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Evidence-based recommendations for reproductive health in developing countries

No. 2
Department of Reproductive Health and Research

World Health Organization, Geneva, 1999
Editors
About RHL - How to subscribe - Comments/Feedback
Acknowledgements - Copyright & Disclaimer - Technical support

WHO Reproductive Health Library 1999 Issue 2
Page 1

Evidence-based reproductive health in developing countries
Health care priorities are different in developing and developed countries. Yet in many developing
countries the allocation of resources for health care as well as health care practices remain modelled
after those of developed countries. The result is that in developing countries health care in general,
and reproductive health in particular, have suffered from inadequate staffing and inappropriate
allocation of resources.

A prerequisite for need- and evidence-based allocation of resources and appropriate health care
practices is access to scientifically solid and up-to-date information. The lack of access to sound and
current information has even more damaging consequences for health care in that practices of
unknown effectiveness, or, in some cases, of practices that are known to be harmful, become
entrenched in clinical practice. This places a further burden on the limited resources for health care in
developing countries.

A variety of problems are caused when clinical practices that are not based on sound scientific
evidence find their way into established medical/health care practice. It is generally acknowledged
that removing an entrenched practice is much more difficult than introducing a new one. Thus, not
only valuable resources continue to be used for practices of unknown effectiveness, but also,
research is needed later to evaluate the usefulness of these practices. For example, large trials had
to be conducted to show that routine episiotomy is not beneficial. Furthermore, routine electronic fetal
monitoring during labour, and routine ultrasound assessment during pregnancy, have not been
shown to decrease morbidity and mortality. Yet these two practices are used widely in some
developing countries. A more effective resource allocation, complemented by efforts to implement
only those practices that are effective should be a priority in order to improve reproductive health
services in developing countries.
The WHO Reproductive Health Library (RHL) seeks not only to prevent the introduction of
unsubstantiated health care practices into programmes but also to replace the practices that have
been demonstrated to be ineffective or harmful with those based on best available evidence. The
sections below explain the terms and concepts employed in generating evidence-based knowledge in
health care practice. By presenting these terms and concepts in simplified terms we hope to promote
a better understanding and utilization of the data presented in RHL.

Evidence based services
Evidence-based health care means that the policies and practices employed in the prevention and
treatment of health care problems are based on principles which have been proven through
appropriate scientific methods. However, proving clinical effectiveness of a procedure is not
sufficient. It needs to be complimented by evidence of provider and user satisfaction, and feasibility
and cost-effectiveness of the procedure in different settings.
Most health workers and policy-makers in developing countries do not have easy access to the latest
reliable information on effective care. This is not only because of the high cost and erratic delivery of
most subscription journals, but also because few medical journals publish comprehensive systematic
reviews on the effectiveness of health care interventions in developing countries. Such information
remains scattered in different papers in numerous journals, making it very difficult for health
practitioners to get a good overview of all the data available on a given subject.

The Cochrane Collaboration publishes systematic reviews (Cochrane reviews) of effectiveness of
health care interventions in electronic form in The Cochrane Library. These systematic, up-to-date
summaries constitute reliable evidence of the benefits and risks of health care and are intended to
help policy-makers and clinicians make sound practical decisions. RHL includes Cochrane reviews on
reproductive health topics that are relevant to developing countries.
WHO Reproductive Health Library 1999 Issue 2
Pagel

Systematic reviews
“Where is the knowledge we have lost in information" T.S. Elliot, The Rock

Each systematic review attempts to answer one clearly formulated health question. It uses rigorous
and explicit methods to identify, select, and critically appraise relevant research. The data extracted
through this methodology are then analysed using standard statistical methods and presented in the
review.
In contrast to the traditional narrative reviews, systematic reviews adhere to a strict scientific design.
In the case of Cochrane reviews the design requires a comprehensive search for all available data in
all languages on the topic. This helps to avoid bias in the selection of data to be included in the
review. The review methodology is designed to minimize selection bias in order to ensure reliability of
the data to be included. Explicit methodology is used to ensure reproducibility of results. As new data
become available each Cochrane review is updated. An important distinction between a systematic
review and a traditional narrative review is that the former contains a comprehensive summary of all
available information rather than reflecting the views of the authors). The methodological rigour of a
systematic review is achieved by preparation of a review protocol that gives details of how the studies
are going to be searched, retrieved and critically appraised before inclusion in the review. It must be
remembered that the results of a review will only be robust and conclusive if the trials included are of
sufficient quality.

Randomized controlled trials
Currently, systematic reviews are based mostly on data from randomized controlled trials (RCT)
because these are the most reliable method of assessing the effectiveness of preventive or
therapeutic health care interventions. RCTs are experiments in which investigators randomly allocate
eligible people or health care units into groups to receive, or not to receive, the intervention(s) being
compared. When sample size is adequate, randomization ensures baseline comparability of known
and unknown prognostic variables. Outcomes are selected a priori in order to achieve unbiased
assessment of the results.
However, the most appropriate research design depends on the health problem or question that one
faces. For example, if the objective is to evaluate the accuracy of a diagnostic test, cross-sectional
studies of patients suspected of harbouring the disorder are required. Similarly, questions about
prognosis can be answered by follow-up studies of patients having the disorder and corresponding
controls.

Meta-analysis
Meta-analysis is the statistical method used to integrate results from more than one study to produce
a summary estimate of the treatment effect across studies (typical relative risk). It is an application of
a statistical technique used in observational studies (case-control studies and cohort studies) during
stratified analysis. The difference is that in a meta-analysis in a systematic review of RCTs each
stratum is an individual randomized controlled trial. In a stratified analysis of observational studies, on
the other hand, a stratum is a category of the variable under consideration (for example age <20
years versus > 20 years). This technique is commonly known by the names of those who developed
it for case-control studies (Mantel-Haenszel) although several variations of it also exist. Meta-analysis
is only an analytical tool in a systematic review and not all systematic reviews necessarily include a
meta-analysis. In the presence of disparities among trials meta-analysis can help by stratifying
different characteristics, to identify the sources of such disparities. Meta-analysis is conducted in a
systematic review when the review includes more than one trial, although it does not necessarily
follow that a summary estimate of the treatment effect is obtained. When there are clinical or
biological disparities (heterogeneity) between trials, then using meta-analysis to produce a single
summary estimate may be misleading and should be avoided.
WHO Reproductive Health Library 1999 Issue 2
Page 2

Evidence-based reproductive health in developing countries
Health care priorities are different in developing and developed countries. Yet In many developing
countries the allocation of resources for health care as well as health care practices remain modelled
after those of developed countries. The result is that in developing countries health care in general, and
reproductive health in particular, have suffered from inadequate staffing and inappropriate allocation of
resources.

A prerequisite for need- and evidence-based allocation of resources and appropriate health care
practices is access to scientifically solid and up-to-date information. The lack of access to sound and
current information has even more damaging consequences for health care in that practices of unknown
effectiveness, or, in some cases, of practices that are known to be harmful, become entrenched in
clinical practice. This places a further burden on the limited resources for health care in developing
countries.

A variety of problems are caused when clinical practices that are not based on sound scientific evidence
find their way into established medical/health care practice. It is generally acknowledged that removing
an entrenched practice is much more difficult than introducing a new one. Thus, not only valuable
resources continue to be used for practices of unknown effectiveness, but also, research is needed later
to evaluate the usefulness of these practices. For example, large trials had to be conducted to show that
routine episiotomy is not beneficial. Furthermore, routine electronic fetal monitoring during labour, and
routine ultrasound assessment during pregnancy, have not been shown to decrease morbidity and
mortality. Yet these two practices are used widely in some developing countries. A more effective
resource allocation, complemented by efforts to implement only those practices that are effective should
be a priority in order to improve reproductive health services in developing countries.
The WHO Reproductive Health Library (RHL) seeks not only to prevent the introduction of
unsubstantiated health care practices Into programmes but also to replace the practices that have been
demonstrated to be ineffective or harmful with those based on best available evidence. The sections
below explain the terms and concepts employed in generating evidence-based knowledge in health
care practice. By presenting these terms and concepts In simplified terms we hope to promote a better
understanding and utilization of the data presented in RHL.

Evidence based services
Evidence-based health care means that the policies and practices employed in the prevention and
treatment of health care problems are based on principles which have been proven through appropriate
scientific methods. However, proving clinical effectiveness of a procedure is not sufficient. It needs to be
complimented by evidence of provider and user satisfaction, and feasibility and cost-effectiveness of the
procedure in different settings.
Most health workers and policy-makers in developing countries do not have easy access to the latest
reliable information on effective care. This is not only because of the high cost and erratic delivery of
most subscription journals, but also because few medical journals publish comprehensive systematic
reviews on the effectiveness of health care interventions in developing countries. Such information
remains scattered in different papers in numerous journals, making it very difficult for health practitioners
to get a good overview of all the data available on a given subject.
The Cochrane Collaboration publishes systematic reviews (Cochrane reviews) of effectiveness of health
care interventions In electronic form In The Cochrane Library. These systematic, up-to-date summaries
constitute reliable evidence of the benefits and risks of health care and are intended to help
policy-makers and clinicians make sound practical decisions. RHL Includes Cochrane reviews on

reproductive health topics that are relevant to developing countries.

Systematic reviews
"Where is the knowledge we have lost in information" T.S. Elliot, The Rock
Each systematic review attempts to answer one clearly formulated health question, ft uses rigorous and
WHO Reproductive Health Library 1999 Issue 2

explicit methods to identify, select, and critically appraise relevant research. The data extracted through
this methodology are then analysed using standard statistical methods and presented in the review.

In contrast to the traditional narrative reviews, systematic reviews adhere to a strict scientific design. In
the case of Cochrane reviews the design requires a comprehensive search for all available data in all
languages on the topic. This helps to avoid bias in the selection of data to be included in the review.
The review methodology is designed to minimize selection bias in order to ensure reliability of the data
to be included. Explicit methodology is used to ensure reproducibility of results. As new data become
available each Cochrane review is updated. An important distinction between a systematic review and
a traditional narrative review is that the former contains a comprehensive summary of all available
information rather than reflecting the views of the author(s). The methodological rigour of a systematic
review is achieved by preparation of a review protocol that gives details of how the studies are going to
be searched, retrieved and critically appraised before inclusion in the review, ft must be remembered
that the results of a review will only be robust and conclusive if the trials included are of sufficient
quality.

Randomized controlled trials
Currently, systematic reviews are based mostly on data from randomized controlled trials (RCT) because
these are the most reliable method of assessing the effectiveness of preventive or therapeutic health
care interventions. RCTs are experiments in which investigators randomly allocate eligible people or
health care units into groups to receive, or not to receive, the interventions) being compared. When
sample size is adequate, randomization ensures baseline comparability of known and unknown
prognostic variables. Outcomes are selected a priori in order to achieve unbiased assessment of the
results.

However, the most appropriate research design depends on the health problem or question that one
faces. For example, if the objective is to evaluate the accuracy of a diagnostic test, cross-sectional
studies of patients suspected of harbouring the disorder are required. Similarly, questions about
prognosis can be answered by follow-up studies of patients having the disorder and corresponding
controls.

Meta-analysis
Meta-analysis is the statistical method used to integrate results from more than one study to produce a
summary estimate of the treatment effect across studies (typical relative risk). It is an application of a
statistical technique used in observational studies (case-control studies and cohort studies) during
stratified analysis. The difference is that in a meta-analysis in a systematic review of RCTs each stratum
is an individual randomized controlled trial. In a stratified analysis of observational studies, on the other
hand, a stratum is a category of the variable under consideration (for example age <20 years versus >
20 years). This technique is commonly known by the names of those who developed it for case-control
studies (ManteFHaenszel) although several variations of it also exist. Meta-analysis is only an analytical
tool in a systematic review and not all systematic reviews necessarily include a meta-analysis. In the
presence of disparities among trials meta-analysis can help by stratifying different characteristics, to
identify the sources of such disparities. Meta-analysis is conducted in a systematic review when the
review includes more than one trial, although it does not necessarily follow that a summary estimate of
the treatment effect is obtained. When there are clinical or biological disparities (heterogeneity) between
trials, then using meta-analysis to produce a single summary estimate may be misleading and should be
avoided.

Meta-anatyses in the Cochrane reviews can be viewed in the "Summary of analyses" section in the
review by double-clicking on the MetaView: Tables and Figures. To view individual tables double-click
on the outcome that you are interested in. The results can be viewed as per different parameters,
including relative risk, odds ratio, etc. RHL editors recommend that you view the results using relative
risk (at 95 % confidence interval) as the summary estimate using a fixed-effects model.

The RHL contribution
WHO Reproductive Health Library 1999 Issue 2

Page 2

RHL Clime to provide health oaro planners and providers in developing countries with the most Current

ana the best available information on reproductive health care. RHL is updated annually and this issue
(No 2,1999) contains 40 Cochrane reviews and corresponding commentaries. These include the 27
Cochrane reviews that were included originally In issue No.1. Ten of these 27 reviews have been
updated and are included together with 13 new Cochrane reviews 'with corresponding commentaries in
this issue.

The expert commentaries on the reviews included in RHL reflect the opinions of the authors of the
commentaries on the findings of the reviews and their relevance to developing countries. Each
commentary also includes practical advice from the authors on the management of the specific
reproductive health problem in resource-poor settings. RHL editors accept that the opinions expressed in
the commentaries and the advice presented under "Practical aspects" in the commentaries may not apply
to all developing-country settings. Readers who have different views and experience of handling specific
reproductive health problems in developing countries are encouraged to submit their opinions to RHL.
RHL editors will give due consideration to publishing such opinions in future issues of RHL. Please
subh?*t your opinions to:
Dr. Metin GUimezoglu
The WHO Reproductive Health Library

World Health Organization
1211 Geneva 27
Switzerland

E-mail: aulmezoaium@who.ch .fax: +41-22-791 4171

Qualitative Data-Gathering for Reproductive Health Research

Pertti J. Pelto

Johns Hopkins University Working Paper

It is now widely accepted that effective research in community health problems should involve
an integration of qualitative and quantitative methodology. In many cases qualitative research will have
the "lead role,” in order to get full, descriptive materials of complex subjects. This is particularly true

with reference to reproductive health research because of the many sensitive issues such as abortion,
sexually transmitted infections, domestic sexual violence, and related problems. While the basic forms
of Quantitative data-gathering are well understood among health researchers in developing countries, the

newer developments in qualitative data-gathering have not yet been assimilated into the research
thinking of most research organizations.

This paper reviews some main features of qualitative methods as they are being applied in the
newest reproductive health research in South Asia and other developing areas of the world. I will
suggest guidelines concerning use of specific qualitative research methods, based on recent experiences
in India. Bangladesh, and neighboring areas. The general idea I want to express is that qualitative and

quantitative research approaches should go hand in hand. Every research group needs to be skilled in
both areas, as well as skilled in the inter-relating of qualitative and quantitative materials in data analysis

and writing. In some cases qualitative, in-depth contextual materials are used as a supplement to the

quantitative/numerical statistics. In other studies the quantitative methods are a secondary feature, to add
a bit of numerical credibility to the qualitative information. In some cases basically qualitative studies,

with only minor numerical treatment, are sufficient in themselves for presenting the basic "facts” about
some aspect of reproductive health, particularly in the planning of interventions.

Background

Relatively little was known about women’s reproductive health problems in India and South Asia until
the landmark report by Bang and colleagues in Lancet a few years ago (Bang et al, 1989). Primary

health care systems had paid scant attention to gynaecological morbidity except in relation to family
planning programs. It was widely claimed that women do not seek health care for many of their

uynaecological problems, partly because they cannot or will not divulge these problems to male doctors.
Several other reasons are usually mentioned, including the feeling that primary health services have
often been unresponsive to gynaecological problems. Also, there are considerable communications gaps

between women’s cultural understandings about these, complaints and health professionals’ biomedical
approaches to the same problems.

Bang and colleagues found very high rates of untreated gynaecological problems in their study

population in an eastern Maharashtran rural region. Since that time, a number of other studies have

documented high prevalence of gynaecological morbidity in both rural and urban populations of India as
well as elsewhere in South Asia (BCC et al, 1996; Bhatia et al, 1996;Bhatia and Cleland, 1995;
Jejeebhoy, 1996).
During the 1990s the several surveys that asked women about gynaecological problems

*

demonstrated that, when asked, women report fairly high rates of morbidities. Some of the studies have
included clinical examinations and laboratory tests, which confirmed the high prevalence rates, even

though women’s self-reported gynaecological problems do not have unequivocal correspondence with
clinically identified disease. Some women report health problems that are not confirmed through clinical
examination. Other women report no problems, but are found to have vaginal infections and other

problems. All of these studies have revealed numbers of cases of currently untreated health problems.

The various surveys of gynaecological morbidity in India and other south Asian populations

demonstrate the pressing need for much greater attention to gynaecological morbidity in the primary
health care system. At the same time, the studies raise a number of questions for which further research
is needed. Many of these research questions call for qualitative styles of data-gathering, in order to

provide systematic, in-depth information that can be used for designing more effective interventions.
Some of the priority research questions include:

A.

What are women’s culturally constructed explanatory models concerning white discharge,

menstrual problems, and other gynaecological complaints'! What are the different symptoms and signs

they recognize? What vocabulary do they use to refer to these problems? What are the different types

and degrees of white discharge they recognize. What do they call these different types? What degree of
seriousness do they assign to the different types? What do they perceive as the main causes, and

secondary, contributing causes, of these illnesses? What do they regard as appropriate treatment (in light

of different perceived causes); and which providers do they define as competent or available for

providing such treatments?
B.

What are the complexes of cultural beliefs, social relations, and otherfactors affecting their

seeking treatment for these conditions'! To what extent do economic factors affect treatment seeking?

To what extent is lack of treatment-seeking caused by failures of communication or understanding in
husband-wife interactions? What health care facilities are actually available to give treatment for these

gynaecological problems? What kinds of treatments do they provide?

C.

IVhal are the males' explanatory models about their own reproductive tract infections and

those of their wives?
D.

To what extent do women and men in various communities recognize sexual transmission as

contributing to gynaecological morbidities'? How do different rural and urban populations inter-relate

perceptions of sexual transmission with their other ideas about causes of their health problems?
E.

To what extent do women and men communicate with each other about reproductive health ’

problems, in cases ofsexually transmitted disease as well as other reproductive problems'?
F.

In what manner can systematic data about women’s and men's reproductive health problems

be gotten through interviews, given the sensitive nature of information linked to sexual behaviors'?

G.

What kinds of health care interventions can reach the hard-to-reach? For example, the

poorest people in the villages; and the women with few supporting family members, particularly the
widows, divorced, abandoned, and others.

Qualitative research methods are needed to seek answers to these questions for several reasons:

1) Useful information about peoples’ cultural explanatory models of illness are best gotten through
systematic exploration of specific illness episodes, which requires patient, in-depth interviewing, with
careful follow-up probing to fill in important details. 2) The sensitive nature of information concerning

reproductive health issues, particularly as they relate to sexual behaviors, means that the data-gathering
will often depend on developing excellent rapport with individual informants through repeated
conversation-like interviews. 3) Qualitative methods are also useful for discovering all the varieties of

local language use-the vocabularies —by means of which people communicate about reproductive health
matters.

After the qualitative methods have been used for answering some of the questions about
reproductive health issues, quantitative surveys can then be developed to get estimates of prevalences of
particular patterns of beliefs and practices, as well as estimating the likelihoods of the varieties of

treatment seeking behaviors. The quantitative survey methods have a much better chance of getting
useful data if the forms of questions “make sense” in relation to local terminology and usual health
practices.

The Ernie Perspective

There is one other major aim of qualitative research. Many people would say this is the main reason for
using these methods. That is to produce data that as nearly as possible reflect the points of view, the
ideational perspective, the cultural definitions of things, from the people's own intellectual.standpoint.

This data perspective—reflecting the peoples’ criteria, vocabulary, and compartments of thinking, is

referred to as the emic perspective. Survey questionnaires do not get, in any meaningful way, a truly

emic perspective because the questions are framed from the researcher’s point of view, in the
researchers’ (usually middle class) language, asking for “Yes” or “No” or “Maybe” answers to very

complex questions. There is no room or reason for the villager’s or the slum dweller’s owrt cultural and
ideational perspective to enter into answering. Only when the interviewing leads to extensive talking

from the people, the respondents, do we get the possibility for another view, the emic view, to enter the •

data. Those data, from the emic perspective, can only come into the picture in the form of peoples’
narration of events, behaviors and explanations. That is why the prime requirement for good qualitative
research is that the data come to us in the form of extended statementsfrom the informants, in their own

vocabulary; the way they express, or narrate their experiences.

Types of Qualitative Data-Gathering Methods

There is a wide range of qualitative methods, but they are mostly variations of the following main

categories:
1.

Individual in-depth interviews;

2.

Group interviews, including those usually referred to as Focus Group Discussions, as well as

some group methods commonly referred to as PRA (participatory research approaches), such
as social mapping of communities; and mapping of health care resources.

3.

Structured qualitative techniques of various kinds, including pile sorting, paired

comparisons, matrix interviewing, “body-mapping,” and others.
4.

Direct observation of situations, such as treatment events at health centers and private
providers’ clinics and shops.

In-Depth Individual Interviews: The Basic Foundation of Qualitative Research
Whatever mixtures of data-gathering are used in the different types of research projects, in-depth

individual interviews are far and away the most usual, and the most productive methods. To understand

this we need only consider the extent to which all of us rely on first-hand verbal, conversational
. information every day of our lives. Without deeply involved conversations with many types of people,

we would be lacking much practical information for dealing with daily problems.

4

We commonly distinguish two main types of in-depth interviews: 1) key informant interviews;
and 2) case studies.

Key Informants and Key Informant Interviews

The idea of “key informant” is often misunderstood in discussions of research methodology. Many

people seem to consider as key informants only persons in some sort of position of authority or
leadership. We often see research proposals that list as key informants people such as doctors, teachers,

local officials, district medical officers, and other government personnel. Sometimes the list of “key
informants” also includes dais and traditional healers. Such restricted lists are based on a

misinterpretation of the anthropogical concept. Key informants are, indeed, considered to be “experts”
in a cultural sense, but people in positions of authority are not the only experts when it comes to cultural

information. Our most important key informants are quite ordinary people in the community, whose
“expertness” is based on their knowledge of local cultural beliefs and practices.

We usually consider as key informants all those individuals from whom we receive extensive

amounts of information, and who have the following characteristics:

A.

Persons with whom we establish a special informational and social relationship, and1 with

whom we have contact on a number of occasions, instead ofjust a “one-shot interview.”
B.

Persons who provide us with “expert information” not only about themselves, but about local
history, cultural beliefs and practices in the community, the physical, geographic

environment, and other general information.
C.

Persons who are by their personal natures “good observers,” and interested in talking about
their knowledge with outsiders.

D.

Persons who are able to “synthesize” to some extent, and to analyze—to give thoughtful
explanations—to some of the local practices and patterns they are familiar with.

E.

Persons who know a lot more information about a particular area or topic (domain) of

information. Very often, in both rural and urban communities researchers will be directed to
“Go talk with

; he knows a lot more than we do about all the traditional remedies.”

On the other hand, we often discover especially knowledgeable people simply through our

various conversations and interactions in the research communities.
Thus, the really defining mark of a “key informant interview” is that we ask the informant to try
to generalize somewhat about local community behaviors and beliefs, or to give other information that is
not solely concerned with his or her own behaviors. (This interviewing about general information
5

contrasts with a "case study interview" in which we are asking informants to relate information about
specific behaviors, actions and beliefs concerning their own personal lives.)

It is useful to identify three types of key informants, who play somewhat different roles at

various stages of our data-gathering:

Type One Key Informants: Administrators. Leaders, and other "Authorities"

When we begin our research the first key informants we contact are likely to be personnel in government
health services, administrators in NGOs, and others who are broadly familiar with local situations and

activities because of their official duties. These "first-line key informants" can often help us to get
started in the study communities. Also, we often talk first with these types of key informants as we need
their approval before we go on with the rest of our research.
Often researchers will find that these "type one key informants" have rather limited perspectives.
They may be misinformed about important aspects of the local communities, perhaps because of middle

class biases, or the theoretical biases common to their professional status. The attitudes and beliefs of
these informants are nonetheless very important, as they can point the way to certain kinds of structural

obstacles, or systematic determinants, that must be taken into consideration in the design of specific

health intervention activities.

