programmes and Policy: Issues and Debates on Women and
Mental Health
Ihe rights of the mental ill, and improvement of mental health care
Hysterectomy of mentally retarded women
Media and mental health
3
4
4
5
5
5
6
6
6
7
7
7
8
8
10
10
10
1I
30
Mental Health Services and Care
Section Three: Women and Mental Health Research: An agenda for the
future
Society, Women and Mental Health
Mental Health policy and women
Resource Section
Further Reading list
Resource Organisations
Other Resources
11
13
14
15
16
16
18
19
31
4
List of Contributors and Reviewers
Editors
Jashodhara Dasgupta
Abhijit Das
SAHAYOG, Almora
-do-
Contributors
Abhijit Das
Aleyamma Vijayan
Alka Agarwal
Alok Srivastava
Anuja Gupta
C. Y.Gopinath
Dhanu Swadi
Geeta Sodhi
Kirti Iyengar
Jashodhara Dasgupta
Rahul
Ranjan
Sagri Singh
Shubhadra
Vasavi
Vikram Patel
See above
Sakhi, Trivandrum
SAHA YOG, Almora
SAHAYOG, Almora
RAHI, New Delhi
Independent media person, Mumbai
Independent Researcher, Shimla
SWASTHYA, New Delhi
ARTH, Udaipur
See above
KnV, MadhyaPradesh
Jana , Bokaro
Population Council, New Delhi
KnV, Madhya Pradesh
Journalist, Ranchi
Sangat Society; Goa
Reviewers of different
booklets
Abhijit Das
Amitcajit Saha
Bela Ganatra
C. Y.Gopinath
Dhanu Swadi
Jashodhara Dasgupta
Kirtana Kumar
Kranti
Laxmi Murthy
Sagri Singh
Saraswathy Raju
Siddhi Hirve
Vikram Patel
^-See^bove.
-• '
.SHIP, Calcutta
SYNTHESIS, Pune
See above
See above
See above
Independent film maker. Bangalore
Women’s health activist, Mumbai
Saheli, New Delhi
See above
Population Council, New Delhi
SYNTHESIS, Pune
See above
Reviewers of the entire
Resource Pack
( to be added)
32
VO H
\ \I o
FIGO
WOMEN’S SEXUAL & REPRODUCTIVE RIGHTS
PROJECT INDIA
BACKGROUND MATERIAL FOR 24 ™ MAY MEETING
The First Phase of the FIGO - WSR.R Project was successfully completed with the
organization of a National Workshop to confirm priority areas of concern where
human rights failings impact on women’s health.
The Workshop was held on the
11th & 12th of May 2002 at New Delhi. Participants included representatives of the
Government of India,
active national and international NGOs,
activists, religious leaders,
women’s activists, legal representatives
human rights
as well as
members of FIGO and the Federation of Obstetric & Gynecological Societies of
India.
The National Workshop was conducted over a two day period - the first day being
devoted to a Safe Abortion Workshop followed by a Public Forum and the second
day being taken up with a closed door meeting involving Group Discussions to
identify and confirm priority areas where human rights failings impact on women s
health.
Five priority areas were identified for discussion
1.
2.
3.
4.
5.
Making Abortion Safe and Accessible
Anemia Prevention
Adolescent Reproductive and Sexual Health
Preventing HIV/AIDS
Female Feticide - Countering the Menace
The Working Group Discussions discussed, debated and endorsed the above issues and
confirmed the necessity of Ob/Gyn professionals collaborating with other concerned
groups to protect, promote and advance women’s sexual and reproductive rights. It was
recognized that definitive actions would be required for endorsing, articulating and
(2)
advocating for these rights. The role of FOGSI in each of these priority areas was
identified.
It was confirmed that
•
FOGSI could be instrumental in advocating for a change in legal statutes and in
rules and regulations that sometimes act as a barrier to the realization of these
rights.
•
FOGSI as a group and its members in their individual capacity can bring about
changes in medical practice /standards to make them gender sensitive and ethical.
It was also recognized that if any progress is to be made towards the realization of
women’s health rights, FOGSI needs to work in partnerships with a variety of other
stakeholders including the Central and State Governments, NGOs, local self government,
community based organizations and civil society. The intention is to contribute to
national initiatives to promote compliance with human rights principles and
initiate
dialogue and action on how a human rights approach to advance safe motherhood might
be developed and applied.
The Workshop received wide media coverage not only in the national dailies but also in
scientific and medical newsletters and journals. The report of tlris National Workshop
has been printed and copies of the report are being circulated to all 16,000 member of
the national federation and other medical societies.
From the five priority areas identified in the National Workshop two have been
selected for further action
1. Safe Abortion
2. Adolescent Reproductive Health
A National Steering Committee and a National Advisory Committee have been set up
comprising of the following members who are identified below.
(3)
Advisory Committee :
1. Dr.Sadhana Desai, President, FOGSI
2. Dr.Shyam Desai, Hon. Sec. General, FOGSI
3. Dr.LIsha Saraiya, Imm. Past President, FOGSI
4. Dr.Behram Anklesaria, Incoming President, FOGSI
5. Dr.Alokendu Chatterjee, Past President, FOGSI
6. Dr.Narendra Malhotra, 1st Vice President, FOGSI
7. Dr.Kiran Sekhar, 2nd Vice President, FOGSI
8. Dr.Nimish Shelat, 3rd Vice President, FOGSI
9. Dr.C.N.Purandare, Hon.Jt.Secretary, FOGSI
10. Dr.P.K.Shah, Hon. Treasurer, FOGSI
11. Dr.Pushpalatha, Chairperson, Family Welfare Committee, FOGSI
12. Dr.Chandravati, Vice President, FOGSI (2001)
13. Dr.Hema Divaker, Chairperson, Perinatology Committee, FOGSI
14. Dr.Prakash Mehta, President, BSOG
15. Dr.Arul Mozhi, Secretary, BSOG
16. Dr.Mohini Prasad, Incoming President, BSOG
National Steering Committee:
1. Dr.Kamini A. Rao, Coordinator WSRR Project, India
2. Dr.Nozer Sheriar, Chairperson, MTP Committee, FOGS1
3. Dr.Parul Kotdawala, Chairperson, Adolescent Committee, FOGS!
4. Dr.Mandakini Parihar, Hon.Jt.Secretary, FOGSI
5. Prof. R.V.Azad, President, National Board of Examinations
6. Dr.Subhash Penkar, Chairman, Advisory Board, NBE
7. Dr. S. Kantha, Dean , Vaidehi Institute of Medical Sciences
8. Dr.N.C.Saxena, Indian Council of Medical Research
9. Dr.H.Sudarshan, Lok Ayukta
10. Dr.Amar Jessani, Programme Co-ordinator, SCTIMST
11. Dr.Sabu George, Centre for Women’s Development Studies
12. Prof. Joga Rao, Legal Consultant, Pegasus Health Law
13. Dr.V.S. Chandrashekar, IPAS
14. Dr.Lester Coutinho, Packard Foundation
15. Dr.Thelma Narayan, Community Health Cell
16. Ms.Munira Sen , Director, Madhyam
17. Capt.V.V.K. Mani, Editor, The Hindu
18. Justice. Manjula Chellur
•
A meeting of the National Steering Committee has been scheduled between
10.30am and 5.30pm on the 24th May 2003 at Hotel Le Meridien, Bangalore.
•
The aim of this meeting will be to initiate discussions and draw up a preliminary
draft on Professional Standards and Guidelines regarding the respect and
(4)
promotion of Human Rights in relation to sexual and reproductive health with
•
special emphasis on Safe Abortion and Adolescent Health.
Based on the discussions at the meeting a final draft on Professional Standards
•
and Guidelines regarding the respect and promotion of Human Rights in relation
to
Abortion
and
Adolescent Health will
committee.
This draft will be circulated to
•
all
be drawn up
by the steering
FOGSI’s member Societies and 16,000
members prior to finalization as part of a National Code of Ethics.
The advisory and steering committees will meet at regular intervals once in two
•
months to finalize the National Code of Ethics
Based on the draft on professional standards and guidelines and taking inputs
•
from FOGSI members into consideration, the National Steering Committee will
identify appropriate specialists in Ethics and Human Rights, who will be asked to
draft a medical code of ethics in support of women’s sexual and reproductive
rights in general. The Code of Ethics should aim at sensitizing health care workers
and medical professionals to ethical and human rights issues with respect to Safe
Abortion and Adolescent Health and contribute to improvements in professional
standards of practice.
•
The Code of Ethics will tackle the following issues:
a)' Access to safe abortion services; counseling regarding all options; safe and
technically competent procedures, as well as to confidentiality and privacy
health risks during
b) Exposure of women to HIV/AIDS and other
<----- —
„ unsafe
abortion
c) The patient’s right to information
d) The patient’s right to confidentiality
e) Enforcing professional ethics for prevention of sex selective abortions
f) Discrimination faced by women from childhood with regard to Health
g) Perpetuation of sexual stereotypes in adolescents
I I"
(5)
h) Discrimination of women by making them the sole targets for family
planning measures
i) Adolescent Health in terms of high percentage of early marriage, early child
bearing, lack of contraceptive access etc.
•
On finalization of this Code of Ethics it will be forwarded to the Medical Council
of India, for adoption as part of the National Code of Ethics.
•
Health being a State subject in India,
stimulated
FOGSI’s member societies will be
to co-ordinate with the State’s
Directorates of Health & Family
Welfare as well as the Directorate of Medical Education in implementing this
Code of Medical Ethics and incorporating it into the medical curriculum, both for
undergraduate and post graduate education.
@$@$@$@$@$@$@$@$@$@$@$@
WOMEN’S SEXUAL & REPRODUCTIVE RIGHTS PROJECT
24 ™ MAY 2003 AT HOTEL LE MERIDIEN , SANKEY ROAD, BANGALORE
AGENDA
1030 AM
WELCOME BY PRESDENT BSOG
DR.PRAKASH MEHTA
1035AM
ADDRESS BY FOGSI PRESIDENT
DR.SADHANA DESAI
10.45 AM
WSRR PROJECT
DR.KAMINI A. RAO
TEA
11.15 AM
1130 AM
to
130PM
FORMATION OF TWO GROUPS & GROUP DISCUSSION
GROUP I : SAFE ABORTION
GROUP H : ADOLESCENT REPRODUCTIVE HEALTH
130 PM
LUNCH
230 PM
230 to 3.00PM
3.00 to 3.30PM
PRESENTATION OF REPORTS BY RAPPORTEURS
GROUP I REPORT
DR.NOZER SHER1AR
GROUP II REPORT
DR. P. KOTDAWALA
330 to 4.45PM
CONSENSUS ON RECOMMENDATIONS
DR.SADHANA DESAI/DR.AMAR JESSANI/DR.KAMINI RAO
4.45 PM
4.50 PM
VOTE OF THANKS
TEA
DR. MOHINI PRASAD
(2)
WORKING GROUP I : SAFE ABORTION
Chairperson: Dr.Amar Jessani
Rapporteur : Dr. Nozer Sheriar
Members :
1. Dr.Usha Saraiya, Imm. Past President, FOGSI
rOGSl
2. Dr.Kiran Sekhar, 2nd Vice President, FOGSI
3. Dr.C.N.Purandare, Hon.Jt.Secretary, FOGSI
4. Dr.Chandravati, Vice President, FOGSI (2001)
5. Dr.Prakash Mehta, President, BSOG
6. Dr.Arul Mozhi, Secretary, BSOG
7. Dr.Mandakini Parihar, Hon.Jt.Secretary, FOGSI
8. Prof. R.V.Azad, President, National Board of Examinations
9. Dr.N.C.Saxena, Indian Council of Medical Research
10. Dr.Sabu George, Centre for Women’s Development Studies
11. Ms.Munira Sen , Director, Madhyam
12. Dr.V.S. Chandrashekar, I PAS
CODE OF ETHICS FOR SAFE ABORTION IN RELATION TO :
■
Patient’s Right to Life
■
Patient’s Right to Information
■
Patient’s Right to Decide Whether or When to have Children
■
Patients Right to Respect at the time of Treatment
■
Patient’s Right to Medical Intervention only after free and full Consent
■
Patient’s Right to Privacy and Confidentiality
■
Patient’s Right to Competent and Safe Abortion Services
■
Patient’s Right to Counseling regarding all options
■
Patient’s Right to Equality without any kind of Discrimination
■
Patient’s Right to Post Abortion Contraceptive Counseling
i
(3)
WORKING GROUP II : ADOLESCENT REPRODUCTIVE HEALTH
GROUP II : ADOLESCENT REPRODUCTIVE HEALTH
Chairperson: Dr.Sadhana Desai
Rapporteur : Dr. Parul Kotdawala
Members :
1. IDr.Alokendu Chatterjee, Past President, FOGSI
2. Dr.Nimish Shelat, 3rd Vice President, FOGSI
3. Dr.P.K.Shah, Hon. Treasurer, FOGSI
4. Dr.Pushpalatha, Chairperson, Family Welfare Committee, FOGSI
5. Dr.Hema Divaker, Chairman, Perinatology Committee, FOGSI
6. Dr.Mohini N. Prasad, Incoming President, BSOG
7. Dr.Subhash
I
Penkar, Chairman, Advisory Board, NBE
co
8. Dr. S. Kantha, Dean , Vaidehi Institute of Medical Sciences
9. Dr.H.Sudarshan, Govt. Lok Ayukta
10. Dr.Lester Coutinho, Packard Foundation
11. Dr.Thelma Narayan, Community Health Cell
12. Capt.V.V.K.Mani, Editor, Hindu
13. Justice Manjula Chellur, Karnataka High Court
CODE OF ETHICS FOR ADOLESCENT REPRODUCTIVE HEALTH
RELATION TO :
IN
.
■
Adolescent’s Right to appropriate Sexual|& Reproductive Health Services,
■
Adolescent’s Right to Information and Sexual Education
■
Adolescent’s Right to Privacy, Confidentiality and Autonomy
■
Adolescent’s Right to appropriate Counseling within the Social and Cultural
context of the community about the dangers of high risk SRH behaviour
■
Adolescent’s Right to Equality in Health Care
without
any kind of
Discrimination
■
Adolescent’s Right to appropriate Health care and Health Protection
■
Adolescent’s Right to access effective Contraceptive Services
■
Adolescent’s Right to access support
systems and gender sensitive health
services to deal with their psychological and emotional needs
4’
i-
LOH _ li'JO.
Community Involvement in Reproductive Health:
Findings from a Research Project in Karnataka
Dr. Nirmala Murthy
Ms. Akhila Vasan
Foundation for Research in Health Systems
355, IE Cross, 6th block, II Phase, BSK III Stage Bangalore 560 085
Tel/ Fax: 080- 672 3937
Email: frhs@vsnl.com
1
<
Contents
r
Page
I. Introduction
2
II. Process of Operationalizing the Health Committee Model
7
III. Health Committee’s Performance
14
IV. The Committee Impact
18
V. Factors Contributing to Effectiveness of the Committee Model
26
VI. Sustaining and Up-scaling the Committee Model
30
References
34
Appendix 1
35
Appendix 2
36
Community Involvement in Reproductive Health:
Findings from a Research Project in Karnataka
I. Introduction
In April 1996, the government of India (GOI) decided to provide a package of reproductive
and child health (RCH) services through its existing family welfare program (1). To deliver
those services GOI decided to adopt a community needs assessment approach (CNAA) that
was largely based on ICPD principles, recognizing women’s right to reproduce and regulate
their fertility; gothrough pregnancy and childbirth safely; and have sexual relations, free from
fear of pregnancy and diseases) (2).
To implement this approach, the GOI replaced its 3-decade old centralized contraceptive
target setting method with a decentralized planning method. In this method health workers
were to estimate reproductive health needs of women in their areas and prepare local plans
to meet those needs. They were expected to involve community leaders in this exercise,
thus promoting community involvement in the RCH program (3).
However, several field studies carried out during 1998-2000, showed that the CNAA had
achieved little in terms of increasing community involvement though it had helped relieve
health workers off the target pressure (4).
This was because, GOI had provided little
guidance to health staff on howto involve community and also provided little incentive to
community leaders (such as devolution of funds) to get involved (5). Health staff was also
not too keen to involve community leaders since they feared their interference (6).
Past experiences of community invoivement in health programs
In India, there have been three well-known experiences of the government involving
community in health programs. These were - Community-Based Distribution (CBD) project,
Community Health Volunteer (CHV) scheme, and Link Worker scheme.
In the CBD project, village health committees selected “Sanyojak” (organizers) to function
as depot holders, mainly for contraceptive methods. They received free supply of
contraceptives from the government, which they sold for a small price. That small profit was
their incentive to work as organizers.
2
In the CHV scheme, introduced in 1977, village leaders selected health-volunteers from
within villages. Government provided them training, medicine kits and a small monthly
honorarium. CHVs provided treatment for minor ailment and motivated couples to accept
contraceptive methods.
This scheme was discontinued in 1983 when CHVs started
demanding that they be absorbed in government service.
In the Link Worker scheme, government appointed volunteer couples from among villagers
and paid them a small honorarium to function as contraceptive depot holders. They
promoted contraceptive use in their communities as long as the government paid them the
honorarium.
Thus, in all three schemes, community involvement meant appointment of one volunteer per
village, selected either by village leaders or by health officers. Volunteers received
honorarium or incentive from the government and in return they performed certain tasks
assigned to them.
Many of them considered themselves village level government
functionaries.
Besides the government, most non-government organizations have also tried to involve
community in their health programs by using volunteers and paying them honorarium but
rather more successfully, by ensuring that community selected volunteers and volunteers
received adequate training that built their capacity to address community’s health needs
Recently some states have attempted to involve community through mechanisms such as
gram panchayat and village level health committees. A notable among these attempts has
been Kerala’s people’s plan model. It involved people in the identification of development
issues, in resource allocation decisions as well as in carrying out social audit of development
programs. Two distinguishing feature of this attempt however, have been the devolution of
35-40 percent of state’s plan funds to local self-government and clearly articulated project
formulation / resource allocation guidelines that helped curb misuse of those funds by local
vested interests (8).
Many states have also tried use mechanisms such as village health committees such Mahila
Swasthya Sangha (MSS) and Health Advisory Committees.
But these committees are
usually seen as being dominated by village elite and their role has remained confined to
mobilization campaigns such as pulse polio (9). Health staff often uses them to spread
3
health education messages but not so much for planning or monitoring of health delivery
services.
The Project Background
Under the India Population Project-IX (1997-2002), the government of Karnataka had tried to
form Sub-center Health Advisory Committees to promote community participation. Each
committee was to have 8-10 members, with panchayat leader as its president and female
health workers as its member secretary. Other members included development functionaries
like mukhya sevika, local doctors and prominent women from community. State Government
had directed female health workers to constitute these committees and agreed to provide
Rs.200 / per month to cover meeting expenses. But most health workers had not formed
these committees and the state government had also not pursued the idea vigorously.
However, in the context of decentralized planning under the RCH program, the state
government was interested in revisiting it.
The Foundation for Research in Health Systems (FRHS), an NGO working in the area of
health systems research, was also interested in finding effective ways of involving
community in decentralized planning. Therefore it sought collaboration with the state
government in an action research project to be carried out in Hunsur block of Mysore district
in Karnataka, from July 2000 to June 2002. The project was funded by the Frontiers Group
of the Population Council, New York.
Mysore district is located in the southern most part of Karnataka, about 200 Km from
Bangalore City. Its population of 2.6 million is divided into 7 blocks of which Hunsur is one
block consisting of 216 villages and a population of about 258 thousand. This block has 14
primary health centers and 70 sub-centers of which 64 are rural and 6 are urban.
This block is well connected to Mysore City by road. Government buses ply on this route
rather frequently though 25 percent of its villages are not connected to this route. Hunsur
town is situated on the state highway linking Karnataka to the neighboring state of Kerala. It
is close to the Nagarahole National Park, a major tourist attraction. This block also has a
Tibetan refugee settlement residing in five out of its 64 rural sub- centers. They live in small
settlements (Haadis) distant from main villages.
4
In this block FRHS decided to experiment with a new model of health committee which was
to be different from the health committee proposed under the IPP-9 project, in terms of its
structure, formation process and role. And to assess impact of this model on community
involvement and consequently on RCH performance, FRHS a-priori selected ten indicators —
five to assess committee performance and five to assess awareness and use of reproductive
health services in communities.
This paper describes this new model of health committee in terms of its functionality and
effectiveness and how it could be up-scaled and sustained in the regular health program.
Description of the Committee Model
At the outset, FRHS convened a one-day meeting of health staff from Hunsur block, active
women panchayat leaders, local NGOs and representatives of successful Community Based
Organizations (CBO) such as School Betterment Committees, Youth groups, MSS. FRHS
used this meeting to discuss objectives of the experiment and to seek their suggestions on
how to modify the IPP-9 health committee concept. After some deliberations, participants to
the conclusion that for health committees to be effective they must have the following
features:
•
Committee members should be selected by community and not by Government staff
•
Committees must have both, men and women and must have caste representation
•
Committees must have some funds for start-up activities to facilitate their work
•
Committees must get some help at least initially, to decide what to do or not to do
FRHS accepted all these recommendations and accordingly decided that:
Committee structure
• Health Committee would be formed at sub-center level with representation from all
constituent villages.
•
Each member would represent a cluster of 50-60 households in a village
• Each committee would try to select at least fifty percent women members
•
Committee members would select president and secretary from among themselves
•
Committees would co-opt health workers, anganwadi worker and gram panchayat
members
5
Formation process
Health staff would use village maps to identify clusters of households of different castes
•
and communities
•
From each cluster of 50-60 households, health staff would suggest potential candidates
for health committee
•
The list of members would be approved / finalized by village leaders, preferably during
gram sabha meetings.
Committee Role
•
Committees will undertake activities to create health awareness and demand for new
health services
•
Members will participate in identifying people’s health needs and developing activity
plans
.
Committees will be responsible to foster trust and understanding between community
and health staff
To implement this model and to give initial support to health committees, FRHS appointed
seven Community Facilitators (CF), one per two PHCs. They were to help form health
committees, train members in their roles and responsibilities as well as guide them in
performing their roles.
The remainder of this paper is divided in six sections. Section II describes the process of
operationalizing this health committee model. Section III presents data on their performance.
Section IV presents data on their impact on community involvement and RCH performance.
Section V presents our analysis of factors responsible for the impact. Section VI summarizes
the findings and suggests strategy for replicating and sustaining this model in the regular
RCH program.
6
Implementation of this project began with a baseline survey in the experimental block. After
the survey, CFs initiated the process of the committee formation and orientation. FRHS then
provided certain inputs to these committees to facilitate their functioning. This section briefly
describes this process that finally resulted in operationalizing 64 health committees, covering
all rural sub-health centers in Hunsur block.
1. Baseline Survey
At the start of the project, a household survey was carried to gather baseline data on
awareness and utilization of RCH services in Hunsur, the experimental block. The sample
consisted of 1000 randomly selected 1000 women of reproductive ages from 30 villages.
Data from this survey were to be used by researchers to assess the project impact as well
as by committees to decide what types of health activities they should undertake. Some of
the major findings from this survey were:
• The contraceptive acceptance in the block was high (72%) but about a third of acceptors
reported suffering from contraceptive side effects.
•
Almost all pregnant-women sought prenatal care but less than one-third of them received
•
all components of that care.
About 60 percent deliveries took place at home and were attended only by untrained dai
or relatives.
•
About one-fourth women reporting complications during delivery and nearly half of those
reporting serious postpartum complications (excessive bleeding, lower abdominal pain,
fever) had received no treatment.
•
About one in four women reported suffering from at least one symptom of RTI but less
than one- third of them had sought treatment.
•
More than half the women had heard about AIDS but did not know how it occurred or
how to prevent it.
•
Child immunization was universal but practice of immediate breast-feeding was low
(31%). Only one in five babies were weighed at birth and less than half of mothers knew
about giving ORS to children with diarrhea.
7
2. Health Committee Formation
After the baseline survey, CFs began the process of committee formation by asking health
workers to map out all villages, then identify clusters of 50-60 households that belonged to
various castes and communities and finally create lists of persons from these clusters who
could be nominated to health committees. Though health workers had agreed to follow this
process, difficulties cropped-up just when they began implement it. In a few committees,
panchayat leaders disagreed on names that workers had proposed and suggested names,
which workers did not accept.
But, instead of calling a gram sabha to finally select
members, both workers and leaders argued that they should be the ones to decide the
membership-- health workers because they had to work with committees; leaders because
they knew what was good for their people.
Researchers then decided to resolve this issue through an experiment. Out of 7 PHCs they
had selected for phase one implementation, they assigned three PHCs to gram sabha
method, two to health worker method and two to panchayat method of selecting committee
members.
The Gram sabha method, involved calling of gram sabhas in which CF and health
supervisors informed people about the project and the role health committees were expected
to play. People then suggested names of individuals from different clusters for committee
membership. If those individuals were present in the meeting, their consent was taken.
These meetings typically lasting one to two hours and took over three months and
scheduling of over 80 gram sabhas to form 16 committees since Gram sabhas often got
postponed due to wedding, death or festival in villages. This method also made substantial
demand on CFs’ time. CFs had to be present in all gram sabhas, each time spending 2-3
extra hours waiting for people to gather.
The health worker method involved health workers listing potential committee members
from each cluster and finalizing the list after consulting a few formal and informal village
leaders. Workers usually tried to accommodate changes suggested by leaders, if any. By
this method, they could form nine committees within one month without making any demand
on CF's time.
The panchayat method involved CF informing panchayat members about the project and
requesting them to nominate members to health committees from each cluster of 50-60
8
houses. Panchayat leaders typically asked CFs to come back later for the lists since they
needed to consult other people, they said. This method took about two months to form 11
committees because leaders were either busy or not available whenever CFs visited them.
After 6 months, researchers evaluated the functioning of these 36 committees on three
criteria - members’ acceptance in the community, member profile and committees’
performance. This evaluation showed that:
•
Members’ acceptance was high in committees formed by gram sabha and by health
worker methods but was relatively low in case of committees formed by panchayat
method.
•
Gram sabha method gave the highest representation to women while the panchayat
method gave the least. Health worker method was in between. However, all three
methods gave similar adequate representation to SC/ ST.
•
Performance, in terms of committees conducting programs was highest in panchayat
method (100%), followed by gram sabha methods (94%) and the lowest in the health
worker method (78%).
In gram sabha method, people knew who was selected and why. There were no serious
disagreements about members’ selection except in three instances. In one instance, leaders
had agreed to accept people’s choice. In another, people agreed to include two of leader’s
men in the committee. In the third, the leader managed to appoint all members of his choice
by not allowing anyone to speak in the gram sabha.
In health worker method also there were no major disagreements or complaints about
member selection.
In panchayat method however, there were many complaints.
Most
leaders, it seemed, had not consulted any one while nominating members and therefore
people asked researchers about criteria for selecting certain individuals. They also
complained about some clusters being left out and some being over-represented.
On the whole, the gram sabha method fared better in ensuring transparency and giving
higher representation to women but it was also a time-consuming method, requiring a lot of
CF’s time and involvement. Health staff was not able to manage gram sabhas on their own
without the CFs’ presence. They told researchers, “because CFs are outsiders they are
respected. We will not get the same response from gram sabha without CFs’ involvement”
9
Since researchers were interested in finding a method that was feasible within the existing
set- up, they decided to try out another combination method in the remaining 7 PHCs of
Phase 2.