Type Two Key Informants: Community-based Outreach Worker.
In most areas and communities there are outreach workers of health services as well as various social
programs and NGOs. These "type two" informants are particularly important because they can

frequently provide direct contacts with some of the people in the study populations. For example
communit)' health workers in NGOs. and ANMs connected with primary health services, are often

excellent guides for introducing us directly into both urban and rural communities. Provided we can
assure these outreach workers of our legitimate good intentions, they can give us "guided tours" of
relevant community settings, and can introduce us to some of their own contact persons in the study

population. They also have wide-ranging information about individual "cases" of illness in the
communities they serve.

Type Three Key Informants: Members of the Study Population

In qualitative research in reproductive health, as in most other research, the prime key informants are the

various types of actors and actresses in the relevant study communities. In gathering information on

"explanatory models of white discharge" for example, it is essential to get information directly from the
speakers of that vocabulary. Collection of local vocabulary and explanatory models of gynaecological

illnesses can sometimes be carried out with small groups, even focus group discussions (see below), but

in-depth exploration of the local vocabularies and ideas should also be done with those individuals who
are "the most knowledgeable" about local cultural features, and who not only tell about their own
experiences and ideas, but can connect them with those of their relatives, friends and neighbors. Such

key informants are the persons with whom field researchers come to feel a sense of friendship and social
exchange.

Case Study Interviews, Illness episodes, and Case Histories
As pointed out above, case study interviews are just as much “in-depth,” but they are focused on
individuals’ own actions and explanations. One of the most useful types of case study is an individual
"illness episode." For example, researchers in a rural area in Bangladesh collected women’s narratives
of their treatment-seeking with white discharge, prolapse, and other gynaecological problems. After

learning from an informant that she currently suffered from one of the illness conditions, the researcher

goes through the following:
One: Ask the woman to “tell about the entire episode, from the beginning." In some cases the

women actually do relate a fairly long narrative, which must of course be followed up with specific

probes and queries.
Two: Using a "checklist of items” (memorized), ask questions to fill in the entire sequence of
treatment seeking. Usually the questions can "begin at the beginning.” in order to find out about the very

first signs, symptoms or experiences the woman remembers: and the very first things she did.
Questioning should focus on issues of "How long was it after you began to feel uncomfortable that you
did something? Did you do anything at home (remedies or other actions)?

Three: Concerning treatment by health providers, we try to get the informant to “tell all about”
the actual encounter with the health provider, including mode of transportation, interactions, medicines
or other treatments provided, costs, and other features.

Four: Probing should continue until you are sure that all the different visits to health providers,

and all the different resorts to home remedies have been covered.
Five: Return to visit the woman two or three times; each time asking for more depth, or more

detail about some aspect of the encounter with individual health service providers.

Six: Ask her for her explanations concerning the cause(s) of the illness: as well as explanations

for the worsening, or improvements that occurred over time. A full history of a complex, chronic,
gynaecological illness can sometimes require three or more sessions to get the full story in detail. In the

course of such in-depth interviewing the informant usually brings out much useful contextual
information, including her comments about the husband’s attitudes and actions, sexual relations with her
husband, role of the mother-in-law and others in health-seeking behaviors; and many other contextual

factors that point to important determinants of treatment-seeking actions.

Sexual Histories

Several recent research projects have taken the form of “Gynaecological and Sexual Histories.” We
recommend that each such "history" should involve at least four or five sessions with each woman. In a

study in Gujarat carried out by Archana Joshi and her colleagues at ORG the in-depth case histories

began with the discussion of the woman’s recent gynaecological illness, as reported in a quick house-to-

house census. The first qualitative interview session was used to “break the ice,” get acquainted, and to
focus on the immediate health problems of the woman. Second and third sessions followed up with more
background history and exploration of specific illness episodes and experiences in menstruation,

including treatment-seeking behaviors. By the time the interviewers met with the woman the third and

fourth time, they were able to discuss very personal matters, including the woman’s own sexual

experiences and current sexual relations with the husband. It is recommended that the fifth session
should use a checklist (memorized) to “fill in” topical areas that may have been skipped over in previous

sessions. Joshi’s group collected a total of over 60 sexual histories from women in several villages.
The development of a checklist ofkey topical areas is an important element in the collection of

sexual histories, illness episodes, and other types of “cases.” A draft checklist should be prepared at the
start of the research, and then revised during the research, based on new types of information that come

to light. The researchers use the checklist to make sure they have gotten data in all the key content areas,
after which they can carry out systematic content analysis, including simple quantifying and categorizing
of their cases.

Mixed Case Study-Key Informant Interviewing

It usually happens that case study interviewing helps the researchers to identify some individuals

who are excellent key informants. These are usually people who have had considerable experience in the
topical area (for example, dealing with their own gynaecological problems), and who have accumulated

8

general knowldge and ideas through talking with the relatives and neighbors as well as other people.
Such persons are often the kind of people that other villagers turn to for advice about their health

problems and other matters.
The conversations with such a person will often switch from her own experience—her own caseto discussion of other people’s experiences. From that transition the informant goes on to more

generalizations or observations concerning "usual practices,” or "cultural norms” of her community.

There is no harm in such mixing of two different styles of informant interviewing, though it may
sometimes be difficult to get the "key informant” to switch back to talking about her own personal life.

It is usually best to complete all or most of the “case interviewing,” and then follow up with full-scale

key informant interviewing.
In most qualitative studies the researchers return to the study communities for follow-up of
selected key topics. Such follow-up contacts can be especially fruitful with those key informants from
whom one has a personalized case history. The background of case materials gives the researchers a

clear picture of "where the key informant is coming from” in her cultural ideas and descriptions about
the community.

Group Interviews: Myths and Realities

Focus Groups
For some people previously unacquainted with qualitative data-gathering, “focus group discussions”
(FGD) have come to be regarded as some sort of “panacea” for quickly getting lots of rich qualitative

data about what the community people "really think." The so-called focus group discussion often results
in a great amount of animated (often vociferous) conversation, covering a wide range of topics. Skillful

discussion leaders can usually keep the discussions somewhere within the intended topics, and there are

usually some sorts of opposing views and debates concerning health problems, health care choices, and
other materials.
For some topical areas these group discussions can be quite useful, if properly managed. On the

other hand, several warning flags should be raised immediately, to head off the tendency for over­

reliance on group interviews, as well as some other serious hazards in their use and misuse. We will first
present some of the main warnings about group interviews, after which we can explore some

recommended uses.

9 •

Problems about Focus Group Discussions (FGD)
1.

The first cautionary note is that most group discussions are not, properly speaking, FGD. The

literature about focus groups, which developed mostly among marketing and advertising people,

specifies that the people in such groups should not be acquainted with one another. A second

recommendation is that they be quite homogeneous in composition, in terms of age, marital status, socio­
economic status and other key characteristics. Most group discussions concerning health matters, as
described in India and other parts of South Asia, do not conform to those specifications. Most such

groups are actually informal neighborhood groups of women who all know one another. They are best
labelled simply "informal group discussions.”

2.

One problem concerning these group discussions, often overlooked by research planners, is

the question of how to transcribe and analyze the complex mixtures of opinions and arguments—
including the times when two or more people are talking at the same time. Usually such group
discussions are tape-recorded. That, of course, should only be done with the consent of the people in the

discussion group. But transcribing the tape is a massive task. One hour of good, lively discussion can
take as much as 10 hours to transcribe into the computer. Another solution is to eliminate tape recording
and use two note-takers, each of whom must be very quick and very well trained to get high quality

notes. The jottings of notes taken during the session must then be expanded and edited. That process
also requires at least two or three hours for each hour of actual discussion. Special problems arise if

complex arguments result in several persons speaking at the same time, so the recorder has difficulty

keeping up with the pace of their speaking. These transcribing problems can be overcome, but the
requirements in terms of skilled persons must be calculated into the costs.

3.

There are ethical problems involved if groups get into discussions of personal sensitive issues

such as sexual matters, abortions, health-care seeking for STDs, or other socially disapproved topics.
We feel that such topics should not be introduced in group discussions. There are many occasions in

which one person in the discussion will point to another individual and say, “You had an abortion. Why
don't you tell us about it?” Such events in group discussions expose some individuals to inappropriate

(ethically unjustified) public exposure.

4.

The data from group discussions on sensitive topics will often seem frank and honest, yet the

actual data are slanted toward socially acceptable behaviors. This tendency in relation to sexual behavior

was documented by Hellitzer-Allen in a remarkable study in Malawi (Africa), in which she
systematically compared the results of focus group discussions with individual interviews of adolescent

girls (Hellitzer-Allen. 1994).
10

5.

In group discussions one or two dominant persons often "take the floor" and control much of

the discussion. Their views and experiences then dominate the discussion, and give an impression of
unanimity of experience and sentiment that quieter members of the group do not contradict.
In a recent study in Gujarat the women in several focus groups spoke at length about the many
varieties of home remedies they used for white discharge and other reproductive tract illness. The

researchers felt that home remedies were very widely used in the community. A survey conducted at
nearly the same time disclosed that only a very small percentage of women used any home remedies for
gynaecological problems. In retrospect, it would appear that in the discussion groups the "home remedy

experts” (somewhat older women) had dominated the discussions, leading to an erroneous impression of

general community practices.
6.

A main objection to FGD data is concerning the nature of the data. In FGD there is no

possibility for getting a truly connected, systematic "case" or description of an illness episode, a crisis
and its resolution, or other "full narrative." Instead, the data in FGD are the bits and pieces that come

from conversational exchanges, in which no individual story, nobody's "case" is seen in its full pattern.

Pattern is the heart and soul of qualitative data, along with the idea of getting peoples' own perspectives,

the emic version, with the appropriate language that goes with those perspectives. Most of the data from
FGD are too fragmented. Also, it is extremely difficult to separate idealized beliefs from actual

behaviors in group discussions.

Group Discussions and Participatory Research Approaches (PRA)

The research techniques which are referred to as PRA are in actuality simply informal group discussions
with a specific format. In many cases PRA discussions have some material aids in the form of paper and
colored markers: rangoli powders; or sticks, stones and other things used for marking locations, amounts,

or other information. In all of the following examples of group discussions, material equipment is used
to facilitate the construction of a specific product. One useful definition of PRA-style group discussions,
then . is that "specific products are produced (maps, diagrams, "bar charts," etc), using paper, markers,

pencils, and other readily available marking materials.” .

1.

Listing and mapping of Providers and Health Facilities

Informal community groups can quickly list and map the locations of the health care providers that
"women usually go to for their health problems.” Careful prompting and facilitation is necessary, to be

sure that they are not just listing the "high end” of MBBS, clinics and hospitals. If you don’t get TBAs,
medicine shops, traditional healers, etc. then you must probe deeper. Here are the main steps in the

listing and mapping.
A.

After explaining your general project objectives, explain to the group that: “We need to know

where you go for help when you have any health problems. Lets start by just listing all the people and
places that you and your neighbors and friends go to when you have any health problems when you need

some medicines or medical advice about what to do about a health problem.”

[Ils useful to have a blackboard or newsprint to write out the listing in plain v/etv.]

You w ill need to probe and prompt, at first: "...for example, what are all the places and the

people that a woman might go to if she can't get a child. ..” "How about outside this area...do people go
to other places? [Keep prompting and asking}.

B.

The second stage of this PRA-style interview consists of mapping the locations of the

different providers. The map can be drawn on the dirt or cement floor with chalk; or onto newsprint with
markers or pencils (or other equipment).

2.

Listing of Ail the Health Problems (Vocabulary of Health Problems)

The listing can start more widely, and then you can focus on "problems during pregnancy;” “problems »
during childbirth" and "problems after the child is born.”

Try using a "time line " as a visual aid:

X[first sign ofpregn.]------------------------------------------------ [childbirth]------- [six weeks]------ X

Mark the problems into the appropriate times in the pregnancy sequence. Find out their
vocabulary for the different parts of the pregnancy, as well as their terminology for the significant

period after childbirth.
You are trying to find out "what are all the things that happen; all the problems at each of the
stages of pregnancy and child birth."

1’2 ' " ’

3.

Rating of Degree of Seriousness, “Contagiousness,” or other characteristics of illnesses

Select about 15 or 20 conditions or health problems, be sure to include some that you consider
■ mild. Write them on index cards, (each on a separate card), with an illustration to help illiterate persons

remember the different conditions. Ask the group to discuss each health problem and to put them into
three piles: "most serious” "intermediate” and “not so serious.” You can suggest that they start with

picking out a problem or condition that is: “the most serious of all.” If the women debate sharply over
two or three items, you can say: "OK.- then you are saying that all these three conditions are "very

serious", lets put them here in a pile. Now, which are the one or two that are "not at all serious,” or
"least serious." When all the "very serious" problems have been put in a pile; and all the “not serious”
problems are in a separate pile, any remaining items are left in the "intermediate” category. After the

group has finished sorting the illnesses into the different groups or “piles,” ask them to discuss the

reasons, or explanations, for individual ratings. For example, “why do you consider

to be very

serious?" Probe for several reasons.
(Note: This same method is also very useful with individuals. I recommend that you collect 20

to 25 individual responses, and compare with the focus group results.)

4.

Sorting (with Index cards) of Providers/Health Facilities

Pick 25 or 30 providers (results of example No. I above). Write the names of the providers on index
cards. They should be identified in the way that the women have identified them:
I. “Sushila dai”; 2. “Rameshbhai”; 3. “Dr. Asma Clinic”; 4. "Green Blvd Clinic”;

“Kanapur dawakhanna”; 6. “Govt. Hospital”; 7. “Farooq Medicine Shop;”

5.

8.

“Nursama;” etc. etc.

Tell the people to sort the cards (providers) into piles or groups “that are similar”, using any
criteria, any reasons, that they feel like using. “There is no right or wrong way—just any way you feel

that some are similar/resemble each other. After they have grouped the providers (health facilities and

persons) into groups, ask the group to explain (give the criteria) for each of the individual groups.

5.

Present “Cases” For the Group of Women to Discuss

For example: "This woman, Kalpana, 25 years old, has no children. She has been married three years.

Her husband works in construction work. They have a tiny bit of savings, but they are quite poor. One
child was born, but died two weeks after it was born. Kalpana is pregnant, and it is almost time. She
thinks it will be two more weeks. She had been working Fiard all day, doing laundry, cleaning, and many

other things. In the night, about 2:00 AM, she wakes up and realizes that she is bleeding quite a lot.
What will she do? Who will she talk with? What would be the usual thing that happens in this kind of

situation? What are the different possible ways that different families/people would handle this

situation?"
Be sure to ask the women to discuss and outline several alternative outcomes. Several different

“coping strategies.’’ Ask the women what factors (conditions) would bring about different actions;

different coping strategies.

6.

Ask the Group to list and discuss various channels of communication

If the research is directly connected with development of intervention strategies, it will be very useful to
get peoples' views of appropriate channels of communication. Group discussions are useful for this

purpose, including not only their listing of the “inventory” of all possible communications channels (and
forms of messages, etc.), but also their assessments of the contents and vocabularies for use in different
kinds of information channels.

When you are nearly ready to start specific planning of intervention strategies, you can try out a
few very simple, preliminary ideas about IEC to get the women’s reactions. The women’s groups are

also important in sorting out who all the different targets of messages should be: a) husbands; b)

mothers-in-law; c) the pregnant women; d) teenage school children; etc. etc.
There are several other frequently used PRA-style group interviews. Some additional “models”

include:
A. Social Mapping of the village, slum community, or local region. (E. g., in

preparation for an intervention project.) This is the most common, best known example of the
participatory research (PRA) technique. You simply ask a group of women or men to draw a
schematic map (you provide the materials) of their own village or slum neighborhood. You

must assure them that you don't care if its "rough and ready;" it doesn't have to be exact. You
will need to insist that they draw the map; not you. Often people will resist, saying "You are

educated and we are not." To which you then reply: "Yes, but you are the ones who really know
all about your own community." After the basic form of the community has been captured, you
can ask the people to put in special features such as "all the local dais and other health

providers;" "all the places where alcohol is available," and so on.

14'

B. Construction of the Annual Cycle: Migration Patterns, Rainfall, Crops, or Other data.
(Usually this is done in the form of “bar charts” which show different amounts of migration or

rainfall (etc.) for the several different times of year (or 12 columns representing the months of

the year).
C.

“Body-mapping” to show peoples’ ideas of the physiological processes involved in

pregnancy, childbirth, and in reproductive health problems.

The Fertility Transition in Tamil Nadu: Example of an FGD Study Design

Ravindran and her colleagues (Ravindran, unpublished) carried out a comprehensive study of factors

affecting acceptance of family planning in selected communities in Tamil Nadu. Their research design
covered 15 villages, in which they carried out a total of 92 focus groups and 138 in-depth interviews in

the period from November 1994 to May 1995. Half of the FGDs were females; half were males.

Each FGD can be treated as a "case "for statistical comparisons. For example. Ravindran
reports the following statistics concerning the question: "Has women’s status improved?”

Has women’s status improved?
Yes
In some respects
No
Not here, but yes in towns and
cities
(Ravindran, no date, page 57)

Male FGDs
46
17
9

Female FGDs
32
3
22
18

In this example we note that the researchers have used the 92 FGDs as cases, and have carried

out a thorough content analysis concerning their main research questions. Each case has been given a '
"value for each research question. Similarly, for the question of sources of information concerning
family planning, the researchers found that the overwhelming majority (88 of 92 FGDs) said that they
got their information from: “hospital/PHC/Doctors/ANMs/Nurses/teachers/govt. Employees.” (Page
58).

Content analysis of focus group discussions requires that the researchers make careful definitions

of coding rules for assigning the values, as in the table above. If one follows very strict methodological

standards, one should have two independent coders (encoding teams) to go through all the cases, to
decide which FGDs said “yes,” “no” and other more ambiguous responses. In such coding there will

always be some ambiguous cases, for which the coders will disagree. The procedures for such rigourous

coding should be described when one publishes the results of the counting of cases. All ol this can be a
tedious process, but for certain types of data (subject to the reservations above), the l-GDs give quite

informative results because the conclusions are “distillations” from complex, free-ranging discussions.
Many research projects combine group interviewing, indepth individual interviews, and direct

observation. A recent study by M.E. Khan and colleagues on quality of family planning services, in

Sitapur District, U.P.. is an excellent example, demonstrating the power of triangulation, using more

than one data gathering method. The researchers interviewed health providers at several levels, with
particular focus on the community-based health workers. Both group and individual, indepth, interviews

were conducted. f)irect observation was also employed in examining the facilities and equipment

available in the primary health care locations. ("Triangulation” as a research strategy involves bringing
together data from two or more different methods, in order to strengthen the credibility and validity of

data. The metaphor of "triangulation” is derived from traditional navigational practices for establishing a

ship's position in relation to points of land.)

Structured Qualitative Interviews with Individuals
There are several types of structured qualitative interviews that are generally used for discovering etnic

patterns in relation to peoples’ explanatory models of reproductive illnesses, categories of health
resources, and other domains of cultural information.

Free Listing to Explore Cultural Domains
In the examples above, particularly concerning informal group interviews, we mentioned that it

is very useful to get such groups to develop lists of health care resources and lists of illnesses. Those are

only two examples of the usefulness of lists. There are many more, and most lists are very easy to get «
from key informants, group discussions, and casual encounters with people in your study communities.

Although we often collect such lists in group discussions, we get more complex and interesting data

when we collect lists from a number of persons, individually. The chief advantage of the individual lists
is that we get a good idea of the salience (the degree of general awareness), based on the number of
people who mention a particular illness (for example). The following table (Table 1) shows the illnesses
most frequently mentioned by women in a tribal area of-Gujarat-,interviewed by P. Patel. If she had

gotten the list from a group interview, she would not have been able to report that "safed pani" was the
most frequently mentioned illness, since we can’t know from group interviews the actual individual

knowledge and awareness.

16

Table 1. Results of Free Listing of Illnesses in Panchamahal District of Gujarat
(Number of Respondents = 41)

Local Word

Approximate English Equivalent

White discharge
Safed Pani /dhat
Leg and hand pains
Hath pag lute
Backache
Kamarma mar chale
Heavy bleeding in childbirth
Pakhado
Mathuchale
Headache
Miscarriage
Choru vachotijay
Tav
Fever
Kamshakti
Weakness
Swat chale
Breathlessness
Irregular menstruation
Chadine/vahelu masik
Night-blindness
Ratondi
Burning in urination
Peshab bek ave
Diarrhoea
Jhada
Jaundice
Piliyo
(Adapted from Patel. 1994, p. 60)

Number of Persons who
Mentioned this item
37
26
25
24
23
22
22
_____________ 18____________
17
14
12
12
9
6

These data from a simple “free listing” of illnesses show some very interesting features. They
show us, first of all, that the women in the Panchamahal District do, indeed, consider safed pani to be an

illness, rather than something “normal.” The fact that the condition was mentioned by nearly all of the
41 respondents is an important indicator of salience: safed pani is “on the minds” of nearly all the

women—much more than such health problems as night-blindness, diarrhoea, and jaundice. Often (not
always) we can regard those conditions mentioned by most people as the most serious in their minds.
There was a long list of other illnesses that were mentioned by only one or two persons. Those
illnesses, we believe, are among the “less important,” “less salient” in the thinking of the local people of

the area. On the other hand, we should be aware of some important exceptions to this generalization. As
in all data-gathering methods, there are some problems. Very few illnesses in the category of “sexual

diseases” were mentioned. Thus, free listing tends to get the social acceptable, more important items.

We have to go into intensive key informant interviewing to get (he others—the illnesses people may be
embarrassed to mention.

Generally it can be recommended that 20 to 30 free lists are enough to get a good “inventory” of
a specific domain. If you have very good key informants, sometimes eight to twelve lists from “local

experts" (for example, of local “home remedies”) will provide a very good introduction to that domain of

information. Other important topics for free listing include: “home remedies;” symptoms of specific
illnesses: “all the causes you can think of for

(illness or condition);” “ways to prevent

pregnancies;” "places/people to go to for abortions;” and “problems women have during pregnancy.”

Your research group is likely to discover other interesting domains to explore with free listing.

Pile Sorting to Establish Groups and Categories

The idea of pile sorting was also introduced above, in connection with informal group

discussions. Usually pile sorting is carried out with index cards, or any sort of cards, each of which has
the name of an item (e.g., safed pani: lav: ratondi), sometimes with pictures to illustrate the concept

(illness, symptom, health provider, or whatever). You ask individuals (or groups) to sort the cards into
groups (piles), according to similarities. “Put things into piles that are similar to each other in some

way.”

If we don’t give people any other instructions, other than “put them into groups of similar

items,” then we find out about emic categories and principles ofgrouping. The important point here is
to get the informants themselves to come up with their own criteria for grouping. Finding out about
people's groupings of illness categories, types of health care services, types of medications, types of

contraceptives, and other topics is an important step toward understanding the systematic organization of

cultural ideas that people have in every community.
The last step in connection with the sorting exercises is to find out from people their specific

criteria for sorting and categorizing. People will use many different criteria for grouping. Some may

refer to the characteristics of people: “these are illnesses of children;” “this only happens to older

women;” “only men get this problem;” and so on. Other criteria are likely to be “acuteness,”
“seriousness,” “may be transmitted by sexual contact;” and others. These criteria for groupings give us

clues for further questions and additional structured techniques.

Rating, Ranking, and Sorting Concerning Characteristics

While the free, general pile sorting is useful for getting the emic principles of categorizing items
(illnesses, people, remedies) in a cultural domain, we need to go further, to find peoples’ ratings, or

assessments about those characteristics. For example/in'all societies everywhere, people rate illnesses in
184 " 1



terms of severity. We of course want to know which illnesses or conditions people rale as ’‘most

severe.”
For example, some writers have said that women regard white discharge as ‘‘normal,” or simply

‘‘women’s burden.” Sometimes the implication is that women do not seek treatment because they do not
regard the condition as serious. On the other hand Bang and Bang have found in their research in eastern
Maharashtra that the women in their area ‘‘...regard white discharge as a chronic disease which drains the
body of energy and blood, leading to severe weakness and ultimately death.” (Bang and Bang, 1994:84)

Often the easiest systematic way to get peoples’ ratings (e.g. “severity of different illnesses”) is*

to use the card sorting technique, described above. On the other hand, we can ask people to use a threepoint scale: “high, medium and low” and ask people to respond to each item as we read them for a list.

Direct Observation of Events

Direct observation usually includes some attention to peoples’ speaking, but most attention is directed to
physical characteristics of specific locations (e.g. health clinics), equipment, and peoples’ actions and

interactions.

Observations of Complex Events: Laproscopic Camps in Madhya Pradesh.
Recently Lakshmi and associates (CORT) observed several instances of laproscopic camps in Madhya
Pradesh (Lakshmi and Barge, 1995). Some of the laproscopic camps were in PHCs, but others were in

outreach areas with very few facilities. Observations of this type of event usually require a team
approach, since the clients (women being sterilized) pass through a succession of “stages” in the process.

These stages can be broken down into (I) arrival and registration; (2) brief interview concerning any
current illness; (3) waiting; (4) taking of blood and urine samples for laboratory purposes; (5) anesthesia

(xylocaine and penidura); (6) surgery in operating room; (7) post-operative lying in “recuperation area;”
(7) payment of “incentive money” to the woman (and taking of thumb print); (8) departure for home. In

order to present this sequence clearly, it is useful to include sketch maps as well as descriptions of the
buildings and related physical locations. Light, electricity, and water sources should be noted,
particularly in those many cases where makeshift arrangements are necessary to get power, water, and

other necessities in marginally served outlying areas. .
Each of the stages in the process involves physical locations, equipment, and actions of health
care personnel. In each location the observers made careful note of hygienic conditions; antiseptic

precautions of personnel; durations of clients’ stay in each stage; "auditory and visual privacy for the

19”

client; and other features. The operating room was of course a main focal point of observation. The
general cleanliness of the OR was noted, as well as efforts to insure aseptic conditions. In some, at the

outlying camps, temporary, makeshift sources of electricity were arranged. In some cases the operation
of the laproscopic equipment had to rely on power generated from a motor vehicle parked outside the

building.

Lakshmi and her associates found that many of the procedures in the laproscopic camps included

violations of, or compromises with, antiseptic procedures. Equipment was reused time and again without
proper sterilization; power supplies were irregular iii some of the outlying areas; water supplies were
unsatisfactory. Also, some activities involved violations of the women’s modesty—including the ways in

which the women were carried (by men) from the operating room to the recuperation area. (Lakshmi and
Barge, in press). Detailed observations of this type are useful for identifying possibilities for improving

quality of care in difficult circumstances.

Guidelines for Direct Observation of Complex Health Events

1.

Complex events (such as laproscopic camps or RTI/STD camps) should be analyzed in terms
of a series of stages, with detailed points of observation identified for each stage.

2.

The observation team should include enough persons to cover all the stages.

3.

When the observation team does not have enough persons, then two adjacent stages may be
assigned to one person.

4.

A written observation protocol should be developed for each stage.

5.

Observation protocols must be field tested during pilot observations, and modified to suit
specific local conditions.

6.

If large numbers of clients are processed during the event, then observers can use sampling
techniques, such as “every third client.”

7.

If the event continues over many hours, observers may find it useful to break observations
into time blocks, including time off for lunch, and occasional short periods of relaxation.

8.

Observers should keep time records, so that the precise timings of unusual events; lengths of
time of clients in specific stages; and other chronological features are recorded.

9.

Observation records should include lists Of all health care personnel and others involved in

the complex event.

120

10.

Brief informal interviews with key personnel can be carried out, to get their explanations of
complex processes; reactions to specific problems encountered; and other details that may
come up unexpectedly. If some procedures are unusual, or some conditions appear to be

unsatisfactory (e.g., likely to contribute to infections), it is useful to get the reactions of the
doctors and other persons to those problems.

11.

Brief informal interviews with clients can also be carried out, to get specific background

information, and perhaps to make appointments for later follow-up visits at their homes.
12.

Brief informal interviews can also be carried out with husbands, in-laws, and/or other
persons who accompany the women to the “camp event.” All such additional interviews

should be carefully integrated into the “time budget” of the observations. Usually it is best to

have extra observer/interviewers on hand, to specialize in the spot interviews while the other
observers concentrate on direct visual observations.

13.

Photography is generally a very good additional way of recording physical features of

complex health care events. However, researchers should be very careful to obtain

permissions from patients, practitioners and others, otherwise it is a violation of ethical
standards to take photographs of potentially sensitive medical situations.

Observations of Patient-Provider Interactions
Unlike the observations of laproscopic camps and other special events, patient-provider interactions
occur on a regular basis, so that observations do not have to be concentrated into a special, short-term

time frame. Direct observation of patient-provider interactions was carried out by Hunte and Sultana in a

rural area near Quetta, in Pakistan (Hunte and Sultana, 1993). They particularly noted the ways in which
male doctors carried out the consultation with female patients without any physical examinations. Some

studies of the activities of Auxiliary Nurse Midwives (ANMs) in India have included informal

observations of interactions between ANMs and the community people they encountered in the course
of their duties. Observation of patient-provider interaction has a number of distinct features:

1.

Much of the interaction is verbal, so the main observations involve careful notes concerning

the exchange of words between provider and patient.

2.

Observers write down as much as possible of the verbal interactions as well as describing any

physical examinations, in order to determine the basis for diagnosis, amount of health history
elicited from the patient, answers to patients’ questions, and other details.

3.

The elapsed time per patient is noted.

4.

Other features of the interaction are also written down, so that observers can give concrete

evidence of “politeness,” “responsiveness,” “rudeness,” and other characteristics of the

interaction.

This kind of detailed observation of patient-provider interaction has not been used much in
health care research in South Asia, but the methodology would be very useful for answering certain
questions about the relationships of health providers to their clients.

Writing Up the Notes: A Prime Concern

This section will cover writing of notes from both informal observations and interviews. Formally
structured interviews (survey interviews) on the other hand, are generally recorded directly on prepared

interview forms.

Unquestionably the most difficult part of qualitative research is the documentation—getting the

data written down in sufficient, extensive detail so that complex analysis can be carried out, and so that
“the voices of the informants” can be clearly distinguished. Even experienced interviewers must be

carefully retrained, supervised, and checked to be sure they have thoroughly documented (written out)
each interview and observation. For that reason this section is presented as a set of guidelines you can

use directly in training field interviewers.

Field Notebook
The field notebook should be small enough to keep in your pocket or purse. The notebook should not be

overly conspicuous, but it is often a good idea to make it obvious to community people that you (and

your team members) are taking notes. Writing things down from interviews demonstrates to the
informants that you are serious about wanting the information, and you regard them as "experts" about
their own local cultural practices.

22

Explain to people why you are taking notes
People do not generally object to note-taking, but it is important to explain to your informants why you
are writing things down. You can say something like: "I talk with many people here in your community,

so 1 might forget some things that you tell me. That’s why I need to write things down in my notebook
(here), so I can remember exactly what you said. This notebook is a big help to my poor brain.” (It’s
often helpful to make this sort of statement partly jokingly.)

Descriptive notes in the study area.
No matter what the topic(s) you are studying, you should write notes and prepare sketch maps of

the community’ in which you are carrying out the interviews. You and your research team members

should write notes giving descriptions ofplaces (e.g. details about health facilities; and sketches or
diagrams of places of meetings, encounters, homes, as well as comments about the appearance and style
of one's informants. It is important to include in your notes such comments as: "The male community

worker. X. is a very good key informant, but it is best to get him in the morning, before he starts drinking

heavily...." "The water tap near the

building is a good place to find some women to talk with,

especially in the first part of the morning....”

Many of the things you write down in descriptive notes are the same information as your "street­

wise" community outreach workers carry in their heads. The difference is that it is available, and
organized for direct use in getting a better understanding of living conditions and life styles, locations of

facilities, and other features that are important for planning interventions.

Writing and Managing Notes in In-depth Interviews

Sometimes you will meet your informants informally, “just for a chat.” Sometimes the “chat” [very
informal conversation] will be so “ordinary” that you don’t take down any notes; you just sit and gossip,

discuss the weather, and other “light conversation.” During these “light” meetings, you might just keep
your notebook in your bag. On the other hand, it is sometimes useful to get the informant accustomed to

the idea of your taking notes. She says something about a health condition, and you quickly take out
your notebook to jot down a few words, perhaps asking her to repeat what she just said:
Interviewer:

“Let me just get this down in my notebook so I will remember it tomorrow.... Could you

just say that again? How did you say that? You said the word, bimari—what bimari were you referring

When you get into your in-depth interviews (often starting with your second meeting with an

informant), you will try hard to get the woman to “open up” and talk about health problems, and the

behaviors, decisions, and other things in connection with her health problems. The same applies to the
other topics you wish to connect with her health concerns, and treatment-seeking behaviors. You explore
ways to get the woman to talk, to narrate, to “tell her story” and you also try to take enough notes so you

can reconstruct “her story” afterwards.
Obviously you can't write down everything the informant says. But you jot down key words and

phrases (sometimes entire sentences), to keep a running "log" of the ideas and answers as your informant
responds to your probes, comments and encouragements.

The "jottings" are intended to give you enough framework to jog your memory when you expand
them into fuller statements--as soon after the interview as possible. Sometimes when your informant

says something particularly interesting, you can stop her, saying, “Excuse me. I want to write down

exactly the way you said that, so I can remember it. Please, would you say that again, just the way yqu
said it? Let me check to see that I understand exactly how you said this.” [When you do this kind of

note-taking seriously, the people you are talking with you often take the matter quite seriously, and try to
help you to “Get the exact words.”]

Some additional guidelines'.
1.

Look for key words and special vocabulary. (Words for illnesses, symptoms, types of treatments;

words for “self-esteem,” personal self-worth, etc. etc.). Be sure to write down those key words in the

exact language of the informant. Note especially any words that are special to this population and which
identify special roles, (e.g. “Woman who knows many medicines”) and special words for actions or
behaviors (or ideas) that might be useful in structured questions later on. Also note the use of English or

other foreign words. They are often used for special meanings.

2.

Check with the informant to be sure that the special vocabulary is actually used by the local

population, that it is an "insider vocabulary." You many have to label special words—e.g. "that's what the

police call them" or"is the word used by the people in ethnic group A only." Often it is
useful to ask people, “What other words are there for this condition (or this illness; or this type of person,
etc.).
3.

Particularly important ideas of the key informants should he written down in their exact words (at

least key phrases showing how they expressed the idea). For example, in most urban areas you will find

24

that people have special words and phrases for different health clinics, different hospitals, and for the
different types of healers/doctors in the local area.
4.

Often it is useful to check some part of your "jottings" during the interview. Sometimes you can say

to the informant "Let me just check this thing I have here in my notes...lets see...you said that many

people go to the

hospital, but it is better to go to the

clinic for these kinds of illnesses. Did

I get that right?”

5.

It is a good idea to go over your notes thoroughly right after an interview, if you can find a private

place (such as the back seat of a vehicle). Just go through and add in a few details to the written notes.

That will help to make sure that you will remember clearly when you sit down to write out the notes
more fully. Check to see that you can still read words that you scribbled down quickly.

6.

Expand and write out full field notes from your jottings as soon as possible after an interview. If you

don't have the opportunity to write out the full notes immediately, try very hard to get all the notes
written out the same day of the interview.

7.

As you write out your notes more fully, try to preserve as much as possible of the "play-by-play" flow

of the interview. Don't try to write a polished essay—just go through the specific information...what the

informant said...in the order that it occurred in the interview. Often during the interview you have
interrupted to go back to some more information about a point made earlier. Usually it is best that those
later additions be written in the order in which the interview actually happened.

The preferred way to write out your expanded notes is with a microcomputer. If possible, your
team members should become familiar with using a "word-processor" system in the microcomputer, so

that all the interview notes and other fiehiote materials will be accumulated in computer files. That
makes it much easier to go through the files of notes to find particular points of information.
If one of your team members cannot type, they must write out the notes fully by hand, and those

hand-written notes should be checked by others to be sure that they can be read easily. In some cases, if
you have typists available, it is possible that your information gatherer can dictate out loud from the field
note jottings, while the typist writes out the full text.

8.

Include in your notes some of your own interpretation of things that your key informant said. You

should also include comments such as "At this point the informant seemed to be covering up something,
and quickly changed the subject. Next time 1 should ask her some more about this. This time it seemed

to be a touchy and emotional subject." When you write such personal impressions, you will of course,

make sure they are clearly your ideas and not the words or ideas of the informant.

25

9.

Allow at least Avo hours of writing time for each hour of interview. That's right—two hours! If you

are quite slow in writing with the word processor, then it is three hours. It is slow work, because often
you will be remembering many different things that your informant has said, at the same time trying to

make sense of the very short and cryptic jottings in your field notebook.
10.

In some cases you may be able to use tape-recording of some informant interviews. This is not

usual, because so much of the information concerning peoples’ reproductive health problems, as well as

other areas of data, is sensitive information. Even when people say that they don’t mind the tape

recorder, there will be some hesitation when you get into sensitive subjects. On the other hand, when
you have developed a social relationship with an individual, after two or three meetings with them, they

may be more relaxed about talking in general, with or without a tape recorder.
11.

If you use a tape-recorder, be sure to transcribe the interview(s) into the computer or write them out

on paper as soon as possible. Never leave tape recorded materials in unwritten form, as it is very

difficult to go back to find information on tapes. Often you won't be able to hear everything clearly in
the recording, especially after several weeks have passed after the interview. All highly confidential
materials should be erased from tapes after you have transcribed them into your field note files.

12.

When you translate local language statements into English (for example, writing notes into the

computer), keep the translation as close as possible to the word order of the local language, even though
it is slightly awkward in English. Translate from the local language into English observing the
folioowing general guidelines:
(a)

Do not expect that words, especially health terms, can be translated exactly into English. For

example, kamjori is not exactly the same as “weakness.” “Gartni" cannot be translated into

English, but you can “explain” the meaning through giving examples of the word in context oft
phrases and sentences. Therefore, your English language notes should keep many of the local
language words, even after translation.

(b)

We should collect up examples of these “key words” in context, for our “dictionary of

special language” in relation to reproductive health and other important topics.
(c)

Be sure to put informants’ exact words in quotation marks.

Keep allfield notebooks and your written out field notes in safe and secure places where
unauthorized persons cannot get them. Remember that your ethical responsibility is to protect your

informants. Do not allow the field notes to fall into the hands of authorities, or others who might use the
materials against your informants. It is best that you don’t include your informants' identities (names.

26

etc.) in your regular interview notes. Use code names or initials, and keep your codclist of persons in a
different, very safe place. This is especially important if you are collecting very sensitive information.

Summary and Conclusions
Most projects concerned with health issues include a medley of different individual research
techniques. Experience has demonstrated that in-depth interviews--case studies and key informant interv

iews—are basic to the entire process. Group interviews are often used, but are best seen as a secondary
data-gathering approach. Sometimes group activities (particularly PRA style) are used for introducing a

project, motivating local people to cooperate in ongoing intervention activities. Qualitative methods are

sometimes used as a preparation for quantitative data-gathering, to identify and sharpen key questions, *
obtain correct local vocabulary, and other aspects of questionnaire construction. Again, some

researchers have found qualitative research to be useful to search out post-hoc explanations for results

obtained in quantitative surveys. On the other hand, in recent years it has been recognized that
qualitative data-gathering methods often stand on their own, with relatively little need for elaborate,

large-sample surveys.

As noted above, qualitative research is particularly important in topical areas in which very little
is known from previous studies, and in which the information is relatively personal and sensitive.
Research in reproductive health is a topical domain in which both of those characteristics are present.

Another feature of qualitative research is that the methodology produces a great amount of contextual
detail. Such detailed information, essential for effective program planning, is generally lacking in

quantitative (survey) research.
In several examples above we have noted that qualitative research data can and should be
subjected to some numerical analysis. This is particularly true of all studies that consist of the collection
of several dozens of“cases”-in group interviews, case studies of individual patients, provider-client
encounters, and others. Thus we do not draw a hard-and-fast distinction between qualitative and

quantitative research in actual practice.

Qualitative research is not a new idea. In fact, all sciences, particularly in earlier centuries, were
largely qualitative in nature. Darwin’s Origin of Species, one of the most revered models of biological
research, contains practically no numbers. Geologists, palaeontologists, botanists, zoologists, medical
scientists, chemists, and others developed their theoretical and descriptive frameworks largely based on

qualitative research methods. In all of those sciences, significant progress toward effective theory, and

hence practical applications, depended on the sharpening of peoples’ powers of observation, often with
27

the help of newly developed research tools such as microscopes and telescopes. The refinement of

numerical procedures and mathematical/statistical tools was not useful until a great deal of basically
descriptive information was assembled. Even the monumental achievement of unraveling the structure
of the DNA molecule (the double helix structure), by Watson, Crick, and others, involved a good deal of

descriptive, non-quantitative work. The tasks ahead for research in the area of reproductive health will

require much painstaking, careful qualitative data-gathering, but numerical analysis will also play a vital
role in these processes of advancing our understanding.

References
1.
Bang. R. A., A.T. Bang, M. Baitule, Y. Chaudhury, S. Sarmukaddam, O.Tale, 1989 “High
Prevalence of Gynaecological Diseases in Rural Indian Women.” The Lancet. January 14, 1989.

2.
Bang, R.A., A.T. Bang 1994 "Women’s Perceptions of White Vaginal Discharge: Ethnographic
Data from Rural Maharashtra.” (Chapter in Gittelsohn, et al. pp. 79-94).
3.
BCC, CICI, SEWA-Rural, Streehitakarini 1996 “Prevalence of Clinically Detectable
Gynaecological Morbidity in India: Results of Four Community Based Studies. Unpublished working
paper (Reprinted in “Selected Reading Material on Reproductive Tract Infection”. For Workshop
sponsored by Ford Foundation and CORT. Baroda. February, 1996).
4.
Bhatia, J. C.,J. Cleland 1995 “Self-reported Sympdtoms of Gynecological Morbidity and Their
Treatment in South India,” Studies in Family Planning 26: (4): 203-216.
Bhatia. J. C., J. Cleland, L. Bhagavan, N.S.N. Rao 1996 “Prevalence of Gynaecological
5.
Morbidity Among Women in South India.” Unpublished Working Paper (Reprinted in “Selected Reading
Material on Reproductive Tract Infection” for Workshop sponsored by Ford Foundation and CORT.
Baroda. February. 1996).

6.
Gittelsohn. J., M. E. Bentley, P. J. Pelto, M. Nag, S. Pachauri, A. Harrison, L.T. Landman 1994
“Listening to Women Talk About Their Health”. New Delhi: Ford Foundation and Har-Anand.

7.
Hunte. P., F. Sultana 1993 Treatment seeking behavior in a rural community in Baluchistan.
Social Science and Medicine.
8.
Jejeebhoy. S. J. 1996 "Addressing Women’s Reproductive Health Needs: Priorities for the
Family Welfare Programme.” Unpublished Working Paper. (Reprinted in “Selected Reading Material
on Reproductive Tract Infection” for Workshop sponsored by Ford Foundation and CORT. Baroda.
February, 1996).
9.
Khan, M.E.. R.B. Gupta. M.C. Patel 1995 “Quality of Family Planning Services from Provider’s
Perspective: Observations from a Qualitative Study in Sitapur District.” Paper presented at National
Workshop on Operations Research for Improving Quality of Services. Bangalore, May, 1995.

28

10.
Lakshmi R., S. Barge
1995 “Quality of Services in Laproscopic Sterilization Camp:
Observations in Madhya Pradesh. “Paper presented at National Workshop on Operations Research for
Improving Quality of Services. Bangalore, May, 1995.
11.
Ravindran. T.K Sundari. No date. “Factors contributing to fertility transition in Tamil Nadu: A
Qualitative Investigation.” Unpublished report of a UNDP Project.

29

co H- -

-s

GENDER. REPRODL'CTIVE HEALTH AND WEAKNESS:
EXPERIENCES OF SLUM DWELLING WOMEN IN BOMBAY. INDIA

Radhika Ramasubban
Bhanwar Singh

Paper presented at the International Union for the Scientific Study of Population Seminar on
Cultural Perspectives on Reproductive Health. South Africa. 16-19 June. 1997

Centre for Social and Technological Change

402 Zeba Comer, Sherly Rajan Village,

Bandra. Bombay 400050 India

1.

Introduction

Tnere is a great deal of documentation and in-depth analysis to establish that the emphasis of

public policy on treating women as mere instruments of family planning programmes has not
made any dent on the vicious circle of poverty, population growth and high rates of infant
mortality. The search for an alternative course has led to opening of the doors to a whole new

domain, namely women’s reproductive health, within which fertility' control may be more

meaningfully contextualised.

The new thrust in the direction of women’s reproductive well-being

brought to the fore for the first time the considerable burden of reproductive morbidity earned by
poor women in developing countnes (Dixon-Mueller and Wasserheit, 1991, Germaine et al, 1992).

Since the late 1980s and early 1990s, findings from some significant community' based studies set

in developing countnes, which sought to estimate the incidence of reproductive tract infections
(RTI) among poor women, have become available. They revealed that there was a whole w'orld of
symptomatic and asymptomatic women out there in the community' who remained outside the pale

of the clinic-based studies that had hitherto governed thinking on reproductive morbidity. ( Bang et
al. 1989. Wasserheit et al, 1989, Khattab, 1992; Younis. Khattab. Zurayk et al, 1993, Brabin et

al, 1°95; Bhatia et al, 1995. Streehitakarini, 1995. Baroda Citizens Council et al, 1995, Oomman,
1 °96)

It is notable that a number of these studies have been in India with more underway

(Koenig et al, 1996)

The insights afforded by these exploratory' studies have only served to highlight how much more

we need to know - particularly about the underlying socio-cultural and behavioural factors which
bring about reproductive morbidities, and which contribute to keeping them in place -, if
intervention strategies that can begin to address these problems are to be devised.

Are medical

interventions, i.e., enhancing women’s care seeking capabilities through facilitating access, the
principal means of reducing reproductive morbidities? Or are there a range of reproductive
illnesses which defy direct medical intervention alone and which require more broad-based

approaches?
Attempts at looking at how women rank their health problems in order of severity, and the way

they group common illnesses, have revealed vaginal discharge and weakness to be among the most

severe and common afflictions (Patel, 1994; Narayanan and Srinivasan 1994). While there have
been attempts at probing the question of vaginal discharge (Patel, 1994; Bang and Bang 1994),

the unravelling of the phenomenon of weakness remains unattended to. It ought to be
acknowledged, however, that vaginal discharge is closely linked to weakness.
This paper attempts to capture the various dimensions of weakness, which is the most common
and nagging problem concerning the health of women in poverty. There is a two-way relationship

between weakness and reproductive health. Just as weakness impacts upon reproductive health

(bearing children in a state of anaemia, lowered immunity' and therefore greater susceptibility to
infection including of the reproductive tract), it also has its roots in specific reproductive episodes

(problematic pregnancies and deliveries, sterilisation). Overall, it engulfs women deeply, as well as
extensively

Poor nutrition which finds its expression in the feeling of weakness, complicates pregnancies and

translates into maternal deaths, low birth weight infants and low child survival, which in turn
encourages high fertility among women Gender relations leading to nutritional discrimination
aginst women in the household, impede the realisation of genetic potential in body size Tins
impacts upon reproductive success Lower caloric intakes coupled with high energy expenditures
on physical work and at the time of pregnancy and lactation, drain the body of energy and lead to

weakness, persistent feelings of physical distress from an early age, and in some cases to
premature death
Social problems such as unemployment in the household, male alcoholism, and gender abuse such

as wife beating, too, could be hypothesised as contributory factors to the weakness and sickness
load experienced by women. Health seeking behaviour is yet another aspect impinging upon
women’s ability to cope with weakness and to bolster reproductive health.
Finally, there are certain reproductive episodes which are perceived to cause weakness These
pertain to problems during pregnancy, delivery, the post partum period, abortions, child loss and
sterilisation.

This paper addresses the problem of weakness in relation to all these aspects, through an in-depth
study of a small number of slum dwelling women in Bombay. The structure of die paper runs as
follows. We begin with a brief description of the overall environment in which women lead their
day to day lives. This is followed by a synoptic presentation of the scope and design of die study.
Section diree of the paper deals with die construction of weakness symptoms, as well as their
causcs/associations, as perceived by die women concerned Section four contains a discussion of
women’s perception of weakness as contextualised in dieir pregnancy narratives and narratives of
reproductive healdi histories and life circumstances and health seeking behaviour. Section five
summarises the mam points and conclusions emerging from our probe.