The combination method involved combining some features of gram sabha and health
worker methods. In that, health workers listed potential members as before, but instead of
consulting a few leaders individually they called a meeting of panchayat leaders, members of
SHG, youth groups, caste leaders, anganwadi worker and teachers to finalize the list. By
this method, they formed 28 committees in 3 months, without involving the CFs. However,
CFs attended all first meetings of these committees to find out whether a proper selection
process was followed and membership norms were met.
The total of 64 health committees thus formed using four different methods, were again
evaluated at the end of the project period using 8 performance indicators (Table2).
Table 2: Committee performance by method of formation
Sr? Indicators
Gram
Health Panchayat|Combination Total
sabha worker leader
16
9
11
28
64
% Committees with 50% or more women 75
56
27
43
50
33
64
50
52
78
100
86
89
78
36
75
70
Number of Committees
1
method
members
2
% Committees with more 40% or more 56
SC/ ST members
3
% Committees conducted at least one 94
program
4
% Committees with good relationship with 82
health staff
5
% Committees Mobilized resources
88
56
63
79
75
6
% Of committee meetings held
58
45
53
54
54
7
% Members attended committee meetings 44
38
34
48
43
8
% Committees where members shared 69
30
64
71
64
414
52
441
55
506
63
497
62
tasks
Total Score
Average score
566
71
10
This analysis once again showed the gram sabha method as the best. It scored better than
the “combination” method on all indicators, especially on giving due representation to
women. That was because of the moderating role CFs had played during gram sabhas. CFs
had ensured that women participated in the meetings and their voices were heard.
3. Orienting committee members
After committees were formed, CFs organized orientation meetings for members to discuss:
•
Their roles and responsibilities
•
Community Needs Assessment approach (CNAA) under the RCH program
•
Problems people faced in getting services at PHC, and
•
Actions health committees could take to improve health conditions in villages
PHC staff usually attended these meetings. Typically these meetings began with CFs
explaining the purpose of this project and the role health committees were expected to play.
CFs especially emphasized the need for committees to function in partnership with health
staff, local CBO and panchayat.
Next, health workers informed committee members about Community Needs Assessment
(CNA) approach under the RCH program and presented health data collected from their
respective communities. Most members expressed satisfaction with their data but some
also expressed doubts aboufquality of that data.
Committee members then discussed problems people faced in getting services at PHCs.
They usually complained about health staff not being friendly, doctors not giving free
medicines, health staff demanding money, not being available etc. Though these complaints
used to upset the health staff, most tried to respond to them politely. CFs, on their part, also
explained that committees’ role was not to find fault with health staff but to work with them.
Through such interventions they ensured that most meetings ended cordially though many
had begun belligerently.
After the end, each committee had to decide its first activity that it would implement in the
following one-two months. Since a key to activating a committee was to ensure that its first
activity gets implemented successfully, CFs urged them to select activities that were easy to
implement. They also provided support to them, if needed. For example, one committee
had planned a village-level clinic as their first activity. That activity was about to be cancelled
11
because the health worker was on leave that day. CF then met with the PHC doctor and
requested him to send another worker in her place. The doctor agreed and the clinic was
held as planned.
Each CF had a calendar of activities that committees had planned. They followed each of
those until they were implemented.
4. Provision of Project inputs
This project provided five types of inputs to facilitate committees’ functioning. These were:
1. Community facilitators
2. A start-up grant of Rs. 2000 per committee
3.
Identity cards for committee members
4. Bi-annual meetings of committee presidents
5. Publication of a monthly newsletter
Community Facilitators (CF) helped in forming committees and facilitating their functioning.
They were young men and women with college education and experience of grass roots
development work. Of the 7 CFs appointed, five belonged to Mysore district and two came
from North Karnataka. They all had good communication skills and were trained to be good
moderators. They were good listeners, non-partisan, respectful to community and were
highly motivated.
They attended all committee meetings and activities in their respective areas. Initially they
also gave committee members ideas for activities and helped them identify local resources.
For example, they identified State Resource Center (SRC) to help organize health education
for adolescents. They also helped committees to keep accounts and facilitated their
interactions with health staff.
Start-up grant of Rs. 2000 was provided to each committee to meet its expenses. This
amount was paid to them in installments, according to their activity levels and during
committee meetings. Members collectively decided where to keep that amount and howto
spend it. Some committees opened accounts in post office; some divided the amount among
themselves and paid interest to the committee. Members decided not to spend any amount
on themselves, not even reimbursement of travel expense, if any.
I2
They maintained accounts of receipts and expenses and reported those to CFs every month.
These reports showed that all committees had spent the grant judiciously and built on it
further through contributions from members and others.
Identity cards were given to committee members to legitimize their role and to boost their
status in community. Initially PHC doctors had objected to members getting l-cards, fearing
their misuse while researchers thought it to be a good idea to show appreciation for their
voluntary work. Therefore, while issuing these cards, members were clearly told that the
cards did not entail any privileges for them and would be withdrawn if health staff
complained about their misuse. Till date, no health staff has complained but members have
reported getting cooperation from health staff because of the l-card.
Presidents’ meetings at block level gave them opportunity to share experiences among
themselves and with district and state health officers. During these meetings, CFs paid a lot
of attention to see that invitees felt important and respected. All invitees sat around a large
table. Each had a nameplate in front and got 5-7 minutes to address the gathering. Health
officers listened to them and promised cooperation. These meetings were very successful in
terms of attendance and in stimulating presidents’ interest in the project.
Monthly newsletter, Arogya Midita, informed committees about programs being organized
and highlighted some innovative programs, with photographs. Newsletters also included
other items such as a PHC doctor’s speech on the World Population Day, nutritious recipe
by an anganwadi worker, findings from studies on adolescent behavior and on hysterectomy,
etc. The newsletter became a prime mover in motivating committees to do more and better
programs. For example, when it reported about an eye-camp organized by one committee,
five others also organized similar camps.
13
Ill Health Committees’ Performance
In this section we present data on how well health committees have performed under each
of the three roles expected of them. These roles were:
•
Creating awareness and demand for health services
•
Participating in community’s health needs assessment and planning health activities
•
Fostering trust and understanding between community and health staff.
Role-1: Creating health awareness
Among the three tasks listed above, health committees first focused on creating health
awareness in the community by organizing awareness programs and service camps. In one
year, 57 out of 64 committees had organized 172 programs of 18 different types (Table 3),
while 7 committees had remained dormant.
Committees typically decided these programs in consultation with health staff.
CFs
encouraged them to undertake activities in hitherto neglected areas like adolescent health,
family education for newlywed couples, treatment of RTI/ STI etc. and incorporate in them
various participatory methods like games, songs, skits, and quiz. Committees also followed
some traditional practices like inviting pregnant women by going to their homes and honoring
them by giving fruits, coconut and token gifts. Combination of these practices made their
programs very attractive, as one young mother reported,
"I was reluctant to come for this program but I am glad I came. They honored me and made
me feel good."
All programs were well attended, attendance ranging from 50 to 350 people per program.
The most popular among them was the program for adolescents and their parents. Many of
these programs were reported in local newspapers.
14
Table 3: List of programs carried out by committees as of June 2002
Sn
Name of program
No. of programs
1.
Awareness program for adolescent boys and girls
35
2.
Awareness program on ANC care for pregnant women
32
3.
Awareness program on nutrition for mothers
28
4.
Awareness program on diarrhea control and use of ORS
13
5.
Village cleanliness drive involving school children
13
6.
Health awareness program for newly- wed couples
11
7.
8.
Awareness program on various government health services
09
First -aid training for committee members / volunteers
05
9.
Free eye check - up camp
05
10.
Awareness program on RTI/ STI
04
11.
Getting water tank cleaned in the village
04
12.
Awareness program on gender sensitization
03
13.
Anti- malaria drive
03
14
Awareness program on prevention, Control and treatment of ARI
02
15.
Free health check- up
02
16.
Celebrated World Health day/ Women's day
02
17.
Training committee members to weigh newborn
01
18.
RTI/ STI detection & treatment camp
01
Total number of programs
172
**: Even though there were only three programs specifically on gender sensitization, gender issues have been addressed in all
programs on nutrition, pregnancy, adolescents and newly- wed couples.
il
i
I
I
Role-2: Assessing communities’ health needs
After organizing health awareness activities for about 6-8 months committee members
learned about various components of the RCH program but were not clear about their role in
community needs assessment (CNAA) in the RCH program. Some members sporadically
accompanied health workers doing the CNA survey but they were not involved in developing
workers’ plans. Some used CNA data to decide what activities they should undertake in
their areas. One committee for example, planned mother care awareness program because
I
♦
II
the CNA data had indicated low level of institutional deliveries in their area.
I
1
15
I
ri
Under the CNAA, they wanted to meet the health needs of the poor in their community.
Some committees considered giving the poor money during health emergencies. But they
quickly realized that their resources were too meager. “If we start giving money everybody
would claim to be poor. Then giving to some and not to others would be inviting trouble”,
they said. Instead, they wanted PHCs to give free medicines to the poor on committees’
recommendations. PNC doctors rejected that idea saying that government had “no such
scheme”.
Some committees proposed the idea of helping the “real” poor to benefit from government’s
various welfare schemes such as the old age pension, rehabilitation for disabled persons
and BPL card etc. Based on this idea, they started a “pro-poor planning” exercise. This
exercise consisted of four steps:
•
Identifying the "poor"
•
Developing a "poor household" register giving their details
•
Identifying problems of the "poor"
•
Listing actions to address those problems
Using the CNA register, committee members identified the “real” poor families in their
villages. They defined "poor" as those earning livelihood only through daily wages or having
difficulty to obtain two meals a day. Sometimes they used their discretion to decide whether
a family was "poor”. For example, a family where the sole earning member had gangrene,
was included in the list though the family did not meet the other criteria of being “poor”.
After identifying poor households, committee members visited them to find out about their
health problems and their access to health and welfare services (See appendix 1). CFs
helped them to compile that data, based on which they identified priority problems of the
poor and actions needed to address those problems (See Appendix 2: A sample plan).
One committee, for example, found many malnourished children among the poor. Since this
village had no anganwadi they planned to undertake growth monitoring of those children
every alternate month with the help of anganwadi worker from the neighboring village.
Another committee found many physically challenged children among the "poor” so they
planned to conduct an “awareness cum service” camp for them through the District
Rehabilitation Center. At the time of this evaluation of the project, five committees had
completed this exercise while others were at various stages of completion.
16
Role 3: Building trust and communication with health providers
From the beginning, committee members were oriented to view health staff as partners in
the project and to seek their involvement. As a result, most committees invited health staff as
resource persons for their programs. Local newspapers published names and photos of
health staff who attended those programs. That pjeased the health staff who started giving
ideas to committee members about programs they could organize and helped them contact
resource persons/institutions. For example, one worker suggested to her committee that
they could organize an eye-camp because there were more than 40 cataract cases in their
area. She also suggested contacting the eye specialist at the Taluk hospital. The committee
followed her suggestion and organized a very impressive camp, which became a model for
other committees to follow. In another instance, a PHC doctor put a committee in touch with
a charitable trust called Vedavati Charitable Trust, recognized by district blindness control
society for organizing Eye-camps.
As a result of these activities, interaction between health staff and committee members
increased, bringing positive changes in health staffs attitude towards them.
Out of 64
committees, 22 (34%) developed very good relationship with health staff while another 23
(36%) developed moderately good relationships, in spite of the fact that during the baseline
only 20 percent staff had supported the committee idea. At the time of end-evaluation nearly
80 percent health staff gave positive feedback about health committees, as one health
worker reported, ” if we are friendly with committee members they ease our burden in the
field".
17
IV: The Committee Impact
After (completing 2-year project period in June 2002, researchers evaluated its impact on
community involvement and RCH service utilization, using two types of indicators-- process
indicators and outcome indicators (Box 1). Process indicators assessed the level of
community involvement as reflected through committees’ ability to organize programs,
mobilize local resources and involve other CBOs including panchayats in health activities.
Outcome indicators measured the awareness and utilization of RCH. Data for evaluation
was gathered from a household survey, similar to the baseline survey, as well as from
interviews with health staff, committee members and panchayat leaders.
Box 1: List of Process and outcome indicators
Process Indicators
1. % Committees conducting health activities
2. % Committees mobilizing local resources for their activities
3. % Committees with self-motivation and networking capacity
4. % Committees maintain cohesive and collective style of functioning
5. % Committees having respectful and supportive relationship with health staff
Outcome Indicators
1. % Pregnant women received full pre-natal care and safe delivery
2. % contraceptive users report self-motivation and less of side effects
3. % Women following appropriate child care practices
4. % Couples and adolescents participating in health committees’ activities
5.
% Women know about RTI/ STI and seek treatment in case of problem
Achievements on Process Indicators
Process indicators measured the extent to which health committees succeeded in seeking
community involvement in their activities, in mobilizing local resources, in networking with
CBOs, in working collectively and getting cooperation from health staff. The indicators used
to assess each of these aspects are presented below.
18
Community involvement in health Activities
Out of 64 committees formed, 57 were active at the time of this evaluation; 3 had stopped
functioning and 4 never became active. The 57 active committees had carried out 172
programs in a period of 10 months, average of one program per quarter.
Among them,
there were 17 “very active” committees who had managed to conduct health programs every
alternate month while the remaining 40 “moderately active” had organized programs once in
4-5 months (Table 4).
Moderately active committees had typically started off with large programs, attracting many
participants and then to compensate, took up smaller programs after considerable time
gaps. The very active committees on the other hand, had organized programs of uniform
and manageable sizes and therefore more frequently.