2.

I he study and setting

Our observations on the problem of weakness are drawn from an ongoing research study of socio­
cultural and behavioural determinants of reproductive health , and may be seen as one of the
second generation of studies on women's reproductive health, with a greater emphasis on
qualitative investigation of underlying causes and meanings of states of reproductive healdi, illness
and morbidity The study is investigating a wide-ranging set of issues through die instrument of
individual interviews widi around 60 women. These are: menstrual, pregnancy and obstetric
histories, experience of illness and morbidity, health service use, family and neighbourhood
support in daily life and during crucial events such as pregnancy, childbirth and major healdi crises
in die family. It seeks to place diese within the context of household dynamics - family size, gender
and age hierarchies, male employment I unemployment, alcoholism and domestic violence and,
communication between marital partners on healdi related isues
The study is being conducted in the urban environmental setting of Bombay, which is among die
most populous cities in die world. Its focus is on the urban poverty groups who are concentrated
in slum pockets It is important to note here that there is considerable diversity among the slum
dwelling households themselves, in terms of income levels, assets, skills, physical environment, and
ethnic identity Within individual slum pockets ( made up of between 1000 and 2000 households),
some measure of homogeneity may prevail, in terms of ethnic identity, economic levels and micro­

cm ironmental conditions

One study found significant differentials in disease prevalence between

slum pockets, particularly where airborne transmission is the major route, depending upon
household socio-economic correlates such as income, the presence of a salaried member in the
household, educational structure of the household i e , educational attainment of adults (having
completed at least middle school), and presence of school going children, and physical
environmental correlates such as quality of housing and density within the dwelling
(Ramasubban. Crook and Singh, l006) A large scale study (Singh 1990) of poverty groups in
Bombay highlighted the existence of three distinct environmental settings in Bombay. Those living
in multi-stoned, one-room tenements in die island city represent die stable face of die poor in
Bombay, in terms of their social history’ and skill levels. They are relatively more responsive to
institutional and technological innovations In comparison, pavement dwellers emerge as a floating
group, lacking in die back-up of strong kinship and family support They have die lowest incomes,
there is a preponderance of males among them, and they are the least responsive to intervention
strategies The third and largest group is represented by slum settlements outside the island city,
in the suburbs and extended suburbs. Each of these pockets houses a large community of upto
2000 households Households have divergent social histories coming as they do from different
parts of the country; kinship and caste ties are resilient, the asset base and income levels are low
and enviommental quality is generally poor Hoyvever, they have a strong desire to make it good in
die city and die provision of public goods and services is crucial to die amelioration of their
conditions The women in our study are drawn from die last-mentioned universe

The study is based on intensive qualitative investigation of around 60 ever-married women using
the tool of repeated in-depth interviews The women are distributed over four pockets of around
1000 households each. A list of around 300 women in the age group of 20 to 45 years was
prepared, from which our sample was selected randomly. Wliiie the first round of interviews
collected life histories, pregnancy and obstetric histories, health service use patterns, and support

systems, the second round was a detailed probe into specific illnesses and morbidities, relating to
discharge, menstruation, urinary' problems, prolapse, back pain and other pains, weakness, sexual
problems, mental tension, etc. Currently clinical investigations are underway, both to meet ethical

considerations of providing medical treatment to women suffering from remediable problems
(since almost all the yvomen reported various reproductive health problems), and to gain further
insights into health seeking behaviour and family dynamics. These tools are being supplemented
by key informant interviews with local health care providers, men (both husbands of some of the
women and non-husbands), older menopausal women and adolescent girls.
The field investigators were themselves selected from within the same communities and underwent

a four week long training in the project objectives and in carrying out in-depth interviews. The
investigators are married women who have done high school, and who have proven communication
skills Their greatest strengths are not only their gender appropriateness, but that they speak the

same language, come from the same class, and reside in the same localities as the women being
interviewed. Their friendship and kinship networks have facilitated getting women’s consent to
being repeatedly interviewed for a research project with no immediate and apparent practical

usefill outcomes for themselves. The investigators have been part of the research team study from
the start and act as facilitators betyveen the social scientists in the team and the communities. The
selection of the interviewers was facilitated by two NGOs with experience of credible and
longstanding involvement with these communities
As the study is still in progress, we have restricted our evidence on yveakness in th is paper only to
around half of our sample Hence, our observations here are tentative and by no means

comprehensive. Slum pockets of the type included in this study are generally ordered along ethnic
lines The women on whom this discussion of weakness focuses are Marathi speaking, neo­
Buddhist by religion, and scheduled caste by background. They reside in two slum pockets in M
Ward in the north-eastern suburbs of the city, the ward with the highest concentration of scheduled

caste population living in slums. In their socio-economic, demographic and cultural profile, these
women may be said to be fairly representative of this underclass. The average age tn this sub­
sample ranges from 28 years (in pocket A) to 35 years (in pocket B) Average age at menarche
was 13 years, and average age at marriage 16 years. Within a year of marriage, i.e.. at age 17.
these women were mothers There is a discernible pattern in their descriptions of weakness, the
causes attributed to this illness, and the background reproductive health histones.
Except for
two persons, all these women reported suffering from weakness.

The slum pockets concerned are permanent and “recognised" (which means that they have access
to electricity, and public water and toilet amenities, and that they cannot be demolished by die
local government). The quality of housing is mostly semi-brick, semi-corrugated iron sheet walls
with corrugated iron sheet or tiled roofing The average size of a dwelling is 15' x 10’, usually
with just one window, with the door kept closed when privacy is required. One comer of the room
is taken up by a tiny badiing area Some of die residents own the houses diey live in. while odiers
rent diem annually on die basis of a large cash deposit and mondily rent.

Families have strong links widi dieir villages of origin In fact, die village is in die city, as
observed from the cultural nonns governing the daily lives of these women and, the pattern of their
interaction within dieir families and neighbourhoods Where families still own some land in die
village, the trend is for parents to leave the city after retirement to return to their roots, leaving die
laboriously secured city dwelling to be shared by die younger generation. Annual vacation visits to

the village are made in the summer by whole families or at least by women and their children,
village deities are regularly propitiated bodi by newly married couples visiting from the city and on
other occasions such as when vows are made, to restore the temple for instance, or during major
fairs or religious occasions Brides are also regularly brought to the city from die village, and an
overwhelming proportion of marriages are arranged within the close kin group or arranged between
migrants hailing from the same or proximate village(s). With women married to men from within
a known circle of relatives and acquaintances, and with natal homes close-by, do we then have
more supportive environments for women during their reproductive years?

The educational levels of these women are low Less than a fourth have done between 8 and 10
years of schooling, broadly the level required for absorption and retention of health related
information (Ramasubban, Crook and Singh, 1990). While around a quarter of all the women in
the sample are illiterate, the majority have only been through between 2 and 5 years of schooling
and can barely read and sign dieir names Their being taken out of school generally coincides widi
the onset of menstruation Tins is die overwhelming cultural explanation'women give for their
families denying daughters die chance to finish school even in metropolitan cities like Bombay. .
Parental fears for die personal safety of dieir daughters, fears of roaming male youdi gangs in die
slums and their potential for destroying girls’ reputations and thereby their marriage prospects,
fears of girls becoming independent enough to make their own marriage choices and diereby bring

shame to their families, all lead to suppression and close supervision of daughters. There is an
additional explanation, dus one being through the agency of the State. Most villages in the country
have schools which only take children upto middle school (i.e., seven years of schooling) For
high school children have to travel to odier nearby villages. This becomes a reason for parents

keeping their daughters at home, since this is also about die time when pubertal girls are kept away,
from the male gaze. Even in metropolitan Bombay, the free municipal school system which locates schools within easy reach of poor income housing areas, does not go beyond middle school. A
poor family wishing to educate its children beyond middle school must access private schools,
which demand “donations" as a price for admission and which are generally at a distance from die

low income areas In keeping widi die tendency of poor households to allocate resources more
readily for boys’ education, die husbands of diese women are relatively better educated dian dieir
wives; almost three-fourths have done between 8 and 10 years of school.

The husbands of these women are by and large unskilled Among them, only a very small number
have permanent jobs ( e g., as sweepers or watchmen with the municipality or private commercial
establishments). The majority are in unstable jobs or are self-employed: unskilled workers in the
conservancy department of the Municipal Corporation, in textile mills, and casual workers on raifr”
and road works, watchmen in small private commercial units, or driving autorickshaws. Almost
all of them have experienced prolonged periods of unemployment at some time or other, and a few

are currently umemployed or laid off due to alcoholism or advanced TB.
As long as the extended family lives together, with the patriarch still in employment, - and this is
usually during the early years of the sons’ marriages when, additonally, younger sons and
daughters have yet to finish school / find employment / be married off / - , there is a pooling in of
resources of earning members, while die unemployed son(s) waits out the period of unemployment.
But as die patriarch ages and eidicr retires or becomes unemployed, as daughters are married off
and the sons’ families begin to grow, the extended family splits up into nuclear fragments. Given
the space constraints in Bombay, it is not uncommon to find two, three or even more nuclear
families sharing a 15’x 10’ space, through an arrangement of curtaining off little sections for each
family. While each family has its own individual kitchen, the bathing comer is common to all In

such a situation, the parents may generally choose to live with any one of their sons,where they do
not have a house in their native village and some farm land to go back to.
Alternatively, if diere
are resources available, a mezzanine floor might be built (accessed through a steep staircase from
the outside or inside), or the “room" next door may be rented or purchased to accomodate the
growing family. Where women face daily conflicts in the husbands’ families and where support is
forthcoming from their own natal families, diey may move widi their husbands and children to a
dwelling closer to die natal home.

A negligible minority of the women in this sub-sample work for wages. It is only in the direst of
circumstances, as when the family is threatened with prolonged starvation and disorientation due to
the husband’s prolonged unemployment, his alcoholism and wilful refusal to undertake paid work.
or when the husband’s total wages go into buying liquor, that women seek work outside the house
In these cases, the options open are of piece work which women bring into the house, such as:
sewing buttons / ironing and folding of readymade garments, making light switches, etc., which
they carry out sometimes with die help of other women members of die family, or wage work in
small workshops, or part-time domestic paid work, or carrying headloads at fishing wharfs, or
retailing dried fish and vegetables in the local market. A miniscule minority are self employed in
somewhat more daring occupations - one woman in this sub-group is a broker for “house" seekers
in the shanty colony, for liaising with the police in die matter of arrested persons, in evicting
unwanted tenants, etc., while another vends liquor from out of her house (generally liquor vending

is an occupation that women undertake when diey are forced into becoming sole earners, grown up
sons may be coopted into the business if expansion into distillation takes place and, when married

,

7
daughters find themselves in the position of having to support husbands and children, they may

take to retailing liquor)

The majority of women, however, stay at home where their movements and behaviour are closely
supervised by their husbands, and by mothers-in-law where the latter continue to live with the
couple. Where there is no mother-in-law, the husband uses a mixture of detailed accountability,
direct confrontation, threats of violence, or seeking intelligence reports from neighbours - kin and
non-kin - on his wife’s movements, in order to maintain surveillance over her. Women going out to
work live in constant threat of violence Husbands monitor their timings to and from work, closely

watch their deportment for signs of independence and their interactions with persons in the
neighbourhood for signs of infidelity, and daily extract liquor money from them as the price for
permission granted to go out to work The women in the study live cloistered defensive lives, their
physical movements being severely restricted to the immediate neighbourhood . Most women are
used to this, having been brought up this way even in their natal homes. The majority of the

women who were put into school were withdrawn from school when they began to menstruate,
their movements even in the immediate neighbourhood were severely monitored, they were
ideologically conditioned to refrain from playing even with girl companions and from talking to
boys other than dieir own brothers, and were generally married off within a year or so of th is event

The majority of the husbands drink heavily and regularly beat their wives Anything could become
a provocation for violence, but the most oft cited reason is when women refuse sex to husbands
who come home drunk and demand sex from tlieir wives, whatever the hour and however severe tlie

lack of privacy There is very little communication between partners around daily lives and events,
and most women know little about the lives that their husbands lead among tlieir peers. It is only

around major decisions - marriages of children, education of children, house repairs - tliat women
are party to a dialogue However men, often with tlie participation of tlieir parents or brothers,
remain the decision makers.

Births in this population are almost universally in the municipal hospitals I maternity homes which
offer free services
Institutional delivery is accepted by all, even the most illiterate, as crucial for
child survival. Ante-natal care, however, is another matter altogether. Since childbirth is seen as a
natural phenomenon and not one requiring medicalisation, contact with tlie maternity hospitals is
kept to the minimum. Registration is done only in die sevendi mondi, which is when even die
hospitals start taking in registration to coincide with the government policy of giving women their
two tetanus toxoid injections in the seventh and eighth months of pregnancy, prescribing iron, folic
acid and calcium supplements and doing a routine urine and blood test. Women with obvious .
problems earlier in their pregnancy (sudden bleeding, pain, or inexplicable swelling of the body )
generally access private doctors or private maternity homes or one of the larger public hospitals.
Otherwise contact with the healdi system is only in the last trimester There is no awareness that
the very high levels of anaemia and early age of childbearing make it imperative that pregnancies

are closely monitored from the start Identification of the fact of pregnancy is generally done by
the experienced women in the family or neighbourhood when two rpentstrual cycles have been
missed.

Tlie average birth weight of babies bom to die women ranges between 1.5 kg. and 2.5 kg. Foetal

and infant loss, too, is an experience which has touched around half of these women.
Spontaneous abortions (due variously to dilatation and currettage as an anti-infertility measure,
violent assault by die husband against his pregnant wife, or odier undetermined causes), perinatal
deadis (due to prolonged labour, low birth weight), die need for caesariean deliveries (possibly due

to poorly developed pelvic structures) are die fate of diose pregnancies which do not result in low
birth weight survivors. Widi die exception of two women (who got themselves fitted out widi
IUDs for short periods), none of diese women has ever used a contraceptive, nor knew of any
methods during die vears when dieir families were being made. Over two thirds of them have
undergone sterilisation, die average age of sterilisation being 24 years. They have never used
condoms.

3.

The construction of weakness

The most commonly used word for weakness among our sample households is ashaktapana.
Ashakta is an antonym for the word shakti (strength) and die word pan is added to mean lacking

in strength’or feeling of weakening’. Ashaktapana is very specific in its connotation. It is not
used to convey a generalised state of helplessness or powerlessness vis-a-vis others or a loss of
control over established gender equations. These circumstances are conveyed dirough die use of
different expressions such as ghara madhey gartht hat (we are a weak household because we are
engulfed by poverty), navara laahya madhey thcwtda nahi (a woman has reduced herself to a
position of weakness by not being able to entice her husband into her grip), and hat koo laahya
madhey thewuh nahai ( a man has lost control over his wife by not wedding audiority sternly).

The word ashaktapana is used specifically to connote a state of weakness with particular physical
symptoms and mental states Based on the experience of women in die community whom we have
studied, the incidence of weakness would appear to be almost universal among women above the

age of 24 years. Its form is varied The most oft-recurring description is diat of feeling physically
ill all the time, and of wanting to lie.down and sleep and to never get up. Other descriptions are:
body being emgulfed by tremendous weakness as a constant feeling; excessive fatigue; generalised
weakness resulting in slow body movements; a feeling of weakness most of die time accompanied
by fever; feeling of being tired most of die time (sapped of body energy); persistent feeling of

always being very ill; wanting to lie down and rest all die time; weakness as both a physical and
mental problem; feeling of helplessness and depression due to die persistent feeling of lethargy;
feeling of being a sickly person; feeling of having a mild fever always; not being able to get
through with the housework briskly; die feeling of no life being left in the body.

More specifically, women describe the various manifestations of weakness as: backache;
breathlessness while walking, feeling of heaviness in the head; chest pain; numbness in die hands

and legs; exhaustion while climbing stairs; exhaustion when overworked in die house; blurring of
vision and blackouts when bending over (as in household work of sweeping and cleaning), doing
heavy work, climbing stairs, lifting heavy things (water for household use has to be filled and
brought in from die public taps), working at heights (such as when fixing / repairing leaking roofs),
giddiness and black outs when walking in die sun, feeling of wobbliness in the arms and legs, or a
sense of them dissolving or becoming lifeless; tremendous exhaustion after intercourse; exhaustion

with the daily housework routine; acute feeling of weakness after lifting weights or walking a
little more than usual; headaches; inability to do heavy work

Along widi die above-described manifestations of weakness, women also report odier health
problems, several of which overlap with die descriptions of weakness. These are blurred vision
and black-outs, giddiness and breadilessness while climbing stairs, lifting weights or doing heavy

work; numbness in hands and feet; inability to walk much. Others which are mentioned are:
pains and aches all over the body; especially in the thighs, calf muscles and ankles; acute low back
pain; and. mental stress.

4.

Weakness and its correlates

We first look at women’s perception of the causes for their feelings of weakness. These
perceptions are then juxtaposed against their pregnancy narratives and narratives of reproductive
illness and life circumstances as well as health seeking behaviour, as gleaned from the individual
interviews.

4.1

Causes of weakness as pcrcchcd by women

(a)

Neglect of diet:

Very few women consciously recognise this On probing, however, some admit this to be a
cause
neglect of one’s diet during pregnancy, not having been properly fed from childhood due
to poverty, and frequent starvation due to poverty in the husband’s house; neglect of one’s health
- diet and rest - from the start and now being faced with the inability to take care of oneself due to
the demands of a growing family; loss of all appetite due to sheer exhaustion; not being able to
eat on time due to the demands of housework

(b)

Pregnancy and childbirth

Women are able to identify which one of their pregnancies sparked off the ptoblcin of weakness;
also, the experience of too many and too closely spaced pregnancies; having had too many
children; the experience of caesarian deliveries; lack of blood in die body; lack of rest after
deliveries; overwork during pregnancies; die experience of an accident during pregnancy.

(c)

Experience of sterilisation:

Although sterilisation is more closely linked in women’s minds with the experience of white
discharge and low back pain, it is also an oft-cited cause of weakness. It is when talking about
sterilisation that descriptions of weakness symptoms overlap with descriptions of other
reproductive health problems, with women attributing almost all feelings of physical distress to this
episode: weakness, white discharge, severe low back pain, deep abdominal pain, giddiness and
black-outs and blurred vision particularly when walking in the sun, feeling of weakness in the
hands and legs; aches and pains all over the body, particularly in the thighs and calf muscles; and
irregular menstruation. Many of these symptoms, ^particularly, white discharge ,-.ar.e jnm turn .
seen to be exacerbated by weakness.
.

(d)

White discharge

Around half die women report the associated problem of white discharge, seen as result of

weakness

10

(eJJLB
A few of the women have been diagnosed to be suffering from T B. or have husbands with active

T.B

But none of them have consciously associated this with weakness

(f)

Excessive housework

The responsibility of having to look after each and every need of husband and children; the
exhausting nature of house management and the difficulty in getting through with the daily routine
(particularly fetching water, lifting heavily loaded containers); the worsening of problems in this
regard during menstruation and pregnancy; sheer inability to do housework during extreme bouts
of weakness but there being no escape from die drudgery due to tins being a woman s lot; die
exacerbation, due to overwork, of other symptoms of physical distress such as low back pain,
giddiness and blurred vision, body pains in general, and insomnia which is a frequently mentioned
complaint. The capacity to do housework is also described as being affected by mental distress,

leaving no will to work. ..

(g)

Menstruation:

Painful menstruation, feeling of tremendous exhaustion just before and during menstruation;
excessive bleeding (for over ten days); severe abdominal pain due to late or delayed periods;
tension during die menstrual period leading to exhaustion.

(h)

Mental stress:

. This is universally cited as among the most important problems women have, along with
weakness. The main causes of stress mentioned are: poverty; worries about how to make both
ends meet; husband’s alcoholism; unemployment of the husband and of grown up sons; worries
that women have about dieir own healdi, and dark fears about what their reproductive problems such as prolapse, continuous white discharge accompanied by burning and pain, urinary
incontinence - might lead to; T.B. or odier major disease in the family; the future of the children.

4.2
Weakness as contextualised in pregnancy narratives and anrratives of reproductive health
histories, life circumstances and health seeking behaviour

(a)

Neglect of eating habits and of health in general during childhood and through the pregnancies.

Much of women’s feelings of weakness are rooted in their poor nutritional status. However, they
themselves do not easily admit to sufferring from any nutritional deficiencies. In their own eyes,
their food is adequate in quantity and quality. Nor are they conscious1 of the implications of their
poor diet during pregnancy. The importance of diet and nutritional supplements during lactation,
too, is poorly understood by them, although scvcial of them say that they arc generally aware that
a diet rich in greens and fruits has benefits Only few of the women mention that neglect during
childhood and during pregnancies could be a deep rooted cause of their weakness.

Il

Women’s state of undemutrition can be gleaned from their life histories. The narratives describe a
continuous experience of poverty in the natal family followed by poverty in the husband's home.
Over and above poverty during childhood and there being simply too little food to go around, early
death of the mother in many cases exacerbates this neglect. When women describe a continuous
existence of poverty, they do not generally make any connection with physical debility. It is
significant that despite probing, not a single woman mentioned any conscious experience of

unequal food sharing between girls and boys in die natal home. Despite the poverty, the happiest
memories for almost all the women are childhood memories of growing up in the natal home.
Poverty in the husband’s home combines with cultural expectations of what constitutes a proper
wife and daughter-in-law to determine a woman’s food intake. In the early years of marriage, the

husband is often unemployed or unstably employed, and dependent on pooled earnings of his father

and brothers). So the young wife must play out her pregnancies, which follow in quick
succession during these early years, as best as she can Where he is employed and contributing to
the family expenses, it is culturally impermissible for him to be showing interest in his wife’s
eating habits or in the allocation of food in the household by his mother. Even where affectionate
and supportive parents-in-law are the case (and diis is not rare), the importance of diet during
pregnancy and lactation is simply not understood

The inability to make a separate dietary provision for oneself during pregnancy, despite problems
of vomiting and inability to retain food virtually throughout the pregnancy, is cited by women
universally. Most women seem to find it very natural to have eaten miniscule quantities during
their pregnancies, due to vomiting, giddy spells and disinclination for food. Some of the more
extreme cases describe themselves as having subsisted on tea and pan (bread made from refined
flour and bought cheap from the market) through their pregnancies. Detailed probing into eating
habits reveals an upto 30 per cent deficiency in caloric and protein intake.

Visits to private health providers in the neighbourhood (of whatever variety) for the problem of
vomiting and giddiness during pregnancy may be sanctioned by die decision makers in the
husband’s home, since these symptoms are seen as pathological if they persist. Doctors’
prescriptions, that special or more nutritious food be eaten during pregnancy, are ignored, and
only prescriptions of pills to stop the vomiting are acted upon. Where additionally tonics and takat
golis (tablets for strength) are prescribed, they are not bought, both for reasons of expense and
because it is not becoming of a woman to be seen to be hungry and to .eat “a lot", since women’s

experience of the tonics, especially of the liquid variety, is tlrat they increase the appetite. Tonics
are also seen as making women fat, also a sign of eating too much, and thus drawing negative
attention to oneself in a situation of economic precariousness. Even the vitamin supplements given
free by municipal hospitals to ante-natal women are not always consumed.

Culturally, women are not supposed to make demands on the resources of the husband’s home.
Short of being admitted to the hospital for rest, supervision or saline administration (which some
of the women report doing with the husband’s support under doctors’ insistence), all advice
(special foods, reduced housework, etc.) other than tlie most minimal medical intervention (anti­
vomiting pills) are not acted upon either by the woman concerned or supported by other members
of the family. The woman's status within the household simply does not permit this preferential
treatment.

12

But the most efficient self censors are the women tliemselves, who do not easily admit to eating less
than tliev should, or who do not not dunk it it is abnormal that dieir food intake is inadequate in
quantity or in quality generally, but specially during dieir pregnancy or when they suffer from
chronic diseases like TB and are prescribed better food to be able to ingest the powerful antibiotics
Wien households have to be run on meagre and uncertain earnings, women s socialisation lead
diem to first minimise dieir own food intake. Tins is explained by diem as having to place dieir
roles as mother and wife - providing for die needs of children and die husband - on a higher plane

than looking after their own needs. This ideological conditioning is unable to surmount die health
education argument diat a woman has a responsibility to herself for her own healdi. This would
seem to suggest that women need both relative freedom from poverty and tremendous support from
the husband / his family to be able to act on advice regarding their own health, particularly during
their pregnancies and lactating periods As long as men even in poverty groups are socialised into*
thinking that dieir own needs and pleasures come before diat of dieir families, as when dieir

earnings go predominantly into buying liquor and marketed snacks for diemselves, leaving wives to
run the household on extremely slender budgets, women’s skewed roles as wife and modier will
take precedence over dieir self concern The unrefonned attitudes of men serve to perpetuate the
socialisation by women of newer generations of men into dns mindset.

(b)
Weakness relating to pregnancy and childbirth' problems during pregnancy, post-delivery /
post abortion / post child-loss
A number of associations emerge from die narratives

(i)
Early age at marriage and early age at die first pregnancy are attended by several problems, die
most important of which are lack of knowledge of ante-natal care, i.e., about diet, physiological
changes during die course of a pregnancy, and the need for continuous monitoring, particularly
given die age of die mother and her anaemic status Households have die fixed notion diat the
hospital is to be accessed only in the seventh month, i.e., when registration officially begins (even
then, compliance is mainly for the tetanus toxoid injections and urine and blood tests, while odier
prescriptive supports such as tonics are mostly ignored or are taken haphazardly). This may
partly be rooted in'die cultural practice of the pregnant woman being taken to her natal home to
stay there for the remainder of the pregnancy; indirectly, therefore, her well-being during
pregnancy and delivery is the responsibility of her parents. It is only when women experience
major problems, such as acute swelling of their bodies, sudden pain, sudden and heavy bleeding, or
unbearable weakness of the kind that keeps diem in bed, that the healdi system is accessed before
the seventh month. The reasons for dns are a combination of ignorance about the dangers of
pregnancy in a state of anaemia, a wait and watch approach, die belief diat childbirth is a natural
process which should not be needlessly medicalised, as well as hesitancy to spend money.

Women who make the strongest association between problems during any of dieir pregnancies and
the onset of a chronic feeling of weakness are diose who have experienced spontaneous abortions,

perinatal child loss, or delivered stillborn babies. Around half of the women in this sub-group
have experienced perinatal child loss or spontaneous abortions. By contrast, women who had to

be admitted to a public hospital or a private nursing home on account of complications, were able
to bolster their body reserves dirough injections, tablets
during hospitalisation

and saline drip (glucose) given

In some cases successive spontaneous abortions or stillborn / perinatal deaths - with the attendant
physical debility and mental trauma - have followed upon pishwi saaf- literally, cleaning of the

bag’ or uterus - resorted to as a fertility inducing measure. Young wives who do not conceive

within two or three months of marriage may be taken to the hospital for this procedure by
mothers-in-law, who present the problem as one of infertility. It is a commonly held belief in this
community that pishwi saaf is a panacea for many ills.

In the city, it is only when even pishwi

saaf does not work that holy men and temples are visited to ask for the boon of a child. Even 12
year olds may be subjected to this procedure, as happened to PUPA, one of the women in this
sub-group who was married at 10 and brought to her husband’s house at 12 upon attaining
menarche. When by thirteen she had still not become pregnant, her mother-in-law took her to the
municipal hospital for a pishwi saaf


"Despite the doctor s advice against it. saving that I was too young for it and (hat I would
conceive in due course, and his warning that future pregnancies may become difficult to sustain.
I was made to undergo this procedure at my in-laws’ insistence. My first pregnancy did not go
beyond the seventh month Because of the pishwi saaf my stomach pains started. I went to
Rajawadi Hospital with my husband for a check up. The doctor checked me and admitted me
there and then and within 30 minutes I delivered. The feet came out first. It was a boy."
The birthweight of the child was 2.5 kgs.

"Within three days of the delivery I came back to my husband’s house. After ail. I had no
maike (natal home). I had no problems and both the baby and I were well. For 15 days I was
able to rest after which I resumed doing all the work in the house. After the delivery, the doctor
had told me that the pishwi ka land (mouth of the cervix) had expanded after the delivery and
that the next baby may not be able to stay inside easily. And that if I did heavy work or went out
too much. I would have a miscarriage He warned that if I got pregnant again. I would have to be
very careful after the delivery. He had also stitched up the uterus (garhhachapishwila tanke
rnarli). He also advised us against intercourse (sanihandh) for another one and a half years. He
spoke to my husband also about this.

We did not have sanihandh as he had advised, and I got pregnant only two years later. From
the third month. I started getting vomiting and giddy spells, but no other problems. I did the
lighter chores in the house and did not lift heavy weights. My mother-in-law and sister-in-law
(husband s sister) did that. This pregnancy lasted for eight months. In the eighth month the
pains started. My mother-in-law who was living with us came with me to Rajawadi Hospital.
Within an hour I delivered. The child died within an hour of birth. I don’t know the cause.
They kept me in the hospital for one day and I was sent home after that. I rested for two days.
and after that 1 had to resume ail (he housework. I was deeply sad. But my family members
consoled me saying. ’So what if the child died, you still have the first child. Whatever had to
happen, happened. What will you get from continuing to grieve? Stop crying and concentrate on
the living child’. 1 did as I was told. I bottled up my sorrow within me and worked hard at my
household chores.
Within a year I was pregnant for the third time The doctor admitted me in the fourth month
itself. He kept me in bed rest for nearly six months. He was a good doctor and looked after me
well My health really improved. 1 got plenty of food and rest and put on weight. The baby
grew big I was now having problems delivering it. Nine months were fully over and I had not
delivered My back started paining and pandhra pani (white water meaning discharge) started
for one day and one night There was no pain in the stomach. The doctor gave me an injection

14

and soon after, the pains started. After a night of the pains and still no delivery, he started
preparing for a ceezar (caesarian) I was unconscious from the pain. They gave me an injection

to put me to sleep and performed the operation."
The child survived, but PUPA (40 years) went on to have four more pregnancies (seven in all), of

which two resulted in pen-natal deaths Two of her four surviving children died, one at 3 years
and one at 2 years. They died of accidents (eating some poisonous stuff and third degree bums
from a kerosene lamp, respectively) due to being neglected and unattended in the house, while she

was away doing wage labour.

Another is the case of NASA (24 years): married at 15 to a kinsman and pregnant with her first
child within three months of marriage, brought to her parents’ house and registered at a private
maternity home in the 7th. month by her parents.

NASA says that in the eighth month of her pregnancy, she developed a sudden severe pain in
her abdomen Ignorant of what to expect, she describes herself as having tried to suppress the
pain by pressing hard on her abdomen She stayed in this position and did not tell anyone about
the problem. When the pain subsided a few hours later and she noticed that the child did not
seem to move, she told her parents who panicked and took her to the hospital. The child was
found to be dead and was delivered using forceps. (Those might have been labour pains, and it
may have have been a case of obstructed labour leading to hypoxia).

After this experience NASA went through four spontaneous abortions, all in their second
trimester, and finally brought only two pregnancies to term resulting in two live children, after
which she underwent sterilisation. NASA complains of a constant feeling of weakness, she gels
tired easily and gets a pain in her chest when she exerts herself. Her strength is at its lowest ebb
during her monthly periods. She reports visiting a local health provider every month for being
given two bottles of glucose intravenously to treat the weakness and to help her cope with her
menstrual periods.

(ii) Women describe post delivery weakness (halantarog) as something that can be brought on
by several reasons: lack of blood in the body, giddiness, TB, mental tension due to lack of access to
good food , or ill-treatment by the mother-in-law, or due to the husband’s drinking and violence
against the wife. From the narratives, yet other causes may be gleaned for post-delivery
weakness, such as when a woman gives birth to a second or third daughter, or to a weak or sickly
child, or to a stillborn child, or faces perinatal child loss. Spontaneous abortions, too, could result
in neglect and ill-treatment with the resultant mental stress.

Women describe balantarog as a nightmare which every woman dreads, but which many women
actually die of if not supported emotionally and financially through access to prompt health care

by her parents. Women particularly stress the mental trauma aspect, which they refer to as dimag
mejhatka (a state of shock).
Many women start observing fasts voluntarily, they start becoming
thin, and there is a death wish at work. “If I have to die, let me die. I’ll do what is expected of
me and it doesn’t matter if 1 die in die process". They become reckless and start lifting heavy
weights such as filling large water containers and carrying them home, bathing and working in cold

water such as washing the household's clodies, eating very small meals, all of which activities
are traditionally proscribed for post-partum women as die root cause of later ill health.

15

Often, the foetal loss may be attended by severe physical and mental trauma, such as a violent
assault on the pregnant wife by the husband, who loses his self control due to the influence of
liquor or egged on by family conflicts, or by another male member of the family such as the
husband’s brother who becomes the violent face of the conjugal home, resulting in heavy blood
loss. Where the foetal loss takes place at home and where it occurs successively, even a health
facility may not be accessed

MALO (32 years), married at 15 years to a kinsman (20 years).
"As the eldest daughter-in-law. with three younger brolhcrs-in-law and two younger sistersin-law. I was expected to lake complete responsibility for all the housework. Since 1 di£not
know how to cook or do housework. I was regularly berated by my parcnls-in-law. 'Haven't this
girl's parents taught her anything7 They have kept her ignorant.' And my sasur (father-in-law)
would slap me. They would all tell my husband. 'Leave her and marry another woman'.

My husband did not pay any attention to them, but 1 used to gel very scared to be there.
When my husband was away al work and everyone al home was asleep. I would steal away to my
parents' home . I had never even thought of marriage. My father had taken me out of school
when I was in the Sth std Whenever my mother-in-law's and sistcrs-in-lavvs' taunts increased. 1
would fight with my father. ' You didn't allow me to study, you've mined my life.' Then my
father would comfort me. We don't keep our daughters like that after they have become big.
Whatever the age. we must marry them off. How was 1 to know that your in-laws would turn out
like this7 But why don't you listen to them and cook as they say'. ...The fights went on for
seven years ."
MALO went on to give birth to two children in quick succession, a girl whose birthweight was 1.5
kg and a boy who weighed 2 kg at birth. Within two months of the second child, she was
pregnant again.

During her second pregnancy:
“One day. when I was eight months pregnant, my husband in a fit of rage due to the constant
fights between my in-laws and 1. took out his anger on me. He pushed me down the flight of 16
steps outside the house. The child in my stomach died. My husband picked me up and carried
me in. At that lime I didn't feel any pain. But I was aghast that my husband, too. had left my
side and had joined my tormentors. But he was weeping as he carried me in and told me that he
had done it in anger, unable to bear the conflict around him. The next day a terrible pain started
in my stomach which lasted for two days, and then, just as suddenly, it slopped. My husband
took me to a private nursing home in Worli. But they wouldn't take me in because I looked bad
and they didn't want a problem. It was only when one of my husband's aunts pleaded with them.
telling them that we had just come to Bombay from the village, that the hospital agreed to admit
me. I was taken to a cot and made to lie down. A doctor came up to me and carelessly looked at
my eyes and face and said. "If you don't deliver, we will do a caesarian and take the baby out'.
At mid-night, (he senior lady doctor came in. She examined me thoroughly and said something
angrily to the other doctor in English. On her instructions. I was given 3 bottles of glucose and
an injection to kill the pain. My pain stopped and the dead child in my stomach was taken out
with the help of forceps. If that senior doctor had not come when she did. I would have died ... 1
became pregnant immediately after that. Il was a boy and he was 1.5 kg. The delivery was
normal..."

16

The crucial importance to the young mother of bringing her pregnancy to full term and of
delivering a live child which survives, is poignant in more ways than one. Whereas municipal
hospitals keep a woman for upto three or four days if she delivers a live infant, she is sent home
in one day in the case of infant / foetal loss. The reproductive trauma that attends an unsuccessful
pregnancy among women from poor households is not appreciated either by die healdi system or
by the community Nor does the woman go back to an evironment where she can recoup from the
mental agony of child loss. She generally goes back to her husband’s home directly; it is only ui
the case of the first pregnancy even if it results in infant loss, that she may be taken back to her
mother's home where she gets the rest and mental peace to recover. In the husband's house she is

generally put to work immediately, if it is a joint household, or she must perforce shoulder the
burden of house management if her household is a nuclear one. She may be the victim of verbal
and physical violence by powerful family members. Within a few months of her return after an
unsuccessful pregnancy, the woman is usually pregnant again. Husbands who are willing to wait
for 45 days after a live birth to resume sex with their wives, are not willing to wait at all after a
foetal or infant loss.

NASA (24 years), married and pregnant at 15 years.

■‘After niv first child was born dead. I was brought home to my parents' place in a stale of
tremendous weakness 1 had become ven- thin After one month my husband look me back to
my in-laws. The people there were nice to me for just two days. Then they started mistreating
me My mother-in-law said just what came to her. and when my husband came back home from
work she filled his cars with complaints about me and urged him to beat me. He would get
enraged with me and would beat me. Il happened everyday Whenever I heated waler for my
bath, my mother-in-law would taunt me. Look at her healing water for her bath as though she
had a live child ' I would get angry and have my bath in the cold water from the matka (earthen
pot in which water is stored). 1 started a fever. One day my father came to sec me and took me
to a private doctor I was gnen capsules for takat (strength) They never gave me enough food
to cat and I was often forced to go hungry Despite all these torments. I never told anyone in my
maike (mother's house) Within fifteen days of my coming back home my husband resumed sex.
I was so weak that it hurt. But I never thought of protesting. It was part of the daily beating and
starvation. Six months later I found that I was pregnant again."
During her fourth pregnancy (following three unsuccessful ones), which was being medically
monitored and paid for by her natal family;

"During my pregnancy-my husband continued to threaten me with divorce if the baby did not
slay in my stomach for nine.months, or if it turned out to be a girl. He threatened alternatively to
beat me and to divorce me. I lived in dread More than him. it was his mother who kept his
attention on me in this manner. "

While halantarog is the extreme expression of post-delivery weakness, such weakness can also
occur due to resumption of heavy household duties in a state of general undemutrition. Wherever
women have got the mandatory post-delivery 45 days rest, it has been due to supportive natal
homes.

(c)

Weakness after sterilisation

The overwhelming majority of women in tins sub-group have been sterilised. On an average.
sterilisation was resorted to as early as between 23 and 25 years (since average age at marriage is

16 years), bv which time the family size had been completed with at least one son. Apart from a
couple of women who used IUDs for short periods, none of die women reported any knowledge of
non-terminal methods of contraception during tlieir child-bearing years. Yet all of them in
retrospect wish that diey had known of some mediod. Most women feel that both men and women
must share the responsibility, and die desired norm is to have two children with a spacing of

between 2 and 5 years

It is interesting to note that while the women in their desire to stop babies willingly went dirough
the experience of sterilisation, a great majority of diem feel that their problems of weakness, low
back pain, white discharge, painful intercourse, burning and itching in die vagina, pain in the anus
and legs, blurred vision and black-outs, can be dated back to dieir sterilisation, or have been
exacerbated by the sterilisation. Although women speak in their narratives of diet and pregnancy
as intervening factors, they do not readily attribute their feelings of weakness, exhaustion, pains
and aches, to their poor nutritional history or history of childbirth. The emphasis on sterilisation
is relatively greater.

As CHNA (27 years).
During her first two pregnancies she suffered from vomiting throughout and survived on tea
and pan (bread made from refined flour). During the first pregnancy, she had a foul smelling
while discharge from the third month that continued until the end. and her hands and feel
including her pubis became swollen Taken by her husband, she was admitted to one of the
large municipal hospitals twice during the pregnancy .and given glucose drip on both occasions.
Neither she nor her husband was told or instructed about anything to do with her problem
During her second pregnancy she started to get severe tremors in her hands and feet around the
second month. This time, accompanied by her mother-in-law. slsc went to another municipal
hospital where she was given some pills and sent home. But the tremors didn't stop and she did
not go back to the hospital The tremors continued uptil the 9th. month. The third pregnancy
was not problematic and after the delivery she got herself sterilised with her husband's consent.

Ever since her sterilisation, her menstrual periods have become irregular, coming once in two
or three months. They arc accompanied by tremors in the hands and legs, her body feels weak
and tremulous and she gets blackness before her eyes. She says she suffers periodically from
foul smelling vaginal discharge, and gets a deep abdominal pain during and after intercourse.
She gets pain in the vagina sometimes, and has seen boils and redness there sometimes. She also
has acute low back pain and tremendous weakness. She is quite categorical that all these
problems have started since the operation (sterilisation). But she has never talked to anybody
about all these problems. She went once to the insurance doctor (her husband used to work with
a maintenance squad in the naval cantonment earlier before he stopped working due to
alcoholism, so she could go to the cantonment-based doctor for free) and explained her problems
to him. He did not examine her but gave her some pills. She took the pills but did not feel
better. She did not go back again.

"I think that sterilisation is the culprit. I was happy to get myself sterilised. But when I came
home. I felt weak. 1 get severe chest pain sometimes It is two years since the operation and 1
have become the victim of pains all over my body."

IX

(d)

Weakness due to housework

Women see the launching of any strategy to overcome or redeem their weakness and die causes
which lead to it. as being far too insurmountable. Weakness is accepted as an inexorable part of

dieir lives of which tliev will be rid only when die life leaves dieir bodies
Food improvement, even when technically and financially possible, is impeded by mental

conditioning which informs women diat a household is built upon a woman s sacrifice.
Ideologically, redistribution where women are the takers, is not accepted by them nor by others in
the household, since the mother's and wife’s role in relation to others takes precedence over her

own health

Even when they are die earners, women do not stake dieir claim to dieir earnings, and

even when the situation makes it imperative, as during pregnancy or lactation, the demand is not
made. Since others' needs cannot be denied, and even die drunk unemployed husband must get his"’'

food first, redistribution whereby women too get a greater share must await a much more bountiful
scenario

The only relief diat women see for diemselves is when their daughters reach pubertal age. an
event which is awaited bv them, since daughters can now be made to share in die burden of
housework

Daughters' educational needs become secondary even in the eyes of their modiers

who are themselves disadvantaged

Weakness due to mental stress

The mam form of mental stress arises from dieir conditions of poverty - worry about how to keep
die house going on the basts of the meagre and unstable earnings of die husband, how to repay
loans taken, and how to get daughters married Every contingency leads to mental stress, since the
day to day expenses permit no leeway to plan for minor or major crises. But most worrying is die
feeling of lack of control, particularly in planning for die future of the children - education of sons
and marriage of daughters, in diat order When die husband is an alcoholic, women’s worries
compound. And where alcoholism is accompanied by violence against the wife and children.
mental stress becomes a physical fact as well There is little dialogue between marital partners,
and the emotional gulf between them is a cause of distress to the women. Women speak of their
husbands spending their eamings on drinking and on friends, and as evincing little interest in how
their wives manage to run these precarious households;

The somatisation of stress would seem to be evident in die way some women speak about
weakness, tension and body pains, particularly pain of the lower back (“My back feels it will
break"). Women use die word lensnn (tension) to describe die mental distress diey have to suffer
in this regard. They speak of brooding when alone in die house, and the consequent neglect of
their own healdi due to the feeling of despair (“Since I brood, 1 don't notice diings about myself')
Weakness itself is seen as a cause of brooding and “bad thoughts" - “what would happen to my
children if somediing were to happen to me"

Sometimes it is almost a deadi wish, as symbolised

in the phrase "I wish I could Just sleep and never get up” Brooding may also become a cause of
domestic accidents, as in die case of one woman whose sari caught fire as she sat before the
burning kitchen stove totally lost in her own gloom after a brutal beating from her husband

19

Women speak of feelings of frustration and despair over having to put up with their intermittent
bouts of sickness, their persistent aches and pains, the feeling of being debilitated in the midst of
so much domestic responsibility, and yet being able to do nothing about it..
“1 can't go to the doctor, because if I do he will say take this or that tonic and there is no
money to buy these things. So it is better not to go at all."

“ 1 feel so weak, but I cannot even afford to buy milk for my lea.”

They speak of fears that their symptoms of vaginal itching or discharge could mean cancer or some
terrible tumour.

Health seeking behaviour for weakness, as for other problems such as chest pain, blood pressure,
and vaginal discharge, remains episodic and haphazard Local doctors, whatever their
qualifications, are resorted to. These providers generally dispense allopathic pills for one day and
/ or give injections, for which a fee is charged, and the patient is asked to come back the next day.
If the acute symptoms persist, she may go back on the next day, but more often than not, she does
not go. Since the fees and the medicines / injections are on a daily basis, it gives the sufferer the
chance to decide how far she wants to go with the “cure". The providers are therefore seen as
being friendly and understanding, and some even pemit credit. But, as the women say, “Even he
has to be paid some day", so visits are kept to the minimum and take place only when the distress

is so acute that housework becomes impossible

5.

Summary and conclusions

From among the range of symptoms reported by the women in our community based study,
weakness emerges almost as a mirror of women's general socio-economic, physical and mental
condition In response to detailed probing on different aspects of reproductive ill health, such as
white discharge, menstrual problems, urinary problems, back pain, abdominal pain, prolapse,
weakness, mental worries, etc., nearly all the women in our study report weakness as one of their
most nagging problems, irrespective of age. It is a pathology which is to be found almost
universally among women of reproductive age, and increases in severity with age and successive •
reproductive episodes. Poverty is a qualifying characteristic of the women covered in our study,
and its strong link with the incidence of weakness is, therefore, axiomatic. It is significant to note
that the word weakness - ashaktapana - is not used to convey a generalised state of helplessness or
powerlessness vis-a-vis others in die society, community or members of one's household.
Weakness - ashaktapana - represents a physical state described through specific symptoms. Also,
the mention of weakness is not just another means of drawing attention to the problem of white
discharge. There is a range of physical symptoms and mental states representing the state of
weakness.

i
In their description of weakness, women are capable of disaggregating specific reproductive
illnesses such as vaginal discharge from what diey describe as weakness, although these specific
illnesses - including urinary incontinence, low back pain, painful intercourse, abdominal pain - may

also carry with them feelings of weakness. It is when seen within the context of a woman's life as
a whole, that weakness emerges as an illness distinct from white discharge (safedpant, pandhra
pam) or other reproductive tract infections, and as symbolic of women's general condition of

20

phvsical and mental distress. The physical distress symptoms are described variously as: extreme
exhaustion, desire to sleep and never get up. giddiness and blurred vision, feeling of being ill all the
time, sometimes accompanied by fever, numbness I looseness of arms and legs, severe pain in the
back and legs, etc The mental stress symptoms are described as: brooding and mental exhaustion
due to economic insecurity, husband’s alcoholism, domestic violence and worries about the

children’s future security

There would appear to be a two-wav relationship between weakness and reproductive health. Just
as weakness has consequences for women's ability to enjoy a state of reproductive well-being, it in
tum has roots in specific reproductive episodes
Our investigation of descriptions of a range of
symptoms, when seen against the backdrop of reproductive histories, suggests that women's
presentation of their problem of weakness reveals strong associations with unfavourable
experiences in those histories.

The narratives, based upon multiple interviews with the women in our study, point to the
importance of awareness raising about nutritive diets for women, both to meet general requirements
of body energy, and in specific situations like pregnancy, lactation and morbidity episodes It
emerges that efforts in this direction must concentrate as much on the husband in a nuclear family,
and on mothers-in-law and mutual caring between sisters-m-law in joint families, as on the woman
herself It becomes crucial for awareness raising strategies to balance an other-centred slant with a
self centred one because, ideologically and culturally, a woman ought not to be seen as caring for
herself Fortunately, our observations suggest that supportive mothers-in-law and sisters-in-law
do exist in the community Among men, however, self centredness is deep rooted. Seeking
supportive roles from husbands / fathers / brothers in the fulfillment of the nutritional needs of
women in the household, requires change in dus attitude among men.

While the nutrition dimension is totally ignored in overcoming weakness, attention is paid when

weakness is accompanied by heavy bleeding during menstrual cycles, complications during

pregnancy, or surgeries (as. for example, sterilisation operations). The bolstering of women’s
survival by and large takes place only when they approach the health system in a virtual state of
crisis, on which occasions they are administered saline intravenously or, in extreme cases, given
blood transfusions. The narratives reveal that almost every major contact with hospitals - as
during pregnancy crises, deliveries, sterilisations - is an occasion for administration of a few bottles
of glucose.