Table 4: Activity level of committees by programs, attendance and expenditure
Activity
Level
of Av.
Committees
Number
programs
Average
of Average
per Attendance
at
amount
spent per program
committee
programs
Very Active (17)
4.88
“50
403.8
Moderately Active (40)
2.23
45
401.6
Total Active (57)
3.02
47
402.6
“Very active” committees were usually the first to take up new types of activities. For
example, one of them had organized RTI/STI detection camp for the first time by inviting a
local NGO called Vivekananda Youth Movement.
Another committee organized an
adolescent program by involving health staff. A third one had organized an Eye camp forthe
first time. These activities then became models for other committees to follow. All activities
were very well attended since committees took all care to ensure that these occasions
became interesting and festive.
In the evaluation survey 42 percent households reported knowing about health committee
activities or having participated in them. People’s participation was found to be uniform by
caste and education status. However, participation of the poor households was much lower
(29%) compared to that of non-poor households (50%) (Table 5).
19
Table 5: Participation/ knowledge about committee by household characteristics
HH Characteristics
% knew about committee or participated in
program
Illiterate or functionally literate women
48
’
Educated women
58
’
SC/ST
46
Other castes
52~
Poor households
29
Non-poor households
50
Mobilizing resources
FRHS had provided an initial grant of Rs. 2000 to each committee to get them started.
Committees also generated additional resources from local philanthropists, grampanchayat,
SHGs, and religious establishments, almost always in kind or service, to avoid cash
transactions (Box 2).
<
2- Illustrations of committees mobilizing resources
When KM Halli committee decided to organize an adolescent awareness program in a local
school, they invited teachers and headmaster to their monthly meeting. Headmaster and
teachers agreed to allot one whole day for the program. On CF's suggestion the
Committee president then called SRC in Mysore and confirmed their availability. Committee
members then requested a local religious establishment to make food arrangements. They
obtained a mike system free of cost and hired a hall at a nominal charge because this was
a social cause. We prefer to take help in kind because then everyone can see how we are
using their contribution and there is no room for suspicion" said the president.
Out of 57 active committees, 25 had generated over 60 percent of their expenditure locally,
20 had generated less than 40 percent while!2 had generated none (Figure 1).
Figure 1: Mobilizing resources
□ Mobilizing > 60% of
the expenses
□ Mobilizing 10%60% of the
expenses
■ Mobilizing none
20
In fact, out of the Rs. 92,500 initial
grant
they
committees
received
had
from
spent only about
21,000 but had mobilized over 48,000
in kind and had saved about 71,500
rupees for their future activities.
20
FRHS,
There was no instance of misappropriation of funds but there were three instances where
presidents had kept some funds and had not made them available for committees’ activities.
Whenever members asked for them, they promised to return them later. But members were
confident that they would secure those funds.
Community Support and local networking
Another process indicator used to assess committee performance was the amount of
interest community showed and extent to which community based organization go involved
in health activities. On this indicator 25 committees (40%) did very well. CF did not have to
remind them to conduct programs because they seemed self-motivated. Their motivation
came from people who encouraged them to organize programs by asking, “when is the next
program?”
Another 32 committees (50%) needed some ‘pushing’ from CFs. They expected CFs to
remind them, to give them ideas on what to do and provide them back-up support. But in the
remaining 7 committees no amount of effort by CF helped to activate them.
More than half of the active committees had the capacity to network with CBOs, NGOs and
panchayats.
Some of them jointly organized programs to save cost. They invited other
NGOs to help them carry out activities (Box 3). Nearly all committees had active involvement
of SHGs, Continuing Education Centers (CEC), youth groups and panchayats.
Box 3: An Illustration of networking capacity
Ratnapuri committee was a very enthusiastic committee. They had conducted an ANC program
within a few weeks of their formation. Their second activity was an eye camp. The committee
president asked PHC Medical Officer (MO) to suggest who to invite. MO put him in touch with a
Trust he knew in Mysore, which had been approved by the District Blindness Control Society.
After finalizing the date, president convened a meeting of PHC staff, Presidents of other health
committees in that PHC, a local NGO, bankers association, transport owners' association, SHG
facilitators, panchayat presidents and facilitators of Continuing Education Centers (CEC) to
discuss arrangements and funds for the camp. Each group agreed to take up a particular
responsibility. On the day of the camp, the CEC facilitators made the camp arrangements.
SHGs listed persons with eye problems and brought them to the camp. Panchayat presidents
supplied food. Transport Owners' Association made vehicle arrangement to transport 32
cataract patients to Mysore and back, free of cost. NGO made arrangement for publicity and
Bankers Association contributed money. In this camp about 300 persons got their eyes
examined.
Almost all committees enjoyed good relationship with panchayat leaders. Panchayat leaders
were involved in committee formation and were also co- opted members of health
committees. Though panchayats were supposed to have health standing committees, they
21
saw no conflict between their role and that of health committees. Panchayat representatives
regularly participated in committees' meetings and even contributed funds for some
activities. Only in five cases, panchayat members actually created trouble for committees. In
one case because one faction of the panchayat supported the committee, the other opposed
it. In other four cases, committee presidents were also panchayat leaders who had no time
for health committees but would not allow other members to function without them.
But most other committees had managed to strike a balance between involving panchayat
leaders and not allowing them to control committees. Many panchayat leaders viewed
committees as making meaningful efforts to improve people's health. As one panchayat
leader said, “we have learnt a lot from our health committees. This is the only time we have
been meaningfully involved in improving health of our community”.
Some panchayats had
transferred funds for chlorinating village water supply to committees, to carry out that work.
Committees’ Style of Functioning
To assess whether committees functioned in democratic style we used three indicators: (i)
regularity of meetings, (ii) attendance at meetings, and (iii) sharing of tasks among
members. On all three indicators we found these committees to be only half-successful.
Overall, they held only 54 percent of monthly meetings. Average 43 percent of members
attended these meetings. And
Figure 2: Dimensions of functioning style
(7)
Moderately
active (40)
0%
61
percent committees,
members shared tasks among
Non- active
Very active
(17)
in
,, I ,| . ,|
□ Members share task
themselves
■ Attendance
>average
□ Meet regularly
remaining 39 percent, only one
while
in
the
or two members were active
Regular attendance at monthly
—k- -4— —I------20% 40% 60% 80%
meetings was rather difficult
for many members as they
came from different villages.
They also belonged to different socio-economic classes.
Those from well off families could afford to come regularly while those from less well off
families could not.
Some committees did discuss this constraint on poor members’
participation and even considered paying them some amount for their time but finally
decided against it by saying uif we pay them then everybody will claim to be poor. If poor
want to participate then they must find time for if'.
22
"Very active" committees met more regularly than "moderately active" committees. But on
the other two indicators, these two sets of committees did not differ significantly. (Fig 2).
In fact, committees’ functioning styles, which varied from committee to committee, did not
seem to have much relation to their activity level. In some committees presidents took all
decisions and others followed. In some others, members took decisions collectively but left
actions to one or two members. A few committees always worked jointly so that they could
organize large-scale activities. Some others fought bitterly during meetings but then
organized excellent programs.
Relation with health staff
In this project, researchers had paid much attention to health committees developing
collaborative relationship with health staff. This task seemed difficult because, initially most
health staff had opposed the “committee” idea. Only 20% health workers had held positive
view about them, 38% were neutral while 42% had held negative views because they feared
that committee members would try to control them.
Notwithstanding their apprehensions, 55 (70%) committees had managed to develop “not
bad” or “very good” relationship with health staff. Only 30 % committees reported poor
relationship. Most of the “very active” committees experienced “good” relationship; most of
the “non-active” experienced “poor” relationship while for “moderately active”, the picture
was mixed (Fig 3). The credit (or discredit) for maintaining good (or poor) relationship was
shared equally by health staff and committee members.
Committees that experienced good relationship usually worked with health staff that had
positive or neutral attitude, to begin with. Health staff gave them ideas and helped them in
conducting programs. Committee members, on their part, showed concerns for workers’
personal safety, heavy workload, family problems, etc.
Committees with average relationship typically had staff that was not interested in getting
involved in committees’ activities.
Committee members also did not insist that they get
involved. Both adopted a “live and let live” policy.
However, where health staff held negative views about committees but committees insisted
that they be involved, the relationships turned sour.
23
In two such instances, committee
presidents had complained about health staff to district officers while in some others health
staff tried to disrupt committee activities by inciting members not to participate.
CFs also played a positive role in bringing health staff closer to people, as many of the staff
reported "when there was no project, we were not close to the people. CF helped us to come
closer to the people
Achievements on Outcome Indicators
In terms of improvement in awareness and access to RCH services the household survey
showed significant gains over the baseline, on some indicators but not much on others.
Indicators that showed gains were institutional deliveries (from 32 to 39 percent), women
seeking treatment for RTI/STI (from 31 to 43%) and weighing of babies at birth (from 21 to
43%), all three being indicators of access to services. Use of DDK also increased perhaps
because DDK was available at the evaluation time but not at the time of baseline.
Table 5: Status on outcome indicators
Sr.
Indicator
Baseline
Evaluation
N1=1057
N2=1050
1
% Full ANC (3 visits + IFA tablets>=90 + TT)
28
31
2
% Institutional delivery
32
39
3
% Home deliveries by health professionals
8
10
4
% Home delivery used DDK
12
18
5
% Using FP method
72
75
6
% Women reported FP use as “self’ decision
60
79
7
% Reported FP side effects
34
25
8
% Women reported at least one RTI symptom
26
26
9
% Women reported knowing about HIV/AIDS
62
66
9
% Sought treatment for RTI
31
43
10
% Reported immediate BF
32
34
11
% Babies weighed
21
43
12
% Low birth weight babies (<=2500 grams)
48
33
13
% Children fully immunized
96
92
14
% women knew about giving ORS during diarrhea
47
23
15
% couples know about committee activities
0
42
24
Contraception use also increased from 72 to 75 percent but the increase was in sterilization
while the use of spacing methods actually declined. There was a significant reduction in
women reporting FP side effects (from 34 to 25 percent) and significant increase in women
describing the decision to adopted FP method as their “own” (from 60 to 79 percent), an
indicator of their empowerment.
However, the survey also registered a significant decline in the proportion of women saying,
“ they would give ORS if their child had diarrhea” (from 47% to 23%) and a significant
increase in women saying “ in case of diarrhea they would take child to doctor/hospital” (from
27% to 59%). These findings came as a surprise because over a fifth of committees had
organized ORS programs, inviting health staff as resource persons. The focus of these
programs was always on making ORS through activities such as women demonstrating how
to make ORS and ORS making competition for school children. However, at the end
resource persons almost always said, “ORS is a primary level of treatment and if diarrhea
persists take the child to doctor”. Women registered that message perhaps better than the
message about giving ORS.
Our impact evaluation seemed to show that the new health committee model was effective in
evoking community participation as well as in helping to improve awareness and use of
some ROH services.
In the next section we discuss the factors that seemed to have
contributed to its effectiveness.
25
V. Factors contributing to Effectiveness of the Committee Model
Though the idea of forming village health committees was not new, this project tested a new
model of health committee. In this model health committees were not expected to play a
dependency role (i.e. government decided what they would do and provided funds), or an
adversarial role (i.e. acting as a pressure group) but a collaborative role (working with health
staff and CBOs as partners). Success of this model therefore, depended on how well
committees could manage that role, resisting pressures to become either dependent or
adversarial.
Earlier health committees like the MSS, consisted mainly of ex-officio members and people
with status in community.
They were expected to attend health education meetings that
workers organized and sometimes help in Pulse polio campaign or in recruiting family
planning cases.
These committees represented different localities in their areas. They were selected by
community and not by health workers. They were expected to organize activities to improve
awareness and access to health services. But they had no financial or administrative power
vis-a-vis the health staff.
Except for the start-up grant, they were expected to raise
resources for their activities and were expected to carry out their task in collaboration with
health staff and panchayat leaders who had different expectations from them.
Health staff wanted health committees to behave somewhat like MSS i.e. passively
participate in activities decided by health staff. Health staff doubted committees’ ability to
identify health problems and initiate activities. They also expected committees to interfere
with their work and harass them.
The initial orientation meetings of health committees
confirmed their fears when members asked questions like, ‘Why do doctors take money?’
‘Why do they always give prescription? Who gets free medicines that government buys?’
‘Why does health staff come late?’ At that stage many among staff wanted to opt out of this
project but the District Health Officer persuaded them to stay on by saying, “community
participation is a government policy".
Community leaders on the other hand, wanted health committees to function as watchdog of
health system. They wanted them to report whether health workers visited villages; which
doctor took money, was PHC staff keeping staff correct timings etc.
26
The role researchers had envisaged for committees however, was to be a bridge between
community and health staff and help create health awareness, encourage women, the poor
and socially disadvantaged groups to seek health care and participate in decentralized
health planning.
In this section we present our analysis on how three factors namely, committees’ credibility,
capacity and motivation, helped them to play that role effectively and what contribution the
five project inputs made to their effectiveness.
Building credibility
In the project, credibility was an important issue for health committees especially because
they were formed by an NGO and not by any government order. Health staff was therefore
skeptical about what they would do and for how long. Panchayat members also wondered
why this committee when there was already a concept of health standing committee under
the panchayat system, though not formed anywhere. Committee members themselves were
not sure of their acceptance in the community.
Some committee members requested for an ID card to legitimize their role, which helped.
But their credibility got built as they began to organize programs, invite health staff as
resource persons and news about their programs began to appear in local newspapers.
Reading them, other NGOs in the area like the State Resource Center and Vivekananda
Youth Movement expressed interest in working with them.
The start-up grant, however small, also helped build their credibility because they could
spend some money up-front for health activities. It helped them generate more resources at
community level, as one committee member reported, "because we had this money we
could make our programs more interesting like having competitions and giving prizes. It
helped to attract more people for our programs. After seeing our programs, now people are
more willing to help".