Attempts at seeking relief from weakness during the post-delivery period is mediated by success or
failure of the outcome of pregnancy
Adverse outcomes, i.e., foetal or infant loss, birth of a
sickly child or birth of a girl child successively, may result in withdrawal of sympathy, medical
attention, rest and care In frustration, many women resort to self-flagellation through overwork,
reducing food intake and recklessness in self care

There is thus a rank order in the perception of problems relating to women’s health which
influences / dictates when health care will be sought Sudden onset of problems to do with
menstruation, pregnancy and delivery rank highest Next in importance for contact with the health
system comes sterilisation (which reflects the family acceptance that die fanulv size and gender
composition of offspring is as desired) Nutritional needs rank below this Other reproductive

illnesses such as white discharge, low abdominal pain. etc., come last

Health care seeking takes

place only when any of these sets of problems puts women into dire straits, i .e.. when they are
unable any more to carry out their household responsibilities

There is also a rank order of factors perceived by women as exacerbating weakness. The link with

feelings of weakness is highest m the case of sterilisation. This is followed by the experience of

foetal / child loss. Reproductive tract infections such as white discharge, low back pain, abdominal
pain. etc come third and it is only when they become so severe that fears of cancer build up, that
women begin to contemplate the next step

The hnk between nutrition and weakness ranks last in

the perception of these women

In sum. lower nutritional intake, gender relations, individual behavioural factors and institutional
arrangements all seem to work in tandem to add to the incidence and seventy of weakness and

mental stress among women dunng their reproductive years

References
Bang. R cl al (1939)

High prevalence of gynaecological diseases in rural Indian women.

The Lancet.

January 14. 85-83
Bang. R. and Bang. A. (1994). Women’s perceptions of white vaginal discharge: ethnographic data from
rural Maharashtra’, in Joel Gittelsohn. Margaret Bentley. Perm Pelto et al (eds). Listening to Women
Talk About Their Health: Issues and Evidence From India. Har-Anand Publications, New Delhi, pp. 7994..

Baroda Citizens Council. Child in Need Institute. SEWA-Rural and Streehitakarini (1995).

Prevalence

of clinically detectable gynaecological morbidity in India: results of four community based studies.
Mimeo.

Bhatia. J C.. Cleland. J.. Bhagvan. L. and Rao. N.S.N. (1995). ' Prevalence of gynaecological morbidity
among women in south India’. Mimeo

Brabin. L.. Kemp. J. Obunge. J et al (1995). Reproductive tract infections and abortion among
adolescent girls in rural Nigeria'. The Lancet. February 4. pp. 3OO-3O4.

Dixon-Mueller. R. and Wasserheit. J.N. (1991). The Culture ofSilence: Reproductive Tract Infections
Among Women tn the Third World. International Women’s Health Coalition. New York.

Germaine. A.. Holmes. K.K.. Piot. P and Wasserheit. J.N. (1992). Reproductive Tract Infections:
Global Impact and Priorities for Womens Reproductive Health. New York. Plenum Press.

Khattab. H.A.S. (1992) The Silent Endurance: Social Conditions of Women's Reproductive Health in
Rural Egypt. Cairo. UNICEF.

Koenig. M.. Jejeebhoy. S.. Singh. S. and Sridhar. S. (1996). ’Undertaking community-based research on
the prevalence of gynaecological morbidity: lessons from India’. Paper presented at IUSSP seminar on
Innovative Approaches to the .Assessment of Reproductive Health. Manila. Sept. 24-27.

Narayanan. N. and Srinivasan. S. (1994). 'Some experiences in the rapid assessment of women’s
perceptions of illness in rural and urban areas of Tamil Nadu’, in Joel-Gittelsohn et al (eds.).

Oomman. N. (1996). ’Poverty and pathology: comparing rural Rajasthani women’s ethnomedical models
with biomedical models of reproductive morbidity: implications for women s health in India’
Dissertation thesis, submitted to Johns Hopkins University. U.S.A.

Patel. P (1994) Illness beliefs and health seeking behaviour of the Bhil women of Panchmahal District.
Gujarat State’, in Joel Gittelsohn et al (eds).

Ramasubban. R.. Crook. N and Singh. B (1996) Urban health and rcsearchcr-NGO coalition in
Bomba)in Pilar Ramos Jimenez and Tudor Silva (cds). Towards Belter Health Building Partnerships
Bern een Health Scientists and Social Scientists in the Asia Pacific Region. Univcsit) of Philippines.

Manila.
Singh. B (1989) Energy use patterns among slum dwellers in Bombay’. Centre for Social and
Technological Change. Bombay.

Streehitakanni (1995).

Gynaecological diseases and perceptions about them in a Bombay slum'. Mimco.

Wasscrheit. J et al (1989). 'Reproductive tract infections in a family planning population in rural
Bangladesh’ Studies in Family Planning. 20:2. pp. 69-80.

Younis. N H et al (1993). A communit) study of gynaecological and related morbidities m rural Egypt’.
Studies in Fanul\ Planning. 24:3. pp 175-86.

co H ~

Autumn/Winter 1997

THE FORD FOUNDATION

NEW DELHI OFFICE

FOREWORD

TThe changes in reproductive health policies andpro­

Women Take Responsibility
For Own Well-Being

3

NGO-Public Sector
Collaboration

6

Complexity Of Abortion
In India

9

Preventing HIV/AIDS

13

Media And Advocacy For
Reproductive Health

17

Autumn/Wintcr iw

j
I

THE FORD FOUNDATION

BULLETIN
NEW'DELHI OFFICE

The Bulletin is published by the
Ford Foundation, New Delhi Office,
55 Lodi Estate, New Delhi 110003.
Tel: 4619441 Fax: 91-11-4627147

grams within India in the threeyearsfollowing the 1994
International Conference on Population and Deve­
lopment, have been both unprecedented and dramatic.
The Indian government has recently launched a seri­
ous effort to reorient thefamily welfare programfrom
a demographic to a client-oriented reproductive health
approach, reversingprograms andpolicies which have
remained largely unchangedfor the last three decades.
An important first step toward this goal has been the
decision by the government to withdraw contraceptive method targets nationally, with a shift in empha­
sis to quality ofcare and client needs. Equally significant has been the government’s decision to expand the
range of its health program from family planning to
reproductive and child health.
Over the last decade, the Reproductive Health Pro­
gram of the New Delhi office has been at the forefront
ofefforts in India to develop policies and programs to
more effectively address the reproductive health needs
and fights ofwomen and men. Through a coordinated
program ofsupportfor social science research, inno­
vative community-based experimental projects and
public education and advocacy, Foundation programs
have sought to foster and contribute to these promis­
ing changes. In this edition of the Bulletin, we present
several of the reproductive health projects supported
by the New Delhi office which reflect the range and
diversity of activities funded under the Reproductive
Health Program.

Editor: Fatima Al-Talib

Designed and produced by Media Workshop
Tel: 6416570,6483613114. Fax: 6217463

Jane Rosser
Acting Representative

Women Take Responsibility
For Their Own Well-Being

Situated about 100 km
from Chennai,
Chengalpattu is
witnessing a
modern revolution of
sorts. The women have
taken up cudgels on
their own behalf by
instituting the Rural
Women’s Social
Education Center
(RUWSEC), one of the
most successful
commu nity-based
grassroots women’s
organizations in India

N an open, peaceful, thatchroofed shed on a rural campus
in Tamil Nadu, a meeting of health
and literacy workers is in progress. The
participants are predominantly women,
about 45 in all, who have gathered to­
gether to report on and evaluate a sur­
vey on indicators that they have de­
signed and conducted for the Rural
Women’s Social Education Center
(RUWSEC). Funded by the Foundation,
it is an attempt to develop an alternative
set of program indicators compatible
with better health care and broader re­
productive health needs.
The scope and quality of their work
is impressive. The women have success­
fully designed a set of impact indicators
for a comprehensive community-based
reproductive health program. They have
covered young married women, adoles­
cent girls, single women, widows and

I

The RUWSEC project
has made special
ejforts to reach dalit
women in its
community-based
program

3

It all began in 1981
when a young couple

decided to join the
governmentsponsored National
Adult Literacy
Program, choosing to
work in rural Tamil

Nadu at Chengalpattu

menopausal women. They have looked
into figures of child deaths, both soon
after birth and during the first five years
of childhood. They have considered
immunization figures and have taken
into account pregnancy, abortion, con­
traception and sexually transmitted dis­
eases (STDs). They have commented on
the materials which have been used in
the survey and made suggestions for im­
provement. They have also suggested
that a survey of male health be organized
through male workers.
This would be an impressive presen­
tation at any meeting. But when one re­
alizes that all the women come from sur­
rounding villages, that most of them are
dalits (scheduled castes) without for­
mal education and training, and that
they were illiterate and reticent only
16 years ago, their achievements are
truly remarkable.
It all began in 1981 when Sundari and
Ravindra - a young couple with ideals
of working for the people - decided to
join the government-sponsored National
Adult Literacy Program. They chose to
work in the rural areas of Tamil Nadu at
Chengalpattu, about 100 km from the
city of Chennai. Chengalpattu was then,
and is still, considered a backward area.
About 80 per cent of its dalit people are
landless laborers. Even their homes, huts
with straw roofs, are built on waste land.
Until about 20 years ago, they were
bonded laborers, tied for life to landlords
who exacted punishing physical labor in
repayment of debts - which were impos­
sible to clear. Treatment was cruel and
harsh. For example, a scheduled caste
man who had stolen a pumpkin was tied
to a tree and lashed as many times as
there were seeds in the pumpkin! Poor
health, not surprisingly, was the norm,
as were maternal and child deaths. Gov­
ernment health programs never reached
the lower castes who lived in their own
demarcated areas outside villages. Edu­
cation, also, was not within the reach of
the poor.
This was the situation when Sundari
and Ravindra set up home in the area.
They began work by recruiting adult
education teachers from the villages, ex­
perimenting with dropouts from the
schooling system and focusing on the

lower dalits and castes. But within a few
years, with a change of government, the
Adult Education Program fell by the way­
side. However, the seeds for develop­
ment had been sown. The women who
had been trained as adult educators con­
tinued to meet regularly, brought closer
together by conflicts in their domestic
lives, opposition from male leadership
in their communities, and the need to
know about the many reproductive
health problems they faced. Sundari re­
calls how the first discussions on
women’s health centered around her
reading aloud from the American
women’s publication-OurBodies, Our­
selves - explaining and adapting the ma­
terial for her rural Tamil audience.
And so in 1981, RUWSEC, a grassroots
women’s organization, was formed. The
founding members were 12 women
from 12 villages in the area. Carrie, one
of the 12 women, is now the coordina­
tor of the many different activities of the
RUWSEC. The founding members felt
that with limited resources, the focus
should shift from adult education and
concentrate on two crucial areas: teach­
ing children and women’s health. Chil­
dren were the future of the community,
and a woman’s health was all she had.
She carried all the burdens of the family,
from bearing children to working in
the field to caring for the home and
the family.
Carrie is forthright and articulate when
she talks about this. Women, she says,
have been the neglected factor in every
program. Nobody has prioritized their
problems or taken into account their
health, work, capabilities or feelings. The
traditional attitude to woman has created
a situation in which her decision-making
ability has been compromised. She has
no power to make her own decisions even about her own body. Husbands and
mothers-in-law determine when or
whether she needs medical attention.
They decide on abortions, family plan­
ning, whether and what kind of contra­
ceptive will be used. Government health
facilities impose their own demands: for
example, insistence on a tubectomy after
the second child is born. The woman
is not ‘advised’ or ‘persuaded’, she
is pressurised, no matter what her

A

(J

Women community health volunteers form the backbone of RUWSEC’s programs

reason for resisting, into undergoing the
procedure.
Carrie is not alone in being a spokes­
person for the group. The women who
attend the indicators’ survey meeting are
equally confident and outspoken. They
have come a long way since the first ten­
tative steps they took in 1981. Now the
areas of their concern have extended to
include community-based action for
health promotion and education, pro­
grams for women’s development, pro­
grams for men and youth, action re­
search and a reproductive health clinic
in Chengalpattu. All the work is con­
ducted in the language of the state Tamil. But the women are well on the
way to learning English - another accom­
plishment which will help extend their
activities and bring more information
and training within their reach.
The RUWSEC is today one of the most
successful community-based reproduc­
tive health programs in India. Its stra­
tegy, from the start, has been to involve
local women, trained as community
health workers, to form the core group
of the organization. Each village - and
there are 92 such villages - form a

women 'ssangham or association. These
sanghams act as catalysts initiating and
promoting a wide range of health pro­
motion activities. The strategy has been
highly successful. Women, coming to­
gether to discuss their problems, their
health and their reproductive rights,
have discovered their power in challeng­
ing other dimensions of their subordi­
nation as women, wage laborers and
dalits. Regularly held inter-village work­
shops have helped identify women with
leadership qualities, and over the years,
have created groups that are largely selfsustaining.
Future plans for RUWSEC include dis­
semination through documentation not necessarily to a larger number of vil­
lages - but by mainstreaming and reach­
ing out to broader audiences. Working
with the public health system is another
future goal, as is the upscaling of train­
ing and campaigning for male involve­
ment in the program. This will
strengthen and sustain a movement
which has proved that the well-being
of women and the communities to
which they belong, ultimately lies in their
own hands.

The women of

RUWSEC have come a
long way since their
first tentative steps in
1981. Their areas of
concern have now

extended to include

community-based
action for health
promotion and
education, programs
for women's

development and for
men and youth,
action research and a
reproductive health
clinic in Chengalpattu

5

NGO-Public Sector Collaboration
To Strengthen Reproductive
Health Services
The Foundation’s efforts to re-orient the
public sector health program include an
innovative action research collaboration
between a women’s health NGO, the
Bombay Municipal Corporation and the
University of Liverpool to address women’s
health needs more effectively
HE last few years have seen re­
markable progress in building
consensus and commitment on
the reproductive health needs of poor
women in developing countries. Repro­
ductive health and women’s rights con­
cerns have, in these years, moved from
relative obscurity to becoming a central
organizing principle for international
health and population policies.
Over the past decade, the Ford Foun­
dation has supported a range of com­

T

6

The public
sector
remains a
key source of
reproductive
health care
for women

munity experimental projects aimed at
developing more comprehensive health
programs for disadvantaged women and
their families. These programs address
a broad range of women’s health needs
- family planning, abortion, maternal
health services, reproductive health care
for adolescents and unmarried women,
treatment for gynecological problems
such as reproductive tract infections and
AIDS/STD prevention. The programs
were for the most part, however, con­
fined to the NGO sector. The Founda­
tion has recently sought to support simi­
lar experimental efforts within the larger
public sector program, which remains
in India the most important source of
health care for many poor women and
their families. This initiative has acquired
or added importance in light of the re­
cent policy decisions of the Indian Fa­
mily Welfare Program to emphasize cli­
ent needs and quality of care rather than

Auxiliary Nurse Midwives have been trained to listen to female clients and to
provide effective counseling
demographic targets, and to expand the
focus of the program to address the
broader reproductive health needs of
Indian couples.

New Initiative
“In a way, the work of the health post
is drab and dry. We never seem to con­
sider the problems and feelings of the
patients.”
“There was quantity in our previous
work, but no quality. Now the quality is
important, not the quantity”
These are the reactions of some of
the 20 Auxiliary Nurse Midwives (ANMs)
of the Public Health Department of the
Bombay (Mumbai) Municipal Corpora­
tion (BMC), who participated in a re­
search study conducted by the BMC and
the University of Liverpool which inves­
tigated the social and clinical aspects of
Pelvic Inflammatory Disease (PID)
among poor women in Mumbai.
Before joining the project, the expe­
rience of the ANMs was confined to
working in health posts, maternity clin­
ics and post-partum centers. Their work

involved persuading women to limit the
number of their children, delivering
their babies in hospital and bringing
their children in for immunization. It
also included visiting women in their
homes to explain the concept of family
planning. But within their usual rou­
tines, they had little time or training
to discuss issues of equal concern to
their clients.
As part of the innovative PID research
study group, the ANMs learned to adopt
a new approach. They began to listen to
their patients, to talk to them about their
needs and problems and to reckon with
the fact that their own knowledge and
skills might need enhancement. For ex­
ample, in a target-oriented program for
family planning, there is little thought
or concern for women who are infertile
and who suffer social and sexual humi­
liation in consequence. Sex and sexual­
ity are never discussed, and even a prob­
lem like cramps during intercourse is not
given due attention.
Understanding these difficulties which they as women also shared - and

An innovative and
experimental action
research initiative
involving
collaboration

between a women's

health NGO (Sahaj),
the Greater Mumbai

(Bombay) Municipal
Corporation, and the

University of
Liverpool represents
an effort to introduce
a women’s health

perspective within
existing municipal

health services

7

The program covers a
population of
almost one million
people, and involves
the participation of
medical

professionals.
community-level
development
workers, health

volunteers and other

Corooration staff

faced with their own inability to cope
with them, the ANMs acquired new per­
spectives on women’s reproductive
health needs and the quality and scope
of services required.
Self-evaluation, inter-personal com­
munication and interaction with the re­
source person resulted in an urge to
share this new awareness with senior
staff and administrators. The ANMs per­
formed plays and made presentations
highlighting the needs of the commu­
nity. The Municipal Corporation has
been sensitized to this critical input, and
made aware of the importance of incorReaching male partners is a critical
component of comprehensive health
care. The program places
considerable emphasis on the
involvement of male partners and
health workers

8

porating changes within regular health
services to reach out to poor women of
all ages. Initiatives are now being taken
to build capacity and expand womenfriendly services.
The new project, supported by the
Foundation, brings together the BMC,
the University of Liverpool and Sahaj, an
NGO with experience in women’s repro­
ductive health field, to collaborate in a
three-year effort to extend the scope and
quality of this work through research
and interventions within the realistic con­
straints of a municipal health program.
Focusing on women’s health centers
and satellite health posts attached to
these centers, the program covers a
population of almost one million people
and involves the participation of medi­
cal professionals, community-level deve­
lopment workers, health volunteers and
other BMC staff.
The planned interventions will focus
heavily upon augmenting the skills of the
existing cadre of trained and experi­
enced female paramedical staff and in­
corporating the perspectives of both
community women and service provi­
ders. The issues addressed will cover
knowledge of reproduction, physiology,
sexuality, disease transmission and other
health problems such as infertility.
Although the health needs of women
are the primary project objectives, con­
siderable emphasis is placed upon in­
creasing the involvement of male part­
ners and on drawing on the services of
male health workers to help improve the
sexual and reproductive health of both
men and women.
Implementing new ideas poses many
challenges. Introducing change within a
well-established system, redefining and
reorganizing jobs and functions, evalu­
ating results, changing attitudes, pulling
together a large number of people to
work together as a team - these are some
of the tasks that need to be successfully
completed. But with the commitment of
the three partners of this project - the
BMC, Sahaj and the Liverpool School of
Tropical Medicine - this innovative and
experimental initiative may provide a
model for larger institutional programs
that reach the poorest of women with
the services they need. _J

Legal But Still Unsafe - The Complexity
Of Abortion In India
Abortion, though made legal in India in 1971, remains an emotive
but little-discussed issue, hidden behind walls of traditional mores
and beliefs. The Foundation is trying to break down these walls
and give greater visibility to the issue through a coordinated
program of research and advocacy

Safe abortion constitutes a key element of reproductive health care: Women
undergoing examination prior to abortion

ERHAPS no aspect of reproductive
health remains as contentious or
emotionally charged as the issue
of abortion. Despite encouraging trends
in legalization over the last two decades,
much of the world’s population conti­
nues to live in settings where access to
abortion is highly restricted. This is es­

P

pecially true in developing countries
where, with few exceptions, abortion
continues to be permitted only in the
event of a woman’s life being endan­
gered, or on broader medical or judicial
grounds such as rape or incest. Yet the
right to terminate an unwanted or unin­
tended pregnancy through safe abortion

In developing

countries, abortion
continues to be

permitted only in the
event a woman’s life

is endangered, or on

broader medical or
judicial grounds such

as rape or incest

9

The Case of Waghapur
AGHAPUR village in the dry
farming area of Saswad taluka,
one of the districts under study by the
Center for Enquiry into Health and
Allied Themes (CEHAT), is a fairly
large and reasonably prosperous vil­
lage. Interestingly, it has a tradition of
providing school tea-chers for the sur­
rounding areas, which makes it one
of the more progressive villages in the
region. But when CEHAT began
work in the village, its field work­
ers faced both mistrust and hostil­
ity. Patience, persistence and assur­
ance of confidentiality, however,
eventually paid off and helped
build a relationship of mutual re­
spect. With the help of local
women, CEHAT was able to gather
information on the incidence of
abortion in the village, the types of
services that were available, and
the responses of the women
involved.
The story that emerged through
these case studies and interviews in
six villages by CEHAT highlighted the
multiple factors that come into play
during the decision-making process
for an abortion: practical and finan­

W

The KEM study

showed that of 1,600
married women who
had undergone

abortion. 70 per cent
cited the lack of

contraceptive means
as the cause for
resorting to abortion

to limit the size of
their families or

10

space births

represents a fundamental element of re­
productive health.
Abortion - or the Medical Termina­
tion of Pregnancy (MTP), to give it its
official name - was made legal in India
in 1971, one of the earliest developing
countries to have done so. Safe abortion,
however, continues to be a major prob­
lem in the promotion of women’s health
and reproductive health. Complex social
and emotional factors inhibit access to
safe medical services, especially in a pre­
dominantly traditional society where the
status of women is low and a recogni­
tion of their rights is rarely taken into
account.
Abortions, however, do take place.
But often enough, they constitute ille­
gal or unsafe abortions: illegal, because
they are performed by unskilled,

cial conditions; the need for secrecy;
the social compulsion to produce
male children; and family planning.
Also underlined was the fact that abor­
tion, in many cases, is substituted for
effective contraception. Lack of pri­
vacy is a crucial factor. For example,
sexual relations can take place in the
field, or wherever an opportunity
arises. Husbands take little or no re­
sponsibility for contraception. What
is more, they often prevent wives
from using contraceptives for fear
about their subsequent fidelity. Vasec­
tomy is never mentioned or consid­
ered as an alternative method. And
the physical and mental trauma suf­
fered by the wife from repeated abor­
tions causes little or no concern to
other family members.
An interesting finding was that
there was almost no ethical or reli­
gious guilt on the question of abor­
tion. In one instance only, was the
woman upset on this account when
she actually saw the four-month old
fetus, and the family was asked to dis­
pose it off. In most cases, women fear
for their own safety, their health and
their status in the family.

non-medical practitioners, and doubly
unsafe because they are often per­
formed in secret, under highly unhy­
gienic conditions, endangering the life
of the woman. Although reliable data is
lacking, it has been estimated that abor­
tion may account for as much as one
quarter of the estimated 100,000 mater­
nal deaths which still occur in India an­
nually. Despite its potential to contrib­
ute significantly to improvements in
women’s health, safe abortion remains
a largely neglected component of repro­
ductive health services in India.
In recognition of this situation, the
Ford Foundation’s Reproductive Health
Program sought to give greater visibility
to the issue through a coordinated pro­
gram of research and advocacy in 1992.
A monograph entitled Abortion in

India: An Overview, was commissioned
to examine the issue of abortion 20 years
after legalization. In 1993, a Foundation
grant supported the first national work­
shop on the current status of abortion
and abortion services through the
Parivar Seva Sanstha (PSS), the non­
profit Indian affiliate of Marie Stopes
International. Later grants enabled PSS
to establish linkages with a large num­
ber of community-based organizations,
provide training to the field staff of
NGOs, and upgrade its current facilities
to include high-quality
abortion services as well
as ante-natal and post­
natal care, treatment
for reproductive tract
infections and STDs, be­
sides counseling and
education.
In 1995, the Founda­
tion supported two indepth research studies
on abortion in rural
Maharashtra to focus on
the experiences of poor
women with regard to
abortion and to better
understand their needs.
The Center for Enquiry
into Health and Allied
Themes (CEHAT) study
took place in six villages
in Pune district, while
the King Edward Memo­
rial (KEM) Hospital Re­
search Center, Pune,
conducted a commu­
nity-based surveillance
study of 1,600 abortion
cases in 200 villages in
the districts of Pune,
Nagar and Aurangabad.
Not all findings from
the two studies were
comparable; in part, be­
cause the KEM study
considered abortions
among married women,
while the CEHAT study
explored abortions
both among married
and unmarried women.
Abortion is far more
prevalent in rural

settings than is apparent on the surface.
Its incidence is, however, difficult to as­
sess because the subject is taboo and sel­
dom openly discussed. It is a strictly pri­
vate, personal or familial affair - one in
which, according to CEHAT findings, fre­
quently the woman concerned had little
say. The parents-in-law, the husband, the
mother and elders in the family are most
often the decision-makers. The woman
herself is pressurized into doing what is
considered ‘best’ for the family, and
her physical and emotional needs are