Another project input that helped build their credibility was the Block level meetings of
committee presidents. At these meetings they could meet with state and district level officers
who appreciated their efforts.
After attending first such a meeting, one president had
reported,
T1
7 thought this was one of those committees that got formed but did nothing. But when I
attended this meeting and saw other Presidents talk about their work and District officers
appreciating them, I realized that this committee was different. That was when I decided to
do something".
The credibility building process took 8-10 months. Committees also contributed to that
process first, by guarding their reputation in financial matters and by not aligning themselves
with any political interest or seeking political mileage out of their work. Since members
belonged to different political parties, they ensured that no one party got mileage out of their
collective work. So far, only one committee has broken this cardinal rule when its president
complained about a health worker to the local MLA who reprimanded her publicly. As a
result, that committee lost the goodwill of health staff and of other NGOs and was not been
able to organize any programs since then.
Developing Capacity
CFs contributed a great deal to committees’ capacity building. They gave ideas about what
programs and how to organize them. They helped them to identify NGOs and other
resources to make their programs effective. They also helped them to resolve conflicts with
health staff. Many committee members repeatedly mentioned in the final evaluation, "They
(CF) have guided us about programs. They have helped us to solve problems within the
committee and to improve relations with doctor".
Newsletter was the other input that helped develop their capacity.
From newsletter
committees learned about each other’s experiences, ideas and innovations as one
committee president said,
"From the newsletter we came to know about the VC Trust in
Mysore for eye camp. We then contacted them for program in our village".
Sustaining Motivation
Sustaining committee members’ motivation over a two-year period was a major challenge
since they were volunteers and received no monetary compensation for their time and effort.
Public appreciation was their only reward, which they received mainly through the newsletter
and newspapers as one committee member reported,
28
"The village cleanliness drive that we had organized was reported in Arogya Midita
(newsletter) along with our photographs. IVe showed it to the people in the village. After that
their participation in our programs has increased ".
The Block-level meeting was another opportunity for committees to showcase their work to a
larger audience and to receive appreciation from district and state government officers. This
intangible reward strengthened their resolve to do more fortheir people. Describing how the
Block- level meeting had helped him, one president said,
"People used to say if I was not getting anything then why was I running around for health
committee? I used to feel bad about it. But when I came for this meeting and saw so many
presidents talk about their work, I felt very motivated. Then I felt that I should not care for
what others say. I must work to make my committee successful"
The identity card was also a source of motivation forthem. Members wore them during their
programs. Many carried them when they visited health facility and found that because of the
ID health staff, both in and outside Hunsur, treating them respectfully.
"I had taken a relative to Bangalore for treatment at a private hospital. I was wearing the I-
card. The doctor asked about it. He was very impressed by our seva monbhavane (service
motivation) and praised us. He also reduced the bill. I feel that social service also brings a lot
of recognition."
All these inputs together sustained their motivation to a considerable extent. The result
seemed impressive. About 88 percent committees remained active for about two years and
wanted to continue working even after the project was over. About 66 percent had mobilized
local resources and felt confidant that they could do more. People from both inside and
outside Hunsur, appreciated their efforts adding to their motivation and desire to continue
working.
In the next section we attempt to answer the questions how this model can be up-scaled to
district level and sustained.
29
VI. Sustaining and Up-scaling the Committee Model
Sustaining this model would require mechanisms that would sustain committees’ motivation,
capacity and credibility.
In this project, FRHS as an NGO facilitated health committee activities by linking them with
other government and non-government organizations for activity based support. Committee
members’ incentive was public appreciation that they received through local media,
newsletter and presidents’ meetings. And though these committees were ad hoc, they could
collaborate with panchayat and health staff because this was an experiment. But to sustain
and upscale them beyond the experiment would require a policy framework that legitimizes
their role and supports it, preferably through the existing structures.
Government recognition, making health committees a legitimate local institution, would be
essential provided such a recognition does not result in health staff using them like CHVs or
MSS.
Any such recognition must also acknowledge that this model’s strength and
uniqueness lies in committees being able to undertake health promotion activities
independently or in collaboration with health staff. Any mechanism developed to support
them must ensure that this ability of theirs is not sacrificed.
One such mechanism could be a joint support by Panchayat Raj Institutions and health
department. This mechanism would help increase dialogue between people and health
providers, which in health sector is virtually absent (9). Involvement with health committees
might encourage panchayats to give priority to preventive and promotive health.
One potential problem with this idea might be the role panchayats’ health standing
committees. In the project block no panchayat had formed this committee and in fact, most
gram panchayat presidents were not even aware of this provision. They knew only about the
health standing committee at district level. Therefore, they saw no difficulty in having health
committee outside panchayat as they perceived no conflict with them. They were even
willing to give funds earmarked for health activities to these committees.
If panchayats agree to formally support health committees that would ensure their
sustainability. But in this case, committees have to ensure that do not also take on the
panchayat’s “controlling” role but remain focused on their health promotion role.
30
Joint
support from health department would help them retain that focus as well as get technical
support from district and block health education officers, of the kind that CFs provided.
To up-scale this model to district level would require creating a layered structure of health
committees (Fig. 4). In this structure, in addition to the sub-center health committee, there
would be one PHC health committee consisting of presidents or representatives of all the
sub-center health committees under it. Each PHC committee would nominate one of its
members (by rotation if necessary) to serve on the Block health committee. Similarly, each
block level committee would nominate by rotation, one of its members to serve on the district
committee. With such a structure in place, this model could be up-scaled with minimum
NGO support.
We however see two reasons why this model will always need NGO support to function
effectively.
One is to help committees identify and access non-government sources of
information and support and the other is to help them develop partnership with health staff
and panchayat leaders. In other words, NGO support of the type that FRHS provided,
though not of the same intensity, would be needed to retain the uniqueness of this model.
Figure 4: Layered Committee Structure in a District
District Health Committee
■
T i:
Block Health Committee
(7-8)
PHC Health Committee
(10-12)
Sub-center health committees (5-8)
In addition to the layered committee structure, up-scaling would also require retaining all
aspects that made this model effective namely, its broad based structure and people’s
involvement in formation, and its proactive role. Committee formation through gram sabha
method would be essential to ensure adequate representation to women and the poor and
they were properly oriented. Since CFs’ had played a major role in that process, during up-
scaling, local facilitators like local NGOs and CBOs might have to be identified to play CFs’
role. If the upscaling can be done in phases, rather than simultaneously all over, health
committee members from older blocks can also help to up-scale this model, effectively.
31
Summary and Lessons
This project was an experiment that tested out a new model of health committee to help
stimulate community participation in health related activities at village level. This model
involved selecting committee members, each one representing a cluster of 50-60 houses.
Members to this committee were nominated by community and not by health staff. Also
committee members were volunteers. They received no payment for their services. On the
contrary they sometimes contributed funds for committee activities.
This experiment was carried out in Hunsur block of Mysore district in Karnataka, for a period
two-years. During this period, total 64 committees were formed (one per rural subcenter) of
which 57 remained active. The remaining seven remained dormant but not disbanded.
It took some time for health staff and committee members to understand and accept their
respective roles in the new model. In this model, their role was to cooperate with health staff
to promote health activities and not to either discipline them or passively listen to them.
Panchayat leaders, who wanted to use these committees to control the health staff, quickly
accepted their new role and provided them good support but health staff had more
reservations about that role. They doubted committees’ capacity to do anything good and
expected nothing but trouble from them. Initially, therefore some of them tried to incite
committee members not to participate in this project or created hurdles by not cooperating
with them. But as more and more committees began functioning, organizing health
awareness and service camps and gaining visibility, most health staff changed their views.
They became active participants in these activities. Initially only 20 percent health staff was
positive about committees, 38 % was neutral and 42% was negative. At the end of the
project, 80 % of them had turned positive.
Committees planned health activities based on the local need assessment. They generated
resources and sought support from friendly doctors, health workers and other CBOs to
implement them. Through such support they were able to reach many people at low cost.
Very importantly, most of them had managed to gain visibility without antagonizing local
politicians or health staff and without trying to get political mileage out of their work.
An impact evaluation at the end of the project showed that over 85 percent committees had
been active and they had organized, on an average, one program per quarter. Most
programs were of good quality and well attended. About half the people in community
reported knowing or participating in those programs. Over two-thirds of health staff provided
32
high to moderate level of support to these programs. Health staff was particularly pleased
with committees that invited them as resource persons and honored them. Over 90 percent
committees also enjoyed support from panchayats, in terms of their personal involvement
and arranging donations. Survey data before and after the experiment, recorded significant
increases in awareness and access to certain RCH services such as treatment of RTI/STI,
safe delivery, weighing of babies at birth.
However, preparing micro-plan that served as a basis for committee action needed
facilitation by NGO and government staff. Another positive aspect of this model is that it
allowed each partner to play its role, instead of trying to control or compete with each other.
Committee members saw their role as that of organizing health activities in the community,
which they could do only with support from health staff. Health staff also realized that their
field-work became easy if they cooperated with committee members. But in this model,
neither could demand support from each other but could earn it through good working
relationship and mutual respect. As a result, most committees did well in converting health
staff’s attitudes from largely negative to largely supportive.
In the process, they managed to create certain level of social capital by acting as
collaborators with the health staff and indirectly creating pressure on them to provide better
quality services. This project also showed that community could exert pressure on service
providers by actively participating in the service delivery process arid by providing support to
them.
To sustain and up-scaled this model within the existing structures would however, require
state government’s official recognition of health committees. But this recognition should not
mean committees would get powers to control the health staff. Nor should it mean that
health staff could treat them like village health workers. Neither of these positions would
help committees to play the collaborative role they have been playing so successfully. To
help them retain while up-scaling the model to district level, there is a need to develop a
layered structure of health committees. That structure needs to be supported both by
panchayats and health staff, essentially performing the tasks performed by CFs and FRHS
in this project.
We believe that district Health Standing Committee in collaboration with district health office
could support such a structure, especially if it co-opted local prominent NGOs in that
arrangement. However, this idea needs to be tested to see if this model, if up-scaled, can
work effectively within in the existing structures, with minimum NGO involvement.
33
References
1. Measham A.R. and Heaver R.A. (1996), India's Family Welfare Program: Moving to a
Reproductive and Child Health Approach, The World Bank, Washington D.C.
2. Rachel Kumar, “Gender in reproductive and child health policy”, EPW vol 37, no. 32, Aug
2002, 3369-3377
3. GOI (1998), Manual on Community Needs Assessment Approach, Department of Family
Welfare, Ministry of Health and FW, New Delhi
4. The Futures Group International (2001), “Review of Implementation of Community Needs
Assessment: Approach for famly welfare in India, Policy Project II, New Delhi, India
5. Kalway K. and Rawat M. (1999), “Family Welfare Programme in MP after ICPD: a case
study”, in Community Needs based Reproductive and Child Health in India - Progress and
Constraints, Health Watch Trust, Jaipur, India.
6. Bondurant Tony (1997), The introduction of the target free approach in West Bengal: a
case study, presented at the national workshop on the performance of family welfare
programme under target free approach, Lucknow Uttar Pradesh, November 24-25.
7. Ashok Sahany (1990), Community Participation in Health and family Welfare: Innovative
experiences in India, Indian Society of Health Administrators, Bangalore, India.
8. S. Mohankumar, From People’s plan to Plan Sans People, EPW, Vol 37, No. 16, April 20,
2002, 1492-1497
9. Panchayat Raj update: Vol 9, # 6, June 2002.
34
Appendix 1:
Information in the register of poor families
1. Name of the head of the HH
2. No. of women 15- 49 years
3. Number of children by sex and age- groups
4. Did anyone in the household have difficulty during pregnancy/ delivery in the past one
year?
5. Have there been any episodes of measles in the past one year among children in the
household?
6. How many episodes of diarrhea were there in the past one year among children below 5
years in this household?
7. How many episodes of pneumonia were there in the past one year among children
below 5 years in this household?
8. Do children below 5 years in the household go to anganwadi?
9. How many of the children below 5 years in the household are malnourished?
10. How many children from this household go to school?
11. How many people in this household are suffering from night blindness?
12. How many episodes of malaria were there in the past one year in this household?
13. How many people in this household are suffering from TB?
14. How many people in this household are suffering from skin problems?
15. How many people in this household have cataract?
16. Does the family have the RTIZ STI card?
17. Are there any disabled children in this household?
18. What color BPL card does the household have?
19. How many people in the household are above 60 years?
20. How many of them get old age pension?
35
Appendix 2: Annual Plan of Thattekere committee (2002- 2003)
Members from different villages met separately to identify the "poor" families in their areas
and used the names listed in the CNA register as a reference. They then met together to
discuss the combined list.
Of the total 740 households, they had identified 104 as "poor". Most of them were living in
huts and were coolie workers. There were a few families where there were only old people
without any young earning member, which they had included under "poor". In the meeting,
the CF discussed with them, the possible ways of collecting information about health
problems and present access to health services. He said they could collect information from
the health worker's or anganwadi worker's registers or actually visit the poor families and
compile it. Members preferred to do the latter so that they have first -hand information
themselves. The CF then explained the various columns in the poor household register. The
committee covered three villages and all members in the committee could read and write. Of
the 18 members, four members took the responsibility of visiting poor families in their
respective villages. Being the first time, the CF also accompanied them. They also got two
volunteers from Kalika Kendra to help them with the visits.
Six persons working together visited the 104 poor families in one day. They met three days
later and compiled the information. They found that of the 38 under- 5 children, 22 were
malnourished, seven of them had had measles, 11 had had repeated episodes of diarrhea.
Of the 22 malnourished children, 11 lived in a village where there was no anganwadi. Also
there were 6 old persons identified with cataract. Based on these problems, Thattekere
committee has decided to carry out the following actions in the following year especially for
the poor families:
❖ Conduct child -weighing sessions every alternate month in the village where there is no
anganwadi and give information on low- cost nutritious recipes.
❖ Conduct awareness program on diarrhea control and management and distribute ORS
packets to poor families.
❖ Increase mothers' awareness about importance of measles vaccine.
❖ Ensure that all six persons with cataract are operated free of cost.
Also the CNA data indicated that institutional deliveries, use of spacing methods and
awareness about RTI/ STI was low. So the committee has planned:
•
An awareness cum service camp about RTI /STI
•
Awareness program for pregnant women and newly- wed couples.
Even in these programs the committee will ensure participation from poor families.
36
I
Foundation
For
Research In Health Systems
A Non Profit Service Organization
FRHS
22nd November 2002
Dr. Thelma Narayan
Community Health Cell
Bangalore
Dear Dr. Narayan,
Foundation for Research in Health Systems (FRHS) recently concluded a study on
"Increasing Community Involvement in Reproductive Health" in Hunsur taluk of Mysore
district, Karnataka. Enclosed is a report that describes the study and its outcome.
We would be very happy to have your feedback and comments on the same.
Thanking you.
1
Yours sincerely,
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Akhila Vasan
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6, Gurukrupa 183 Azad Society, Ahmedabad - 380 015. India
Phone : 6740437, 6745589 Fax : (079) 6740437 Telex : 121 6853 SARA IN
email : frhsahd@adl.vsnl.net.in
World Bank
Population and Reproductive Health
(Some Documents)
1. Population And Reproductive Health - Information Brief
2. India Reproductive And Child Health Project Signals Policy
Change For Family Welfare Program - World Bank provides
largest ever creditfor population project
3. World Bank Group and Population and Reproductive and Child
Health in India
4. Despite Progress, Millions In The Developing World Still
Denied Access To Reproductive Health
Action Programme for People’s Economics and Allied Literacy
A Unit Of
Popular Education and Action Centre
F-93, Katwaria Sarai
New Delhi - 110 016
i lie vvuuu oaiiK vjiuup anci rupuidLiun diiu fvcpiuuuuiivc anu v-iinu ncaim 111 muia
FdgC i U1 U
THE WORLD BANK GROUP
Regions: South Asia
The World Bank Group and Population and
Reproductive and Child Health in India
India was among the first developing nations to recognize the threat rapid population
growth poses to national development and to adopt policies to address the problem. Its
Family Welfare Program, launched in 1951, has contributed significantly to improving the
health of mothers and children and to providing family planning services.
Forty-six percent of eligible couples now use some form of contraception, fertility has
declined by about two-fifths, and immunization coverage of children is approaching 80
percent. However, maternal deaths remain high at 437 per 100,000 live births, and the total
fertility rate, while below replacement level in the states of Kerala and Goa, is as high as
four or more children per woman in the poorer northern states of the Hindi-speaking belt.
India's continued high fertility rate, combined with a two-thirds drop in the death rate
and a doubled life expectancy, have resulted in substantial population increases, from 342
million in 1947, to 684 million in 1981, to 931 million people today. Each year, 16 million
people are added to the population and by 2050, India's population is projected to reach 1.5
billion.
Slow progress in the 1980s made it essential for India to devise innovative strategies to
achieve greater dynamism in its Family Welfare Program. In the early 1990s, the
Government of India began a paradigm shift from a system based on contraceptive method
specific and fertility reduction targets and monetary incentives to a broader system ol
performance goals and measures designed to encourage a wider range of reproductive and
child health services. The Ministry of Health and Family Welfare developed an action plan
to strengthen the program and made several recommendations consistent with the
reproductive and child health approach.
This approach, which was adopted by the Government of India when it initiated the Child
Survival and Safe Motherhood Program in 1992, is also central to the new vision of
population policy that emerged from the 1994 Cairo International Conference on Population
and Development. Reproductive health refers to a state in which people can reproduce and
regulate their fertility, women go through pregnancy and childbirth safely, the outcome ol
pregnancy is successful in terms of maternal and infant survival and well-being, and
couples are able to have sexual relations free of the fear of pregnancy and disease.
In its transition to this approach, India is taking careful account of the links between family
welfare and other health services. More emphasis is now placed on the private and
\ oluntary sectors as they develop in the increasingly dynamic Indian economy.
World Bank Group assistance to India's efforts in population and reproductive and child
health (RCH) dates back to the earliest days of Bank involvement in the population sector.
Between 1972 and 1986, four population projects totaling about US$188 million were
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approved. Since then, Bank Group-Govemment of India collaboration has been stepped up,
with approval of five more population projects and a Child Survival and Safe Motherhood
(CSSM) Project totaling about US$645 million, and preparation of a Reproductive and
Child Health Project for some US$248 million. The objective of each of these projects has
been to strengthen the capacity of the family welfare and health systems to deliver better
quality services more equitably.
The development of this lending program has been based on a number of analytical efforts
and on a continuous dialogue between the Bank Group and the Government of India, which
has allowed the Bank to support India's transition to a reproductive and child health
approach. The Bank has focused an increasing share of its attention on those features of the
Family Welfare Program that constrain it from being more effective, including reorienting
management focus from contraceptive targets to client-responsive quality service. The Bank
Group also continues to emphasize assistance to the national immunization program,
programs in safe motherhood, and the control of acute respiratory infections and diarrheal
disease.
Completed World-Bank Assisted Operations
The First Population Project (1972-80) was financed by an IDA credit of US$21.2
million and a grant from the Swedish International Development Authority. The project
supported the Family Welfare Program in five districts in the state of Karnataka and six
districts in the state of Uttar Pradesh. The project was essentially an experimental
demonstration project intended to test the efficacy of various program activities, and to
develop ways for attaining better performance of the national program.
The project experience indicated ways subsequent World Bank support of the Family
Welfare Program could be improved, and was the foundation for the government's
subsequent accelerated program of family planning and maternal and child health. Also, the
two population centers established under this project have carried out a variety of research.
The Second Population Project (1980-88) was supported by an IDA credit of US$46
million. The project assisted the Family Welfare Program in six districts of eastern Uttar
Pradesh and three districts in the state of Andhra Pradesh. The project was part of a
government effort to obtain external assistance to strengthen the Family Welfare Program in
underprivileged districts of selected states.
The project gave further support for the integration of family planning and mother and child
health care services, emphasized the importance of generating demand for services and, as
in all subsequent projects, stressed the increased use of temporary contraceptive methods
and gave substantial support for the construction of basic health facilities. An estimated
22.7 million women and children benefited from strengthened family welfare services
provided under the project.
The Third Population Project (1984-91) was financed by an IDA credit of USS70
million. It too was implemented in underprivileged districts-six districts of northern
Karnataka and four districts of the state of Kerala.
Project impact was particularly notable in Kerala, where project support helped bring
program implementation in the underprivileged project districts up to the much higher
standard already achieved in the rest of the state. In Kerala project districts, contraceptive
use has increased and, on average, immunization of children has risen from about 28
percent to about 78 percent. Overall, approximately 18 million women and children in the
10 project districts were reached by the project-assisted family welfare program.
The Fourth Population Project (1986-94) was supported by an IDA credit of USS51
million and was implemented in West Bengal. In the four districts where facility
construction was supported by the project, program implementation benefited more than 12
million women and children. The project emphasized maternal and child health. A
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comparison of fertility, mortality, and infant mortality rates between the pre-project year of
1984 and 1992 indicates substantial progress in these three vital indicators.
During the course of the project, the birth rate in West Bengal declined from 30.4 to 24.6
per 1,000, the death rate from 10.7 to 8.3 per 1,000, and the infant mortality rate from 82 to
64 per 1,000 live births. There was also very good progress in the share of couples using
modem contraception, which improved from 33 to 52 percent. State-wide support for
program management information, communications, and training components had a
positive effect on the implementation and impact of West Bengal's family welfare program
in general.
The Fifth Population Project (1988-96), financed by an IDA credit of US$57 million,
supported the National Family Welfare Program in the municipalities of Bombay and
Madras, and was extended to other urban areas in the states of Maharashtra and Tamil
Nadu. The main goal was to improve the service delivery and outreach systems of family
welfare services in urban slums. Innovative features included support for involvement of
non-governmental organizations (NGOs) and private medical practitioners in carrying out
the Family Welfare Program. The project met its service delivery objectives and benefited
some 2.5 million poor women and children in slum areas.
The Child Survival and Safe Motherhood Project (1991-96), financed by an IDA credit of
US$214.5 million, supported the enhancement and expansion of the Maternal and Child
Health (MCH) component of the National Family Welfare Program. It was national in
scope, with emphasis on districts where maternal and infant mortality rates were higher than
the national average.
The project's specific objectives were to enhance child survival, reduce maternal mortality
and morbidity rates, and increase the effectiveness of service delivery by supporting:
o
child survival programs including the Universal Immunization Program, diarrhea
control programs, and the control of acute respiratory infections;
o
a Safe Motherhood Initiative to improve ante-natal and delivery care for all pregnant
women and to identify high-risk pregnancies; and
o
institutional systems development, including improving and expanding training
programs for family welfare workers, education and communication, and
management information.
More than 42 million women and children benefited annually from the services provided
Ongoing World Bank-Assisted Operations
The Sixth Population Project, approved in 1989, provides assistance through an IDA
credit of US$124.6 million. The project supports improvements in the efficiency and
effectiveness of the delivery of family welfare services in the rural areas of the states ot
Andhra Pradesh, Madhya Pradesh, and Uttar Pradesh. The project has established a wellregarded and systematic program of in-service training and a training culture focused on
improving performance of workers and an increased awareness of how to monitor and
improve the quality and effectiveness of training.
Three state institutes of health and family welfare, 18 regional training centers, 91 district
centers/teams, and 23 field practice demonstration areas have been established and are
conducting regular in-service training; 23 basic auxiliary nurse midwife (ANM) training
schools have also been strengthened. In addition, 1,620 sub-centers with ANM residence
have been constructed, equipment and furniture have been provided to sub-centers, and
primary health centers and delivery kits have been provided to traditional birth attendants.
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o a local capacity enhancement component that would fund district and city sub
projects aimed at meeting specific needs of local priority groups.
The project is expected to be approved in mid-1997, and would be financed with an IDA
credit of about US$248 million.
Research and Analysis
Two major studies, Improving Women's Health in India (1996) and India's Family Welfare
Program: Moving to a Reproductive and Child Health Approach (1995), provide
background for the Bank Group's discussions with the Indian government on further
developing public, voluntary, and private sector capacity to address needs of the Family
Welfare Program and health problems of India's women. The former was published as part
of the Bank's Directions in Development series and the latter was published as part of the
Bank's Development in Practice series.
Both studies build on an earlier study entitled Family Welfare Strategy’ in India: Changing
the Signals (1990). Taken together, these studies provide support for the important steps
the government has taken in moving away from a target-driven, demographic approach
emphasizing female sterilization, toward a client-centered approach that helps people meet
their broader health and family planning goals.
Improving Women's Health in India provides a comprehensive overview both of women's
health issues and the government's programs to improve them. Despite considerable
progress, the report argues that India still has a large, unfinished agenda in the areas of
reproductive and child health. The report emphasizes women's reproductive health and the
factors underlying excess female mortality at early ages, especially in the northern "Hindi
belt" states of Bihar, Rajasthan, Madhya Pradesh, and Uttar Pradesh. These states account
for almost 40 percent of India's population and exhibit well-documented unfavorable
demographic trends compared with the rest of India.
The book also points out the needs of women in rural areas where mortality levels are
substantially higher than in urban areas and access to care is limited. Its focus is on the
measures necessary to address existing policy and implementation constraints and improve
the quality, acceptability, and use of services essential to women's health. Further progress
and more resources are needed.
In 1994, the Cairo Conference formalized a growing international consensus that improving
reproductive health, including family planning, is essential to human welfare: reducing
unwanted pregnancies safely and providing high-quality health services both satisfies the
needs of individuals and stabilizes the population.
This perspective, strongly supported by the Government of India in its Program of Action in
the India Country Report prepared for the Cairo Conference, led to a major piece of
collaborative analytical work with the World Bank Group entitled India's Family Welfare
Program: Moving to a Reproductive and Child Health Approach. The report identifies the
major constraints on India’s Family Welfare Program and recommends ways in which these
constraints might be overcome. In addition, it discusses an "Essential Reproductive Health
Package" designed to provide a cluster of recommended reproductive health services
directed primarily at the needs of actual and potential patients. The Reproductive and Child
Health Project was based partly on this work.
For more information, please contact:
In Washington: Rebeca Robboy: (1-202) 473-0699 e-mail: Rrobbov a worldbank.oIn New Delhi: Geetanjali Chopra: (91-11)461-7241 e-mail: Gchopra </wurldbank.oi l
SEARCH
SHE MAP
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SHOWCASE
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Overall, it is estimated that up to 40 million rural households in the three project states are
benefiting from program improvements achieved with project support.
The Seventh Population Project, which supports the National Family Welfare Program in
the states of Bihar, Gujarat, Haryana, Jammu & Kashmir, and Punjab, through an IDA
credit of US$81.6 million, was approved in 1990. This project, which also has a special
training focus, is similar to the Sixth Population Project. At least 22 million families in the
rural areas of the project states will ultimately benefit from project-assisted improvements
in the quality and coverage of program services.
Since the project began in 1991, rates of sterilization and use of IUDs, oral pills, and
conventional contraceptives have been steadily rising. Systematic and regular in-service
training for family welfare workers has also been established.