There is a need for
increasing women’s
decision-making
capacity in all
aspects of the issue

11

Women are beginning

to use the services of
trained medical
practitioners and.

given a choice
between free public
services at
government hospitals
and private clinics.
families are choosing

private practitioners

12

generally overlooked. The CEHAT study
confirmed this. But as reported in the
KEM survey, in 86 per cent of the cases,
the women interviewed claimed, rather
surprisingly, that the decision for abortion
was jointly taken by husband and wife.
There are many different reasons for
abortion in rural Maharashtra: to prevent
the birth of a girl child; an unwanted
birth; when pregnancy is the result of
rape; when illicit sexual relations have
taken place before or outside of mar­
riage, especially if the husband has been
away for long periods of time or if wid­
ows or abandoned women are involved.
However, several interesting findings
emerged from the KEM study which
showed that out of a total of 1,600 mar­
ried women who had undergone abor­
tion, 70 per cent cited the lack of con­
traceptive means as the cause for resort­
ing to abortion to limit the size of their
families or space births. Less than one
out of five women opted for abortion
for the purpose of sex selection.
In the past, abortions in village com­
munities were usually performed by a
dai or local midwife who relied on tra­
ditional practices and local herbal reme­
dies. Not surprisingly, the cost in terms
of women’s health and lives was high,
even in small towns or villages with ac­
cess to basic medical facilities. The rea­
sons for this are not hard to identify. Al­
though abortion has been legal in India
for more than two decades, it is still a
subject that is connected with ‘shame’
in the family. Moreover, spending money
on the woman, usually the daughter-inlaw, has very low priority, even if her
health and safety are at risk. Ignorance,
poverty, social problems and lack of ac­
cess to safe medical facilities compound
the problem.
At the same time, the studies indi­
cated that more and more women are
beginning to use the services of trained
medical practitioners and that, given a
choice between public services at gov­
ernment hospitals which are free and
private clinics where payment has to be
made, families choose private practitio­
ners for reasons of safety (the provider
has performed many such operations),
and quality (the availability of medical
facilities like oxygen/blood in case of

emergencies). The KEM research
showed that 90 per cent of the women
studied opted for the private sector.
Another important factor in the
choice of private clinics is the issue of
confidentiality. At government facilities,
the consent and signature of the hus­
band are essential for an abortion, the
exception being when the woman al­
leges that she is the victim of rape. That
the husband’s consent is not a legal re­
quirement is not generally known, nor
is there widespread knowledge of legal
issues. And, although the population
control program is now moving away
from a target-oriented approach, in the
final analysis, it is still numbers that seem
to matter most in the public sector. The
result is that acceptance of a long-term
contraceptive method is still often made
a pre-condition for the provision of an
abortion.
Once again, on the question of
women’s health and safety, the KEM
study presented a largely optimistic pic­
ture. It found relatively low rates of mor­
bidity and mortality through technically
‘illegal’ abortions, suggesting the need
for allowing more practitioners (nonallopathic doctors and nurses) to be of­
ficially trained in providing early preg­
nancy terminations.
The studies highlighted a number of
significant factors that need to be ad­
dressed in creating an acceptable climate
for the use of safe abortion, particularly
by poor women: strengthening the out­
reach and quality of services provided
by the family planning program; easy ac­
cess and a high quality of abortion ser­
vices in rural areas; the need for more
practitioners (nurses and dais') to be of­
ficially trained to provide safe, early preg­
nancy terminations; legal reform (the
law is ambiguous about certain issues
like unwed mothers) along with active
efforts to disseminate legal information
among women and abortion providers;
and an expanded program of public edu­
cation and advocacy on safe abortion.
Equally, if not more, essential is the need
for counseling before and after abortion
and for increasing women’s decision­
making capacity on all aspects of the is­
sue, especially those of their own sexu­
ality and reproductive health.

From Safe Blood And Safe Sex...
Io HIV/AIDS Awareness For All
In Nasik, the SOS Medical and Educational
Foundation is taking giant strides in ensuring availability
of safe blood and in creating awareness of HIV/AIDS
among the community
Project Red Revolution
As a doctor working in Nasik on a
variety of community health projects
since 1989, Ramesh Goud was distressed
at the unavailability of safe blood for
transfusion as a life-saving measure. In
1992, determined to consolidate his ac­
tivities and work on concrete and fo­
cused projects, he set up the SOS Medi­
cal and Educational Foundation. One of
his first projects was to look into the
problem of ensuring that safe blood
was available for all members of the
community.
India has the largest blood bank turn­
over in the world. The national blood
requirement per annum is eight million
units. Yet only 1.5 million units come

NIL, a young boy in Nasik,
was a drug addict. In an effort
to control him, his parents
stopped giving him pocket money.
So he began to steal to buy ‘brown
sugar’. He stole money and valu­
ables from home and was re­
duced to selling kitchen utensils
to satisfy his growing addiction.
One day, unable to pay at his
regular adda (den), he was
thrown out on the street. Some­
one gave him a bright idea — one
that would solve his problem for­
ever: Why didn’t Anil become a
blood donor? Here was the eas­
iest way to make money. What is
more, he would not have to de­
pend on anyone except himself.
Anil found that it was really easy.
He sold his blood 19 times to
three licensed blood banks
within weeks! ...

A

from the voluntary sector. The rest is
obtained from professional blood do­
nors who are paid for the blood they sell;
75 per cent of this blood is not screened
at all.
When people sell blood for money, it
is because of poverty, drug addiction,
alcoholism or for some other desperate
reason. Not infrequently, the result is un­
safe blood. The hazards of using such
blood for transfusions can be imagined,
especially now, with the advent of HIV/
AIDS, the incidence of which is rising
daily People infected with the HIV virus
may look and feel well and may, there­
fore, be unaware that they are infected.
Even with rigorous HIV testing, it is not
always possible to get 100 per cent ac­
curate results, as the donor could well
be in the window period, a period that
could stretch from six weeks to one year
in which, although infected with HIV vi­
rus, the donor may not test positive.
This was the problem that Dr Goud
had to overcome. From a base-line study
conducted in the Nasik region, some
disturbing findings emerged. It was es­
tablished that 50 per cent of the supply
in blood banks came from professional
donors, 30 per cent was collected
through blood bank camps, and only 20
per cent came from voluntary donors. It
was also clear that, contrary to general
belief, only 10 per cent of it was required
for emergencies, and 30 per cent for
post-operative surgeries. The largest pro­
portion, some 60 per cent, was used in
the treatment of anemia in women. It
could safely be concluded, therefore,
that most blood requirements could be
arranged before planning surgery; that
banking blood could more safely and ef­
ficiently be supplemented by motivating
voluntary blood donors to be on call;

13

The Realities
About Blood
Donation In India
• India has the largest blood
bank turnover in the world (Rs 100
million).
® National blood requirement per
annum is eight million units.
• Only 1.5 million units come
from the voluntary sector.
• 75 per cent of the blood from
professional donors in the coun­
try is not screened at all.
* Average cost per bottle of blood
is Rs 450.
Source: SOS, Nasik

and that alternative remedies for the
treatment of anemia were not only
possible but also more efficacious.
Project Red Revolution, the first SOS
initiative, was thus launched. It has
helped bring about considerable change
in Nasik’s attitude to blood donation.
Meetings with professional blood-sellers,
workshops for voluntary donor motiva­
tion, lectures at colleges, schools, clubs,
offices, factories and gram panchayats
in the villages - all highlighted the need
for gifting rather than selling blood, en­
suring that every patient receives blood
from a known and safe source. The most
tangible result of this effort is the publi­
cation of a Voluntary Blood Donors' Di­
rectory for Nasik city listing, according
to their blood type, willing donors who
are available in an emergency to gift
blood and can be contacted by individu­
als or hospitals, should the need arise.

Project Red
Revolution, the first

SOS initiative, has
helped bring about

considerable change
in Nasik's attitude to

14

blood donation

Project For Commercial Sex
Workers
An unexpected result of Project Red
Revolution was the entry of SOS into the
field of HIV/AIDS awareness, prevention
and control. Unsafe blood was one factor
linked to the spread of HIV/AIDS. Unsafe
sex was another - and more important factor. Now SOS involved itself in the cru­
cial function of creating awareness in com­
munities that were most vulnerable to the
disease through, unsafe sex. The Project

A Crisis Of Confidence
A T a Nasik workshop on AIDS
zYawareness in 1993, commercial
sex workers, who call themselves
“women in the trade”, complained
bitterly about sub-standard
condoms supplied under the
government’s AIDS Control Pro­
gram and proved that the lessons
on safe sex had been well learned.
One of them demonstrated - very
dramatically - how vulnerable
they were to the disease. From sev­
eral layers of wrapping she pro­
duced a used condom, carefully
knotted at the top. The fluid inside
was brown - semen tinged with
blood. How, she demanded, could
they protect themselves if the
condoms were no good or rup­
tured easily?
It was a legitimate complaint.
Despite the fact that condoms
have been placed under the
‘Schedule R' cate-gory, on par with
essential and life-saving drugs,
manufacturers are not held suffi­
ciently accountable for strict
quality control.
At a more light-hearted level, a
woman said they were so con­
cerned about the AIDS menace
that they always turned away a customer if he refused to use a
condom. “Even if he offered me
Rs 300,1 would send him packing.
Even if he offered me Rs 3,000 I
would ask him to get lost. But if
he offered me Rs 3 lakh (a ringing
laugh here), I suppose I would ac­
cept. I know I would die, but at
least my children would be
provided for.”

for Commercial Sex Workers (CSW) be­
gan in 1992 and was at first confined to
Nasik city Today, it reaches out to four dis­
tricts around the city and covers an area
of 1,500 sq km. Although the number of
women it reaches amounts to about 1,000,
the size of the clientele they serve is

enormous.
Over the years, SOS has built up a

Onefocus of HIV/AIDS prevention efforts by SOS is among women in the slums
ofNasik

relationship of trust and respect with
the members of this community.
Distributing condoms and providing in­
formation about safe sex is only one as­
pect of the project. Empowering women
to nego-tiate safe sex is another. But SOS
goes well beyond these immediate con­
cerns. It looks into issues like health,
STD services, addiction and dealing with
the police. It inculcates saving habits, ad­
vises on children’s welfare and visits the
women on festive occasions like Diwali
and Holi.
This has underlined the organi­
zation’s concern and involvement with
the community and brought about a feel­
ing of greater empowerment among the
women. HIV/AIDS is not dealt with in
isolation. It has been treated as one more
problem issue for women. SOS has ex­
panded its activities to reach out to slum
women in many parts of the city, and its
STD/AIDS Sexual Health Counseling
Center in Nasik city is open to all in need
of information or counseling. Work with
CSWs led naturally to other high-risk
behavior groups who were most vulner­
able to HIV/AIDS. Clients of CSWs, truck

drivers, industrial workers and profes­
sional blood donors were identified and
the program was extended to draw them
in. SOS has also developed and con­
ducted training sessions and work­
shops for a variety of public organiza­
tions - among them, the Maharashtra
Police Academy in Nasik, the Central
Jail in the city, and local corporate
groups, factories, colleges, schools,
clubs and gram panchayats. An im­
portant target group are doctors. Many
of these initiatives, like the approach
to the Police Academy, started out as
pilot projects. These have proved so
successful that there is now a demand
from these and other organizations for
more workshops and follow-up
sessions.
Creating a network of sensitized
groups - doctors, police and NGO AIDS
Cells - will, it is expected, make for a
more sympathetic and well-informed
approach to the prevention and control
of the disease and help towards the
health and well-being of-women for
whom the project has ultimately been
designed.

Distributing condoms
and providing

information about
safe sex is only one
aspect of SOS.
Empowering women
to negotiate safe sex

is another

15

Educating The Guardians Of Law
HO is your favourite film star?
Why do you like her best?” This
is the beginning of an AIDS awareness
workshop being held at the Police
Academy at Nasik. About 45 young
men and 15 young women - all train­
ing to become police officers - sit to­
gether in a classroom, a little uncer­
tain perhaps, but all attentive. They
are here to attend a special course
conducted by Dr Goud to familiarize
them about HIV/AIDS and to sensi­
tize them to a problem that they will
have to handle in their own lives and
also as part of their duties as police
officers.
Breaking the ice, and the barriers

W

16

of silence that such subjects invariably
create, is the first step in the process.
But well before the workshop is over,
the young people have been drawn
in, and are participating in a lively dis­
cussion. They are informed about the
gra-vity of the spread of AIDS, their
misconceptions and fears are ad­
dressed, and their questions are an­
swered fully and frankly. Long after
the workshop is over, they continue
to crowd around Dr Goud, clarifying
doubts or seeking reassurance.
These workshops for police ca­
dets have been so popular that ev­
ery year a fresh batch of about 500
officers is trained and sensitized. !

Media And Advocacy
For Reproductive Health
Utilization of the media for dissemination and advocacy
in the field of reproductive health has acquired a
prominent position in the Foundation’s programing
HE 1934 Cairo Conference on
Population and Development
marks a watershed in interna­
tional thinking on population issues. It
achieved a remarkable global consensus
on the need for a new approach to this
most urgent of problems facing deve­
loping countries. What was needed for
the greater success of such programs in
the 1990s, the Cairo meeting stressed,
was an approach that was “non-coercive,
of good quality and client-centered”.
Responding to this call, the Govern­
ment of India abolished its policy of set­
ting demographic targets, implemented
and monitored for the most part by

T

officials. The emphasis now is on an in­
creased coverage and toning up of the
reproductive and child health delivery
systems, the governmental effort supple­
mented by the private and voluntary sec­
tors. However, while India’s new ap­
proach recognizes the importance of this
paradigm shift, an official strategy to dis­
seminate information about the new ap­
proach - and about what the new think­
ing implies at the conceptual, program­
matic and operational levels - is yet to
be articulated.
For over four decades, the Ford
Foundation has been concerned with
health issues in India. Beginning with

Full and accurate
information on
sexuality and
reproduction are
essential pre­
requisites of
reproductive health
and rights

17

Developing radio and

TV' production skills
to promote
reproductive health
and sex education is

an important
component of

Foundation grants

18

in this field

population, it moved into the areas of
infant mortality and child survival, an in­
volvement that later broadened to in­
clude reproductive health. With the gov­
ernment and other large donors also
initiating action in these areas, the
Foundation shifted its focus to the problem of women’s health in its various
dimensions: their health as wives and
mothers, and as individuals whose
problems had long been neglected
or ignored.
The Foundation had concerned itself
so far on funding non-governmental or­
ganizations (NGOs), launching innova­
tive proposals with an operational con­
tent and programs of public advocacy
and policy-making. But it also now
turned its attention to the important goal
of supporting communication programs
utilizing the media for dissemination and
advocacy purposes.
The media today serves a number of
the public; it is increasingly seen as a
powerful tool in the promotion of so­
cially relevant and development causes.
Harnessing this tool in the service of
reproductive health and child welfare is
one of the more recent thrusts of the
Foundation’s development strategy.
Creating public discourse around re­
productive health issues is widely ac­
knowledged today as among the most
critical challenges facing South Asian
countries. A recent consultancy and
workshop on advocacy for women's re­
productive health and empowerment
identified media advocacy as an impor­
tant means through which its objectives
can be pursued and the information
spread among multiple constituencies.
To date, however, NGO and voluntary
sector interactions with the media have
been, for the most part, either reactive
or just plain negative.
In India, the media sector has grown
into a vibrant, independent and diverse
entity, increasingly reaching rural com­
munities. Radio, television and print
media in particular have grown substan­
tially over the past few years - with ra­
dio broadcasting clearly in the lead, cov­
ering approximately 96 per cent of the
country’s population. With India's adult
literacy rate estimated at 51 per cent,
television is naturally another popular

medium although its reach is limited at
present to the more affluent population
of the cities, towns and larger villages.
Despite the high level of illiteracy, how­
ever, there are approximately 40,000 reg­
istered newspapers or magazines pub­
lished in some 90 languages and dialects,
2,500 of them registered as dailies.
Recognizing the importance of more
information, debate and discussion on
reproductive health issues and its inti­
mate links with women’s livelihood and
empowerment, the Foundation's New
Delhi office has made grants to the fol­
lowing organizations:
The Panos Institute, UK, was funded
in 1995 to organize a workshop for jour­
nalists to promote balanced and com­
prehensive reporting of reproductive
health and rights issues in South Asia.
The workshop brought together journa­
lists from the South Asian region and re­
source persons to interact with NGO
representatives from the reproductive
health field. The objective was to review
existing barriers standing in the way of
better coverage of such issues by the
press, and to develop a systematic long­
term strategy to promote more, better
informed and quality reporting on the
subject. The idea of creating a media re­
source center focusing on reproductive
health emerged out of the workshop.
Madhyam Communications in Ban­
galore has been funded to set itself up
as a one-stop archival window for re­
source materials and communication
tools. Books, research studies, videos,
slide presentations, tapes, posters and
innovative communication materials like
toys from research organizations, fund­
ing agencies, filmmakers, documenta­
tion centers and women’s groups can
thus be readily accessed by students,
activists, researchers and all those work­
ing with women’s health issues.
To document three key reproductive
health groups on film is yet another
media initiative advocating reproductive
health policies and programs in India.
The Magic Lantern Foundation, New
Delhi, is producing a set of films on
health groups from different areas to
underscore the commonality of expenence and problems; to present replicable
alternatives; and, to generate awareness

riff

r

of such interventions. The films are tar­
geted at groups working on women’s
health, STDs and HIV/AIDS, but they are
also expected to address a larger audi­
ence of planners, policy-makers and
health professionals.
Street theater and innovative audio­
visual entertainment are the non-conventional mediums put to use by the
Nalamdana Charitable Trust, Chennai,
to raise the awareness levels of HIV/
AIDS-related issues among largely illit­
erate audiences. Support from the Foun­
dation will enable Nalamdana to dissemi­
nate information on STD testing, coun­
seling and other services available in the
inner city slums of Chennai, surround­
ing villages and in factory townships.
Nexus, a bimonthly newsletter on
health issues is produced by Population
Services International, Delhi. Founda­
tion funding has helped it to expand and
strengthen its objectives. A two-pronged
media advocacy strategy encourages
journalists to write on issues of sex, sexu­
ality, reproductive health, maternal and
child care, STDs and HIV/AIDS and pub­
lish them in local, regional or national
newspapers. These articles are then re­
printed in Nexus which serves as a
source of information for journalists,
policy-makers, researchers and health
workers. In order to reach out to the
widest possible readership, a Hindi
insert is now a regular feature of this
journal.
Point of View, Mumbai, has been
funded to create a 30-minute video film
and a 30-second public service TV spot
on the issue of women and HIV/AIDS. A
new project under consideration is an
ambitious 52-part reproductive health
serial for TV and a set of three films based
on Our Bodies, Ourselves.
To create awareness about women’s
health, lives and realities, a new, national­
level media initiative funded through
Aalochana includes the reproduction of
a photographic exhibition documenting
women’s lives over the past 50 years.
This will be published in book form and
the exhibition-cum-book will be distri­
buted in 16 of India’s states through var­
ious channels to coincide with the 50th
anniversary of the country’s indepen­
dence. On completion of the 16-state

Direct interaction at the grassroot level is an important
complement to mass media efforts

tour, the photographs will be used as
long-term resource materials for use in
training and orientation.
A grant made recently to the British
Broadcasting Corporation (BBC) takes
a major step in this direction. National
workshops will bring together radio and
TV producers from different parts of the
country for a general orientation on re­
productive health and sexuality issues.
This initiative will be followed by
longer workshops, combining in-depth
topic material and intensive training on
radio and TV production and formats,
leading to the development of propo­
sals for radio and/or TV programing
around the themes of reproductive
health and sexuality. The BBC would
then select and support, on a competi­
tive basis, a minimum of two TV and six
radio projects for production. In the
project’s final phase, a one-day monitor­
ing and evaluation exercise will bring
together all participants from the prev­
ious workshops to preview completed
projects, to discuss and evaluate ap­
proaches for addressing reproductive
health and sexuality issues in India.

19

What Has 50 Years Of Independence
Meant For Women In India?
Two telling photographs from the In Black and White photo
exhibition, funded by the Foundation and presented by
Point of View, Mumbai and Aalochana, Pune

Abandoned new-born girl and midwife

Mother-in-law and new-born grandson

20

CENTER FOR REPRODUCTIVE LAW & POLICY • INTER NATIONAL PROGRAM

Women’s Reproductive Rights
The International Legal Foundations
All persons have reproductive rights, which are founded upon principles of human ('-mity and equality. But women
have a unique role to play in human reproduction and are uniquely affected by government policies. A reproductive
rights perspective can empower ns to identfy the numerous strategies for social and poh.ical change and to seek
policies and laws that improve women's lives. Women's reproductive rights have thus served as a rallying cry in
many countries around the world. While the human rights perspective is not limited to legal principles, it is
important to note that there is an international legal basis for our demandsfor reproductive self-determination.
Wbmen's reproductive rights under international human rights law are a composite of a number of separate human
rights. In this publication, we seek only to cite selected human rights provisions font major international legal
treaties or conventions that may be understood, at least in principle, to provide protection for reproductive rights.
Widespread recognition of the legalfoundation for such claims is a first step toward ensuring that reproductive rights
become a reality for the world’s women.

The Rights to Health, Reproductive Health, and Family Planning
The International Covenant on Economic, Social and Cultural Rights
(the “Economic Rights Covenant’’)
Article 12

1. The State Parties to the present Covenant recognize the right of
everyone to the enjoyment of the highest attainable standard of physical and
mental health.
2. The steps to be taken by the State Parties ... to achieve the full
realization of this right shall include those necessary for: (a) The provision
for the reduction of the stillbirth-rate and of infant mortality . . .;
(d) The creation of conditions which would assure to all medical services and
medical attention in the event of sickness.

12 0 W A £ £ $ T R

>.Vet

N £ W. Y

The Convention on the Elimination of All Forms of Discrimination Against Wbmen
(the “Wbtnen’s Convention")

Article 10

Article 12.1

State Parties shall . . . ensure . . . (h) Access to specific educational
information to help to ensure the health and well-being of families,
including information and advice on family planning.
State Parties shall take all appropriate measures to eliminate discrimination
against women in the field of health care in order to ensure, on a basis of
equality of men and women, access to health care services, including those
relating to family planning.

Article 14.2

State Parties . . . shall ensure to . . . women [in rural areas] the right . . .
(b) To have access to adequate health care facilities, including information,
counselling and services in family planning.

Article 16.1

State Parties shall . . . ensure, on a basis of equality of men and women: . . .
(e) The same rights to decide freely and responsibly on the number and
spacing of their children and to have access to the information, education
and means to enable them to exercise these rights.

The Right to Life, Liberty, and Security
The International Covenant on Civil and Political Rights
(the ‘‘Political Covenant”)
Article 6.1

Every human being has the inherent right to life. This right shall be
protected by law.

Article 9.1

Everyone has the right to liberty and security of person.

The Universal Declaration of Human Rights
(the “Universal Declaration")
Article 3

Everyone has the right to life, liberty and security of person.

The Right to Marry and to Found a Family
The Universal Declaration

Article 16.1

Men and women of full age, without any limitations due to race, nationality
or religion, have the right to marry and to found a family.

2

The Women's Convention

Article 16.1

State Parties shall take all appropriate measures to eliminate discrimination
against women in all matters relating to marriage and tamily relations ....

The Economic Rights Covenant

Article 10.1

Marriage must be entered into with the free consent of the intending
spouses.