The Eighth Population Project, financed through an IDA credit of US$79 million,
became effective in May 1994. The project supports the improvement of family welfare
services in the slum areas of Bangalore, Calcutta, Delhi, and Hyderabad. It focuses on the
reduction of fertility as well as maternal and infant mortality rates among people living in
urban slums by improving the outreach of family welfare services, upgrading the quality ol
family welfare services, expanding the demand for health services through expanded
information, education and communication activities, and improving the administration and
management of municipal health departments.
The Ninth Population Project, which became effective in September 1994, is being
implemented in three states-Assam, Karnataka, and Rajasthan-and is financed through an
IDA credit of US$88.6 million. The project supports improved access to, demand for, and
quality of family welfare services, particularly among poor, remote, and tribal peoples.
The project aims to:
o
strengthen family welfare service delivery, including establishment of first-referral
units;
o
improve the quality of family welfare service;
o
strengthen demand-generation activities through improved information, education,
and communications planning and activities;
o
strengthen program management and implementation capacity; and
o
provide funds for innovative schemes to improve service delivery.
Future Operations
Building on a major analysis done collaboratively by the World Bank and Government ol
India, and recent Indian program developments, the Indian government is preparing a
Reproductive and Child Health (RCH) Project, which would support the National Family
Welfare Program in improving the health status of women and children, especially the poor
and underserved. An essential package of reproductive and child health services is integral
to the project approach.
The project would include two major components:
o a nation-wide policy reform package, covering monitoring and evaluation,
institutional strengthening, and service delivery; and
ittp://www.worldbank.org/html/extdr/offrep/sas/saspop.htm
10/6/99
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THE WORLD BANK GROUP
NOME
News Release No. 97/ 1368 SAS
Contacts: Rebeca Robboy: (202) 473-0699
Durudee Sirichanya: (202) 458-9031
Paul Mitchell: (202) 458-1423
INDIA REPRODUCTIVE AND CHILD HEALTH
PROJECT SIGNALS POLICY CHANGE FOR FAMILY
WELFARE PROGRAM
World Bank provides largest-ever credit for population project
NEW DELHI, May 29, 1997— The World Bank today announced the approval of a US$248 3
Ch Id HeaZp nt fqtTr1im USt Funii Credlt tO the Govemment of Mia for a Reproductive and
Child Health Pioject. The project will support the National Family Welfare Program in improving
the health status of women and children and stabilizing population growth.
The credit, which is the largest support undertaken by the Bank or any other development agency
for follow-up to the 1994 International Conference on Population and Development wi 11 be
’
provided on International Development Association (IDA) terms.
H
The India Family Welfare Program is the longest established and one of the largest programs in
this field in the world. It was assigned the formidable task of reducing fertility in the world’s
second most populous country. Fertility has declined from 6.0 to 3.4 births per woman, but it is
still shoit of the replacement fertility goal of2.1 births per woman. To address this intensive
eMualmn within and outside the country, as well as the Bank’s highly participatory sector w ork
in 94, contiibuted to a policy shift known as the "participatory planning approach."
The Government of India has taken a bold, imaginative, and innovative step in initiating a shift
in its long-standing program. With the new approach, the program focus will shift from Achieving
contraceptive targets to responding sensitively to the health needs of clients, and provide better 8
quality. gender sensitive information, and services that are more accessible to the poor.
Conimimities, particularly the rural poor, will participate in identifying their reproductive health
'.u°n‘,orl'!S service quality, " says Indra Pathmanathan, a World Bank Public
Health Specialist and project task manager.
Moie specifically," Pathmanathan continues, "theproject will serve the contraceptive needs of
the one in three couples who do not want another child but are not using contraception reduce
the ven high levels of death and illness among pregnant women, and further reduce the hi^h
levels of preventable childhood illness."
The project will assist the Family Welfare
ABOUT INDIA’S FAMILY WELFARE
Program in strengthening management
PROGRAM
performance by shifting to the participatory
management approach. Implementation of such
With 950 million people, India is the world's
policy refonn requires fundamental attitudinal
second most populous nation after China.
and behavioral change in more than 280,000
managers and workers, as well as in the
India has made remarkable strides in
improving family welfare since the Family
community. Recognizing this, the government,
in partnership with the NGO community,
Welfare Program was launched in 1951. In the
spearheaded an extensive series of consultations ; intervening period, mortality levels fell by
with state policy makers, NGO and academia,
nearly two-thirds, fertility declined by about
two-fifths, and life expectancy al birth almost
rural communities, and grassroot providers.
http://www.worldbank.org/html/extdr/extme/1368.htm
10/6/99
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rural communities, and grassroot providers.
These consultations provided guidance on how
to re-direct a massive program without losing its
existing momentum and strengths. This
consultative process will be continued during
project implementation.
rVJLIL I k_n.. rttgc X U1 J
doubled. The Family Welfare Program helped
to bring the country about two-thirds of the
way toward its goal of replacement-level
fertility (2.1 births per woman), with fertility
declining from about 6 to 3.4 births per
woman.
The project will enable the Family Welfare
Program to deliver a package of essential
reproductive and child health services, defined
by the Government of India as: prevention and
management of unwanted fertility; management
of pregnancy and childbirth; reproductive tract
infections; and child survival, including
immunization, diarrheal and acute respiratory
illness, and newborn care.
India has also made inroads in improving
maternal and child health. The country has
established an impressive network of more
than 2,300 community health centers; 21,000
primary health centers; and 131,000 village
level sub-centers to provide primary health
care, including maternal and child health care
and family planning at the grassroots level.
According to India’s Ministry of Health and
Family Welfare (MFHW), more than 40
The project has three major components. The
percent of eligible couples are using
first is a nation-wide policy reform package,
contraception. MFHW's figures also show that
including monitoring and evaluation,
over 60 percent of mothers had received
institutional strengthening, and service delivery.
tetanus-toxoid immunizations during their
It will expand existing monitoring systems
most recent pregnancy, over 50 percent of
through regular client polls and technical
mothers had received iron-folate tablets to
assessments of quality. This component also
combat anemia, and over 60 percent of infants
provides training and technical support for more
had received at least one immunization.
responsive decentralized activity planning.
Source: India's Family Welfare Program:
A second component will expand the essential
Moving To a Reproductive and Child Health
package of reproductive and child health
Approach, Directions in Development Series,
services and improve their overall quality,
World Bank.
coverage, and effectiveness. The upgrading of _______________________________________
quality and scope of services will take place through improved clinical and communication
practices and the establishment of referral procedures from the community to the appropriate
facility. This component will also support pilot experimental schemes designed for tribal areas
and urban slums.
A third component focuses on local capacity enhancement. In India’s most disadvantaged districts
and urban slums, the project will provide additional investment for expanding the family health
care infrastructure by financing the construction of health posts, special NGO schemes, and
stipends for voluntary health workers and women’s village health committees.
More specifically, the project will:
• reduce unwanted fertilitypregnancies aamong the 30 million women reported in the 199394 National Family and Health Survey who have ‘unmet contraceptive needs’, namely,
those not using contraceptives, although they wished to space or not have any further births.
• reduce the health risks and burden of disease associated with pregnancy and childbearing
among the 220 million women in the reproductive age group in India, in particular, the
largely poor women in districts that have high concentrations of scheduled tribes and castes,
and poor women in urban slums.
• increase child survival in the 0-4 year age group by increasing program coverage to an
estimated 10 million additional children over the five year period, improve effectiveness of
ongoing interventions, and reduce poor maternal health which is estimated to be associated
with 30 percent of deaths of children under five years of age.
The USS248.3 million equivalent credit will be provided through theon standard IDA terms with a
10 years grace period and 35 yearsto maturity and includes a commitment fee of 0.5 percent and a
Service charge of 0.75 percent. IDA is the World Bank’s concessionary lending affiliate. The
Indian Government will contribute US$60.5 million. Total project costs are US$308.8 million
equivalent.
http://www.w0rldbank.0rg/html/extdr/extme/l 368.htm
10/6/99
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THFWORLD BANK GROUP
:I I
NOME
Population and Reproductive Health
j^xip.'lnformation Brief
Challenges
The World Bank, its client countries, and other donors
are implementing new approaches in their response to
population and reproductive health issues after the call
by the 1994 Cairo Population Conference (ICPD) to
link population policy more closely to poverty
reduction and human development and to adopt a
reproductive health approach that integrates family
planning, maternal health, and prevention of sexuallytransmitted infections. ICPD seeks to place individual
rights and needs in the forefront of population and
development policies and programs.
Implementing these new approaches poses special
challenges. Population policies and programs need to
be adapted to the diverse demographic, economic and
geographical conditions in countries. Countries with
high rates of population growth require sustained,
coordinated investments in family planning, child
survival, maternal health, girls' education and women's
empowerment.
Experience shows that such investments can have a
significant demographic impact. For a variety of
reasons, including changes in attitudes linked to
increased education and economic opportunities for
women, dissemination of new ideas through the mass
media, and organized efforts to increase access to
modem methods of fertility regulation, fertility rates
have declined to below half their 1960 levels in East
Asia and Latin America, and nearly so in South Asia.
Investments by the Bank and other donors created
enabling conditions for these fertility declines.
Reasons for Investing in Reproductive
Health Projects
• High-quality, user-oriented health
services offering a range of reproductive
health services and information can
improve individual health and welfare.
• Improvements in reproductive health
have multiple benefits : lower fertility,
lower maternal mortality, healthier
children, and better-off families.
• Slowing ofpopulation growth is still a
high priority in the poorest countries:
rapid population growth makes it more
difficult to provide education and health
services, create jobs, and preserve the
environment in poor countries.
• Integration ofpopulation policy with
social policies, including girls'
education, women's status, and poverty
reduction, is more effective in reducing
high birth rates than policies that focus on
fertility reduction alone.
• Empowerment and choice enable
people to make their own choices about
family size by providing them with the
means - family planning information,
education, supplies, access.
• Promoting better reproductive health
helps women avoid the risks of too many
births, too closely spaced, or initiated
when the mother is too young or too old.
• Poor reproductive health undermines
women's potential to contribute to
increased productivity and family welfare.
The poor in all regions continue to experience
___________________ _ ______
unacceptably high fertility, malnutrition, and child and maternal mortality. An estimated 120 million
women who currently wish to space or limit further childbearing are not using contraception. Almost
10% of the total disease burden in the developing world is due to maternal and perinatal conditions.
Among women in the age-group 15- 44, pregnancy-related illness and death impose the greatest
disease burden. While illustrating the high global burden of preventable disease, this statistic masks
considerable regional variation even among poor countries. For example, at similar per capita income
levels, maternal mortality in Yemen is ten times higher than in Vietnam, and almost 30 times higher in
the Ivory Coast than in Sri Lanka.
The Link to Poverty
Improving human development and economic productivity are central to the Bank's efforts to reduce
poverty. Population and reproductive health are linked in various ways to these important agendas.
For example, the growth, age composition and geographic distribution of populations affect and are
affected by progress in reducing poverty and improving living conditions. In poor households, high
mortality and morbidity, along with unwanted fertility, are among the major burdens of poverty.
Reduc.ng them contributes directly and indirectly to poverty reduction.
The linkages between poverty, population and reproductive health are complex. Most of the increase
in global population over the last four decades has occurred in developing countries, and future
increases are projected to occur in the poorest of those countries. Despite the pressures of rapid
population increase, developing countries have made substantial progress in improving living
standards. However, rapid population growth continues to undermine efforts to reduce poverty in
Africa and Asia and poor economic performance combined with a high rate of population increase has
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10 () 99
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led to declines in per capita income in several countries.
The World Bank’s Role
In keeping with its development objectives, the World Bank is working closely with partners and
client governments to address population issues within a broader context. The Bank's main
comparative advantage in population and reproductive health policy is through dialogue and analytical
work to help borrowers understand how demographic shifts affect the social sectors (health, education,
social security) as well as the environment and agriculture, employment, and basic infrastructure.
Over the past 40 years. Bank population projects have included a combination of strategies. In the
1970s, projects supported infrastructure projects to provide facilities to provide reproductive health
services to clients. At the same time, funds were provided to provide technical assistance and training
for the development of skills to implement family planning programs. During the 1980s, the focus
expanded to cover primary health care and communities, particularly addressing the health of children
and more recently, of women. In the 1990s, operations are increasingly addressing health sector
reform and new health problems, including HIV/AIDS. In addition, reproductive health and family
planning are now being addressed as components of broader health programs. The broader approach is
expected generally to be more cost effective and yield greater results.
The World Bank is working with borrower countries and other donors to implement the agreements on
reproductive health and rights agreed upon at the 1994 International Conference on Population and
Development (ICPD) and the 1995 Fourth World Conference on Women and is working to reduce the
gender gap in education and to ensure that women have equitable access to and control over economic
resources.
World Bank Lending
The Bank is the largest single source of external funding in developing countries for human
development (HD) programs: health, nutrition, population (HNP), education and social protection.
Population and Reproductive health activities constitute a significant portion - just less than one-third of all lending for health, nutrition and population. Most of the World Bank's funding for Population
and Reproductive health programs is provided on highly concessional terms to low-income countries
through the International Development Association (IDA).
Population and Reproductive Health Related Development
Impacts of Bank Operations
Sector Outcornes
Operations
Gender-foe used
components of
micro-enterprise
and other programs
Higher incomes,
better jobs for
w o men
H u rn a n D e v e I o p rn e nt I rn p a ct s
Reduced desired
family size
Women are more
empowered
Increased enrollments and
completion rates, and
\ red uce d ge nd er i mba Ian ces
(
Education programs
HNP services,
especially RH
components
/
less unsafe sex, fewer
unwanted pregnancies
Greater capacity to
make RH decisions
Lower rnaternal/child
mortality, fewer HIV
infections, later marriage.
lower fertility1 and pop
growth, age structure effects
Bank lending supports investments in a variety of initiatives that contribute to positive population and
reproductive health outcomes, as shown in the figure above. These programs contribute directly to
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10.6 99
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outcomes that are important in their own right (the middle column of the figure). They also contribute
indirectly through changes in the enabling environment, for example by influencing desired family
size or by increasing women's capacity to make decisions that affect their reproductive health (as
shown in the right-hand column of the figure). At the policy level, recognizing these broader
development links and ensuring that social programs contribute positively to them is much of what
ICPD meant when it called for population issues to be addressed in a broader human development
context.
In the HNP sector, the Bank has lent US$ 3.7 billion over the last twenty-five years to support
population and reproductive health through 192 HNP projects in over 80 countries. Although new
commitments have varied from year to year, the trend has been steadily upward. In recent years, Bank
lending has integrated reproductive health projects with its population programs, financing an average
of nearly US$ 400 million a year since fiscal 1992 for projects involving population and reproductive
health activities. Many Bank projects include grant assistance from other donors or are designed to
complement the work of other donors in client countries.
HNP&P/RH Lending
2500 n
2000
A ------ F
P/RH
-^r-HNP
Uf
______
za;
o 1500
E
S 1 000
/
D
500
I
I
J
a"
«
a'T
/b
,
x^<t5
/
/
\/
—
A
•»
-f
o
___ V__
of*
$
^ Fiscal Year
Other Bank-funded projects also make significant contributions to Population and Reproductive
health issues. Over the past three fiscal years (1996-1998), the Bank and IDA have committed nearly a
billion dollars in new lending to increase education for girls. Outside of the Human Development
sector, rural development projects provide micro-credit, which contributes to the empowerment of
women and indirectly enables them to exercise greater choice in reproductive decisions. Genderfocused initiatives in a number of sectors have similar effects. For example, the Second Egypt Social
Fund Project has a $354 million enterprise-development component providing loans and technical
assistance through NGOs, with special emphasis on credit for poor women.
Regional Perspective
The Bank's six regional units have all made major commitments to reproductive health and family
planning. During the period covering FY 1992 to FY 1998, South Asia accounts for the largest share
(35 percent) of the $2.7 billion in loans and credits. Latin America and the Caribbean countries have
the second largest share with 20 percent, and Africa is third with 17 percent.
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Commitments for PopulatioivRepiuducthe Health in Loans/Credits,
________ Fiscal Years 1992-98 by World Bank Region (Millions of U.S. Dollars)
Fiscal Year
1992
1993
1994
1995
1996
1997
Total
1998
P ercent
25.2
67.1
96.7
145.8
50.7
1.7
65.0
452.2
~T7
0.5
46.6
79.3
9.4
0
93.5
114.4
111.8
8.0
26.1
50.6
2.7
355.7
189.0
13
1.8
2.3
35.6
184.5
54.0
111.8
64.5
98.2
550.9
20
0
79.4
0
46.4
37.5
0
38.0
201.3
8
243.7
78.6
340.0
133.1
423.7
106.6
4487
82.7
508.9
131.7
232.0
171.0
425.5
947.4
2696.5
35
WO
5 u b- S aha ran
Africa
East Asia
Europe &
Central Asia
Latin America
6 Caribbean
Middle Easts
North Africa
S o uth .Asi a
TOTAL
318.3
0“
Effective Action
The Bank's comparative advantage
T he World Bank's partners in the population and reproductive health fields - including UNFPA.
WHO. UNAIDS, UNICEF, bilateral donors and NGOs - provide borrowers with most of the technical
expertise as well as significant financial assistance for their programs. These partners look to the Bank
for support in policy dialogue and resource mobilization. Because of the Bank's access to both finance
and planning ministries as well as functional ministries such as health, education, and women's affairs,
il is well positioned to facilitate actions that link investments in different sectors, including health,
education, and gender, to achieve optimum impact. Further, it has the financial capacity to support
investments in these areas and has committed itself to increased support of the social sectors.
In order to sharpen strategic focus and strengthen
Key Population and Reproductive Health
effectiveness, the Bank's staff in population and
Indicators:
reproductive health are working to ensure that these
perspectives are included in key documents during
• The total fertility rate
policy dialogue with client governments in countries
• The maternal mortality ratio
where such a perspective is expected to have a critical
• The prevalence of HI V/AIDS
impact on poverty and human development. A
• An index of the force of population
database of key population and reproductive health
momentum
indicators (see box) will be maintained to identify key
• Urban population growth
issues for possible discussion in World Bank Country
• Growth of the young working-age
Assistance Strategies (CASs) and other key
population
documents. These indicators will help to identify
• Enrollment of girls in secondary school
population and reproductive health issues in countries
slated for CAS review with the aim of directing
i_______________
increased attention on these issues during discussions with governments.
Strengthening Partnerships
Many Bank Population and Reproductive health projects currently involve a partnership between
governments, international agencies, other donors and non-governmental organizations (NGOs).
Many of these partners have developed specialized skills over the years and Bank collaboration with
these groups is steadily increasing.
• United Nations Population Fund (UNFPA) : UNFPA is the lead international agency in the
population field, with a strong network of field offices that are knowledgeable about local
conditions and issues. The Bank already uses UNFPA's contraceptive procurement facility and
is working to increase collaboration in such areas as training, procurement, strategy
development, and country program management.
World Health Organization (WHO) : WHO is the lead international agency in health, w ith
strong links to the scientific community for maternal, reproductive and child health. The Bank
supports WHO's program for training and research in reproductive health, and WHO provides
the Bank with policy guidance and technical support.
• Joint United Nations Programme on AIDS (UNAIDS) : UNAIDS is a global partnership
cosponsored by the World Bank and five other international agencies. Its goal is to provide
policy and technical leadership to countries in their efforts to turn back the epidemic.
•
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l() 6 99
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.
• United Nations Children *s Fund (UNICEF) : UNICEF is a partner in a number of Banksupported RH operations, and has recently begun to expand its focus on adolescent
reproductive health. UNICEF's specialized skills in advocacy and health communication are
particularly important for reproductive health initiatives.
• Bilateral Donors : Bilateral donors cofinance P/RH activities in a number of borrower
countries and provide a broad range of technical support to country programs.
• Nongovernmental organizations (NGOs) : NGOs have played a critical role in the
population and reproductive health fields - particularly for developing and testing novel
approaches to problems, in research, advocacy, and service delivery in settings where the
government and for-profit private sectors are particularly weak.
Addressing the multisectoral dimensions of population and reproductive health also requires working
with partners outside the HNP sector. Within the Bank, links to the Education and Social Protection,
as well as Gender, Poverty Reduction and Environment, are being strengthened. Outside the Bank, ties
are being nurtured with more general development groups as well as those with a special focus on
gender, the environment and human rights.
Additional Funding Sources
One of the most effective mechanisms for working with these partners is through grants given under
the Bank's newly established Development Grant Facility (DGF, formerly the Special Grants
Program). In addition to the WHO programs mentioned above, these grants have enabled the Bank to
build the capacity of grass-roots groups in borrower countries that work on issues (female genital
mutilation, for example) which cannot be addressed through the lending program. Another initiative
supported by the program, the South-South Partnership in Population and Reproductive Health, is
already helping to bring a range of development partners into collaborative arrangements to assist in
training and interagency coordination.
Making A Difference - Bank Population Programs
INDIA
The India Reproductive and Child Health project is upgrading the quality and scope of reproductive and child
health services. The two central project components include a nationwide policy reform package covering
monitoring and evaluation, institutional strengthening and service delivery, and a local capacity enhancement
component that would fund district and city sub-projects aimed at meeting specific needs of local priority groups.
The project is intended to increase access for particularly disadvantaged groups such as scheduled castes and tribes,
and the urban poor.
BANGLADESH
In Bangladesh, a consortium of development partners, including the Bank and the Government of Bangladesh, has
funded a series of health and population projects. The consortium was established during earlier projects and is now
working with the Government in implementing a sector-wide program that will support delivery of an essential
package of reproductive and child health services. Priority will be given to the needs of vulnerable groups,
particularly poor women and children, and to addressing Bangladesh's high rates of maternal mortality and
morbidity. The program is also supporting key reforms aimed a making Bangladesh's health system more cost
effective and sustainable.
MOROCCO
The Morocco Social Priorities Program/Basic Health Project is working to increase access to essential curative and
preventive health services in 13 target provinces. Safe motherhood goals are being attained by increasing
availability to contraceptives, reorganizing prenatal service delivery, training traditional birth attendants, and
establishing a medical evaluation system for obstetrical emergencies.
MALAWI
The Malawi Social Action Fund is a multi sectoral Bank project. It will upgrade and construct community
infrastructure such as schools, health facilities, community water points, rural/urban markets, and granaries to help
w omen gain better access to health and education facilities and employment opportunities. The project's
promotional activities focus attention on women's priorities and needs and support women's involvement in the
design, implementation and management of subprojects.
The benefits of the projects include:
• Increased access to health care, including family planning, at sites where health facilities have been
constructed.
• Better access to maternal care at sites with maternity facilities.
• Better management of emergency cases as a result of road works, allowing ambulances to reach previously
inaccessible communities.
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Increased food purchasing power and improved women's and children's nutrition resulting from higher
earnings.
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DESPITE PROGRESS, MILLIONS IN THE
DE VELOPING WORLD STILL DENIED ACCESS TO
REPRODUCTIVE HEALTH SERVICES
WASHINGTON, February 4, 1999—Around the globe, 120 million poor couples are still denied
access to good reproductive health services and counseling. Lack of access is most serious in subSaharan Africa and in several countries in Asia and the Middle East, where most of the additional 2 3 billion people will be born before global population stabilizes sometime late in the next century,
according to the World Bank.
As experts and policymakers gather in The Hague, Netherlands, next week to review progress since
the 1994 International Conference on Population and Development in Cairo, population growth
remains a persistent problem. Despite the strides many countries have made, unwanted
pregnancies, malnutrition, and high child and maternal death rates are still far too common in the
developing world.
Tragically, one in every 48 women in the developing world dies from pregnancy-related causes each
year, compared to one in 4,000 in developed countries. Reproductive- tract infectiops are
widespread. The leading cause of death and disability for women in the developing world is poor
maternal health and birth-related problems..
Governments can no longer afford not to invest in population and reproductive health programs—
the most cost effective public health initiatives developing countries can undertake. Because such
investments are inexorably linked to economic growth, the World Bank has been working with
developing countries to implement the landmark agreement signed in Cairo and to integrate its
population and reproductive health activities into its core agendas of poverty reduction and human
development.
"The Cairo conference shifted the focus of population work from demographic targets and control to
an approach that puts people and their human rights first," said Tom Merrick, World Bank Senior
Population Adviser. "This shift parallels the World Bank's own move toward greater emphasis on
social development and on balancing its goals of poverty reduction and human development with
more traditional concerns about public finance and macroeconomics."
The World Bank3/4 the single largest external financier of human development programs in
developing countries^ is also working closely with partners and client governments to address
population issues within a broader context. The Bank's main comparative advantage in population
and reproductive health policy is through dialogue and analytical work to help borrowers
understand how demographic shifts affect the social sectors (health, education, social security) as
well as the environment and agriculture, employment, and basic infrastructure.
Following its commitment made at the Cairo conference, World Bank has steadily increased lending
for population and reproductive health activities-- over $2 billion in loans since 1994-- and
developed a new strategy linking these goals to its core agendas of poverty reduction and human
development. Even more lending has been provided through support for child survival, girls'
education, and the empowerment of women, where the links to population and reproductive health
are indirect. The social sectors now account for a fifth of overall Bank lending.
With access to both finance and planning ministries, as well as to ministries such as health,
education and women's affairs, the Bank is well-positioned to encourage a broader perspective of
population issues and to link investments in various sectors to achieve the best results.
The Bank works with its partners to find the underlying flaws that make health and education
systems unresponsive to the needs of the poor. Constraints like financial disincentives and rigid civil
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service rules—guaranteed employment no matter how poor the performance—undermine efforts to
improve the quality of health and education programs. Improving the performance of health
systems is particularly important for such initiatives as Safe Motherhood, which requires an
effective referral of obstetric emergencies in order to save women's lives.
"For all aspects of population and reproductive health, empowering women is a critical factor," said
Anne Tinker, Senior World Bank Health Specialist. "This requires careful analysis to identify
synergies across sectors such as health education, and social programs. Coordinated support for
programs in reproductive health, girls' education and access to income- generating opportunities
and employment for women will yield gains in welfare for individuals, families and communities."
MAKING A DIFFERENCE - WORLD BANK POPULATION PROGRAMS
INDIA
The India Reproductive and Child Health project is upgrading the quality and scope of reproductive and child health services. The
two central project components include a nationwide policy reform package covering monitoring and evaluation, institutional
strengthening and service delivery, and a local capacity enhancement component that would fund district and city sub-projects
aimed at meeting specific needs of local priority groups. The project is intended to increase access for particularly disadvantaged
groups such as scheduled castes and tribes, and the urban poor.
MALAWI
The Malawi Social Action Fund is a multi sectoral Bank project. It will upgrade and construct community infrastructure such as
schools, health facilities, community water points, rural/urban markets, and granaries to help women gain better access to health
and education facilities and employment opportunities. The project's promotional activities focus attention on women's priorities
and needs and support women's involvement in the design, implementation and management of subprojects.
The benefits of the projects include: increased access to health care, including family planning, at sites where health facilities
have been constructed; better access to maternal care at sites with maternity facilities; better management of emergency cases
as a result of road works, allowing ambulances to reach previously inaccessible communities; and increased food purchasing
power and improved women's and children's nutrition resulting from higher earnings.
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The Second Report Card on Bangalore’s Public Services
SAMUEL PAUL
SIT A SEKHAR
PUBLIC AFFAIRS CENTRE
BANGALORE
NOVEMBER,
(WJ fc-A
V\ kJL^
3.
- Media
RF_WH_.11_10_SUDHA.pdf
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