The Political Rights Covenant

Article 17.1

No one shall be subjected to arbitrary or unlawful in .erference with his (sic)
privacy, family, home ....

Article 17.2

Everyone has the right to the protection of the law against such interference
or attacks.
The right of men and women of marriageable age to marry and to found a
family shall be recognized.

Article 23.2

Article 23.3

No marriage shall be entered into without the free and full consent of the
intending spouses.

The Right to Modify Customs That Discriminate Against Women
The Women’s Convention
Article 2

State Parties . . . undertake ... (f) To take all appropriate measures, ■
including legislation, to modify or abolish existing laws, regulations, customs
and practices which constitute discrimination against women; (g) To repeal
all national penal provisions which constitute discrimination against women.

Article 5

State Parties shall take all appropriate measures: (a) To modify the social and
cultural patterns of conduct of men and women, with a view to achieving
the elimination of prejudices and customary and all other practices which are
based on the idea of the inferiority or the superiority of either of the sexes or
on stereotyped roles for men and women; ....

The Right to Enjoy Scientific Progress and to Consent to Experimentation
The Economic-Rights Covenant
Article 15.1

The State Parties to the present Covenant recognize the right of everyone ...
(b) To enjoy the benefits of scientific progress and its applications....

3

77ie Political Rights Covenant

Article 7

No one shall be subjected to torture or to cruel, inhuman or degrading
treatment or punishment. In particular, no one shall be subjected without
his (sic) free consent to medical or scientific experimentation.

The Right of Sexual Non-Discrimination
The Women’s Convention
Article 1

[T]he term “discrimination against women” shall mean any distinction,
exclusion or restriction made on the basis of sex which has the effect or
purpose of impairing or nullifying the recognition, enjoyment or exercise by
women ... of human rights and fundamental freedoms ....

Article 3

State Parties shall take in all fields, in particular in the political, social,
economic and cultural fields, all appropriate measures, including legislation,
to ensure the full development and advancement of women, for the purpose
of guaranteeing them the exercise and enjoyment of human rights and
fundamental freedoms on a basis of equality with men.”

The Universal Declaration
Article 2

Everyone is entitled to all the rights and freedoms set forth in this
Declaration, without any distinction of any kind, such as race, colour, sex, ....

The Political Rights Covenant
Article 2.1

Each State Party . . . undertakes to respect and to ensure ... the rights
recognized in the present Covenant, without distinction of any kind, such as
race, colour, sex, language, religion ....

Article 2.2

The State Parties to the present Covenant undertake to guarantee that the
rights enunciated in the present Covenant will be exercised without
discrimination of any king such as race, colour, sex,
.

The Economic Rights Covenant

May 25, 1994
Forfarther information on these issues, contact Rachael N. Pine, Director of International Programs, Anika
Rahman, Staff Attorney, or Rebecca Casanova, Associate.

hm G

/

Feminist International Network of
Resistance to Reproductive and
Genetic Engineering

FINRRAGE POSITION PAPER

RU 486

October 1991

.fT?'? "-1GE supports the excl-'ive rights of all wore:: ’c decide whether or not to b/’^r
children without coercion from any man, medical practitioner, government or religion.
FINRRAGE demands that women shall not be criminalized for choosing and performing
abortion.
Declaration of Camilla. FINRRAGE - UBINIG International Conference 1989, Camilla,
Bangladesh

RU 486, synthesised by French medical scientist in 1980, is promoted as a new concept
of abortion. Scientific reports recommend RU 486, administered with adjunct
prostaglandins, as preferable to conventional abortion methods on the basis of its safety,
privacy, medical independence, and community acceptability. Research by FINRRAGE
women denies these claims and suggests that the short and long term biological safety
aspects of these two potent drugs have been inadequately addressed. Specifically, we are
concerned that the RU 486 anti-progesterone activity may extend to other vital organs
such as the adrenal gland, and the hypothalamus and pituitary glands within the brain.
Furthermore, the prostaglandin component of chemical abortion, that has been added
to boost RU 486 efficacy from its 80% when administered alone, to 95%, represents an
unnecessary challenge to the immune system of healthy women. In other words, yet
another time, women are used as an experimental site a "miracle pill".

FINRRAGE
International Coordination
0-7000
2Q

Otfnuhlir nf Germany

Contrary to the reports of chemical abortion by the media, a number of short-term
adverse effects are apparent within the conflicting evidence from the medical literature.
Included are pain, bleeding, vomiting, diarrhoea and several less common, but more
serious, effects such as thrombosis and cardiac arrythmia. The pain experienced is
frequently of sufficient severity to warrant the use of strong analgesia, often opiates.
Blood loss has lowered haemoglobin levels to the extent that emergency curettage and/or
blood transfusion were necessary in as many as 4% of RU 486/prostaglandin-treated
women. The short-term side effects of chemical abortion appear ethically unacceptable
for women in general, and particularly for women from the so-called third world, where
many are already disadvantaged by pre-existing anaemia and have restricted access to
medical rescue facilities.

Proponents of RU 486/prostaglandin have stressed the advantages of chemical abortion
in demedicalising and humanising the abortion process. Yet at its present stage of
development, an RU 486 induced pregnancy termination requires 4 medical
consultations, compared with 2 for conventional abortion. The perception that it is a doit-yourself method is mistaken and groundless. The intensive medically supervised
procedures and follow-up visits are absolutely essential to safeguard women against the
hazards of RU 486 and prostaglandins, both at the time of taking the medications, and
for the immediate 4 to 6 hours, as well as for the ensuing 2 weeks. While this may be
possible in industrialised countries, such safety' precautions will be impossible to
implement in developing countries given their poor infrastructure of medical facilities.
Thus essential safety precautions will be denied to the vast majority of women. With this
in mind, RU 486 and prostaglandin should not be sold (with or without prescription) at
pharmacies and drug stores, so that its unsupervised, self-administered use in women
may be kept to a minimum.

The psychological impact of chemical abortion resulting in miscarriage over a period of
up to 2 weeks is a further argument against RU 486 when measured against safe,
compassionate services'that terminate pregnancy under local anaesthesia within 2 hours.
The vociferous moral objections to RU 486 in Australia, the USA and western countries,
may have prompted some women’s health and community activists to prematurely join
those in favour of RU 486-based abortion to encourage the drug's commercial
distribution. However, FINRRAGE believes that this is a debate that needs to be
urgently broadened to question the health hazards of drug-induced abortion, together
with its ethical and socio-political consequences for women. Multifactorial analysis is
essential to ensure that the global acceptance of RU 486 is not a premature judgement
that represents an unethical hazard for women’s reproductive health and which ironically
may further erode women’s access to the safe termination services presently available.
For all these reasons FINRRAGE strongly reject the promotion and use of RU
486/prostaglandin induced abortion. FINRRAGE sees it as a further part of the medical
"weaponry" to destroy women. Like DES, Net-En, the Daikon Shield and fertility drugs
it is a new form of medical violence against women and violates women’s dignity and
their right to be free from bodily harm.

was

w u r d e s t du

tun?

ohne die

iibe rb evbl ke rung
kqnnten die menschen

mit der natur i.

harmonie leben
christoph

kruger,

18, wrestedt

'Lliis advertising was spread in Germany
Translation: Wliat would you do?

wi Ll iou t over | npn I a I. i on
jcople could live with
nature in harmony

esprit de corp., halikestr. 42-46. 4030 ratlngen

Family Planning at Work
Among the reams of graphs and tables
published by the World Bank, nothing is
as striking as a single chart that relates the
economic status of countries to their fertil­
ity rates. With few exceptions, fertility
rales — the average number of children
bom to a woman in her reproductive years
— are highest in the poorest countries. In
most developing countries the average
woman has more than six children. In the
wealthiest countries, with the exception of
Gulf oil states, women on average have
fewer than two. Reduction in population
growth in developing countries, it is plain.
is vital to economic progress.
Earlier this month the privately funded
Population Crisis Committee published a
report praising the progress of five coun­
tries toward that goal. Each of these coun­
tries has been successful in the years since
1980. for different reasons.
India's fertility rate has gone from 5.3 tc
719 GecaUje of strong local efforts, mainly in
five specific regions of the country.
In Thailand, which has cut its fertility
rate in half. 68 percent of married couples
are using modern contraceptive methods.
with materials and services provided free or
highly subsidized by the government.
Fertility rates in Colombia have gone
from 3.9 to 2.9 largely because of the work
of a private famriv planning association

assisted by the government. Surprisingly.
the report attributes some of this progress
to tacit acceptance of family planning ef­
forts by the Catholic hierarchy and to the
open support of many priests and nuns at
the parish level.
Moroccan women now average 4.5 chil­
dren. as opposed to 6.9 in 1980. because of
mobile teams of nurses and midwives who
saturate the country with information and
material and even make home visits.
And although Kenv a still has a dauntingly high fertility rate of 6.7, it is belter
than 8.1, the rate 12 years ago. There, new
technologies, including injectable contra ceptives and Coniracepiive sterilization, '
have proven effective.
'■
The United States no longer funds Unit­
ed Nations population programs or those
run by foreign nongovernmental organiza­
tions th'kt use their own money to fund
abortions. That is shortsighted policy. But
the American government has not reduced
its overall spending on family planning A
abroad; this year it will be about
million. Each of these successful countries] (
has received direct U.S. population assis­
tance. Still. U.S. participation in multilater­
al population efforts would complement
these programs and contribute even more
to worldwide development.

n .lSW/.VCTON POST.

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CONFIDENTIAL

draft

WORLD

HEALTH

ORGANIZATION

SPECIAL PROGRAMME OF RESEARCH, DEVELOPMENT
AND RESEARCH TRAINING IN HUMAN REPRODUCTION

TASK FORCE ON VACCINES FOR FERTILITY REGULATION

Project Number:

91904

Project Title:

Phase II clinical trial of a prototype
anti-hCG vaccine

INFORMATION BROCHURE AND CONSENT FORM

BROCHURE
20.09.1991

24/1

NOTICE

YOU ARE CONSIDERING PARTICIPATION
TRIAL OF AN ANTIFERTILITY VACCINE.

IN

A PHASE II CLINICAL

IN ORDER FOR YOU TO REACH A DECISION ON WHETHER OR NOT TO
TAKE PART IN THIS STUDY, IT IS IMPORTANT THAT YOU UNDERSTAND
WHAT THE VACCINE IS,. HOW IT IS BELIEVED TO WORK, AND WHAT IS
INVOLVED FOR THE PARTICIPANTS IN THE TRIAL.

THIS BROCHURE HAS BEEN PREPARED IN ORDER TO PROVIDE YOU WITH
THIS INFORMATION.
IT HAS BEEN WRITTEN IN THE FORM OF
ANSWERS TO QUESTIONS LIKELY TO BE ASKED BY INDIVIDUALS WHO
VOLUNTEER TO BE IN THE STUDY.

PLEASE READ THIS BROCHURE CAREFULLY AND ASK ANY ADDITIONAL
QUESTIONS THAT MAY OCCUR TO YOU.
YOU ARE FREE TO ASK
QUESTIONS AT ANY TIME BEFORE AND DURING THE STUDY.
IF YOU DECIDE TO PARTICIPATE, YOU WILL BE ASKED TO SIGN THE
STATEMENT ON THE LAST PAGE OF THE BROCHURE. THIS STATEMENT
SAYS THAT YOU HAVE BEEN GIVEN SUFFICIENT TIME TO READ THIS
BROCHURE, THAT YOU UNDERSTAND ITS CONTENTS, THAT YOU HAVE
RECEIVED SATISFACTORY ANSWERS TO ANY AND ALL QUESTIONS YOU
'MAY HAVE ASKED, AND THAT YOU ARE PARTICIPATING IN THE TRIAL
OF YOUR OWN FREE WILL.

SHOULD YOU DECIDE TO WITHDRAW FROM THE STUDY, FOR ANY REASON
AND AT ANY TIME, YOU ARE FREE TO DO SO WITHOUT IN' ANY WAY
AFFECTING YOUR FURTHER MEDICAL CARE.

Phase II clinical erial information brochure and consent form

Page 1

24?
HOV ARE NEW DRUGS AND VACCINES DEVELOPED?

development

The

often

requiring

dollars.

It

be

stage,

involving

clinical

can

than

more

divided

ten

two

into

and many millions of

years

major

parts - the preclinical

animal experiments and laboratory tests, followed by the

Both

the

preparation

testing

of

the

preclinical

and

clinical stages of new drug and

involving

stage,

volunteers.

drugs .and vaccines is a long and expensive

new

of

undertaking

new

in

human

vaccine development have the following two principal objectives.

objective

first

The

does

and

safe

not

is

determine

to

produce

the new preparation is

that

effects

any

side

to

determine

which

would

make

it

unacceptable for human use.

second

The

or,

in

the

objective

is

that the new preparation is

that

it

prevents, cures or alleviates illness and disease,

case

of

a

in

effective

family planning method, provides protection

new

against unwanted pregnancy.

WHY ARE CLINICAL TRIALS NECESSARY?

2.

Laboratory
same

way

as

experiments

Therefore, however carefully the preclinical animal

laboratory

and

how

safe

clinical

trials

efficacy

studies

satisfactorily

designed

and

carried out, it is

and effective they are in humans.

These tests are called .

and

all of the safety and

are.

and

carried

laboratory

completed

and

out

only

when

to

tests

referred

above

have

been

when

the

information

obtained

has

been

the

appropriate

national

regulatory"

submitted

to,

and

approved

by,

authorities

in

the

country

in

conducted.

are

tests

at some time in the development of all new drugs and vaccines to

necessary
prove

do not always respond to a drug or vaccine in the

animals

humans.

which

the

clinical

trials

are

to be

Question

Page

1.

HOW ARE NEW DRUGS AND VACCINES DEVELOPED?........................................................

1

2.

WHY ARE CLINICAL TRIALS NECESSARY?............................................................................

1

3.

WHAT ARE CLINICAL TRIALS?................................................................................................

2

4.

WHAT ARE VACCINES AND HOW DO THEY WORK?.................................................................. 3

5.

WHAT IS AN ANTIFERTILITY VACCINE?. .... ...................... .............................................

4

6.

WHAT IS HCG?...................................................................................................................................

4

7.

WHAT IS AN ANTI-HCG VACCINE AND HOW DOES IT WORK?.....................................

5

8.

FOR HOW LONG WOULD THE ANTI-HCG VACCINE REMAIN EFFECTIVE?..................

6

9.

WHY IS AN ANTI-HCG VACCINE AN ATTRACTIVE BIRTH CONTROL METHOD? ...

6

10.

WHAT IS THE CURRENT STAGE OF DEVELOPMENT OF THE ANTI-HCG VACCINE?.

.

8

11.

WHAT ARE THE GOALS OF THIS PHASE II CLINICAL TRIAL?................................

12.

WHO IS ELIGIBLE TO PARTICIPATE IN THIS CLINICAL TRIAL?........................... 10

13.

WHAT WILL PARTICIPATION IN THIS CLINICAL TRIAL INVOLVE?...................... 10

14.

WHAT ARE THE POTENTIAL RISKS AND PROBLEMS THAT MIGHT BE ENCOUNTERED?

15.

WHAT ARE THE BENEFITS OF PARTICIPATION?.............................................................. 12

16.

WILL PARTICIPANTS BE COMPENSATED?................................................................................. 13

17.

WHO HAS ACCESS TO THE CLINICAL TRIAL RECORDS?...............................................13

18.

WHO SHOULD BE CONTACTED IF QUESTIONS ARISE DURING THE TRIAL? ....

STATEMENT OF INFORMED CONSENT TO PARTICIPATE IN THE TRIAL

.'......................... 14

9

11

13

3.

'what are clinical trials?
Clinical trials are usually carried out in the following four phases.

Phase I:

Phase I clinical trial is the first time the new drug or vaccine is

A

tested

in

The main objective of a Phase I clinical trial is to

humans.

determine

the

therefore,

to

safety
ensure

of

the

preparation.

that

the

volunteers

care

Great

are

to

exposed

is

taken,

the lowest

possible risk.

The

purpose

Phase

a

of

clinical trial of a new method of birth

I

control

for

women

is

to

test

confirm

that

the

drug

or

vaccine

expected

manner.

Therefore, these studies are done in healthy volunteers

who

infertile

because

are

sterilized,

becomes

of

the preparation, and to
the body in the

by

"processed"

-

Volunteers

their

safety

is

they have previously elected to be surgically

sterilized.

from

the

these

in

Phase

I

Since

participation.

trials will receive no direct benefit

they

have

already

been

surgically

they are unlikely to be candidates for the new vaccine once it

available

for

the

general

public as a method of birth control.

Participation in a Phase I clinical trial serves only to benefit others.

Efra?.e n:

A

is

Phase

tested

method

fertile

information
pregnancy,

efficacy

birth

of

healthy,

clinical trial is the first time the new drug or vaccine

II

for

on
as

(effectiveness) in humans.

In the case of a new

control, therefore, a Phase II trial is carried out with

volunteers.

how

well

effective

as

The

principal

the

new preparation

objective

is

is

to

obtain

in' preventing

to obtain additional information on possible side

effects- associated with its- use;*’ •
ta .-.la. •

.. .........
i.... ...j.

’.ram agsir.rt

usas

Prototype anti-hCG vaccine Phase II clinical trial information brochure and consent form
Page 3

If

during
take

will

the

preparation

works

device

from

of

the trial.

a

intended.

as

protective

the

effect

Phase

II

trial

of the new method

It is possible that the volunteers who

Phase II clinical trial might be future users of the new

when

it

II

Phase

of

or

benefit

course

in

part

role

drug

new

the

volunteers

eventually

available for general use.

becomes

The

trial volunteers is, therefore, different to

clinical

that of Phase I trial volunteers.

Phase III:

If

is

Phase

III

healthy,

of

the

and

does not produce any unacceptable side effects,

clinical

trials

are

started.

volunteers

and

are

fertile

on

information

a

by

larger

participants
of

effect
that

future

for

Phase

II

Phase III trials also involve

designed

to

generate

additional

the efficacy and safety of the preparation when it is used

number of individuals and over a longer period of time.

The

in Phase III clinical trials will benefit from the protective
the

new method during the course of the trial.

volunteers

the

trials indicate that the drug or

results

effective

the

device

users

of

general

use.

It is possible

who take part in a Phase III clinical trial might be

the new preparation when it eventually becomes available

The

role

of Phase III clinical trial volunteers is,

therefore, similar to that of Phase II trial volunteers.

Phase iy:

IV clinical trials are usually carried out when the new drug or

Phase

vaccine

has

monitoring

been

licensed

for

general

use.

These

trials

involve

of side effects and efficacy of the preparation when it is used

by‘ the general population.

4.

WHAT ARK VACCINES AND HOW DO THEY WORE?

Healthy

people

’foreign'' materials
-

that

disease.

have

an

immune

system” that''protects 'then’against

- such as bacteria, viruses ‘and’other micro-organisms

enter or come into contact with.” the. Body and can cause Illness’and

a

person's

immune

an

immune

response

When
produces

the

destroy

foreign
if

protection

However,

and

the

material,

foreign material, it

at

and,

the

same time, provide lasting
later

is a delay between exposure to the foreign material

there

of

production

protection.

this

of antibodies and immune cells.

person comes into contact with the same mat

the

on.

detects

and Immune cells circulate in the body and neutralize or

antibodies

These

system

consisting

sufficient

a

level

of

immunity

to

provide

Sometimes this delay can lead to illness, and, in the case of

the more serious diseases, even death.

been

have

Vaccines
caused

by

this

delay.

foreign

material

but

molecules

are

an

A

which

in order to overcome the health risks

vaccine

are

not

molecules which mimic the

contains

capable of causing disease.

These

recognized by the immune system which responds by producing

response, which

immune

provides

developed

persists,

protection

pre-existing

sometimes for many years, and which

should

the vaccine recipient come into

contact with foreign micro-organisms or materials at a later date.

5.

WHAT IS AN ANTIFEETILITY VACCINE?

Antifertility

vaccines

are

designed

to

protect

than

disease.

Antifertility vaccines, therefore, are not directed against

are like any other vaccines, except that they
the recipient against unwanted pregnancy rather

foreign

materials but against molecules produced by the body and which are

needed

for

directed

successful

a

against

Other

fertilization.

reproduction.

woman's

eggs,

antifertility

Some antifertility vaccines can be
or

a

man's

vaccines

to

sperm,

prevent

can be directed against a

hormone, such as hCG, which is needed for pregnancy to occur.

6.

is

WHAT IS HCG?

HCG

stands

first

produced

before

for

it

attaches

pregnancy.

This

human chorionic gonadotrophin.

It is a hormone that

by the egg after it has been fertilized by a sperm and
to, and burrows into,, the wall of the womb to begin a
process

of

attachment

and

burrowing

is

known

as

Phase 11 clinical criai inxoraacion Brochure ana consenc form
Page 5

implantation.

The main role of HCG is to stimulate the ovary to continue

its

production

of

for

implantation

another hormone, progesterone.

to

Progesterone is needed

completed and without it pregnancy

successfully

be

will not occur.

7.

WHAT IS AN ANTI-HCG VACCINE AND HOW DOES IT WORK?

The
piece,
In

vaccine’ to

anti-hCG
or

order

icaterial-

used in this trial consists of a small

be

peptide,

of hCG which has been manufactured in the laboratory.

that

immune

the

is

it

system

will

see

to

attached

chemically

the

another

peptide

as a foreign

molecule,

diphtheria

toxoid,

and a small amount is Injected into the muscle of the buttock in a

thick,

creamy

suspension.

called

chemical,

an

Also

included

in

the

role

is

to further stimulate the

adjuvant,

whose

of

the

vaccine,

immune

cells

vaccine

is another

immune response.

After
produces

injection

antibodies

and

recipient's

the

immune

system

hgalnst hCG that circulate in her



body and protect her, temporarily, from becoming pregnant.

It

is not known exactly how the vaccine works (this is the subject of

number of ways in which the

ongoing

research).

However,

vaccine

might work.

For example, a few days after an egg is fertilized by

a

and

sperm

pre-existing

has

started

antibodies

to

there

divide,

are

a

it

begins

to

secrete hCG.

The

and

immune cells produced by an anti-hCG vaccine

cells

in

could either:

(a)

. inhibit

the

thereby

prevent

and/or;

(b)

its

the fertilized egg which produce hCG and

production

and

release

into

the blood, .

.

neutralize the hCG after it has been released into the. blood and f
thereby
prevent
it
reaching - the
ovary and maintaining /

progesterone production.

--•*

Phase II clinical trial Information brochure and consent form
Page 6

the

Whatever

the

egg

fertilized

be

cannot

is

result

the

mechanism,

that

the

is

ovary

not

Without progesterone, Implantation of

to produce progesterone.

stimulated

completed

and

a normal menstrual period

occurs.

8.

FOR HOW LONG WOULD THE ANTI-HOG VACCINE REMAIN EFFECTIVE?

anti-hCG vaccine has been designed not to produce a long-lasting

This
or

trial

with

anti-hCG

six months or more.

response

produced

to

able

that

shows

vaccine

it

is likely to provide

against pregnancy for at least three months and perhaps as much

protection
as

this

Information from a Phase I clinical

effect.

antifertility

permanent

become

This means that at the end of this time the immune
the vaccine will drop and the- woman should again be

by

If

pregnant.

control,

she

could

should

provide

a

she chooses to continue practising birth

either receive another injection of the vaccine which

period

second

of protection expected to be of similar

duration to the first or select an alternative method of her choice.

Further

research

individuals

to

is being carried out to produce a range of anti-hCG

different

with

vaccines

a

select

durations

to

vaccine

of

efficacy.

suit

This

would

allow

their own needs from a range

offering protection for a few months or for one or more years.

9.

WHY IS AN ANTI-HCG VACCINE AN ATTRACTIVE METHOD OF FAMILY PLANNING?

An

antifertility vaccine is considered to have a number of advantages

over some of the currently available methods of birth control.-

(a)

It

does

not

involve the use of hormonal steroids such as those

contained in birth control, pills or injectable contraceptives.

Although
small

these

amounts

segment

of

significant
certain

steroid

based

preparations,

are

given in very

and find a high level of acceptability in a large

the
health

high-risk

contracepting

population,

they

do

pose

a small proportion of women in

problems

to

groups.

In a slightly larger proportion of

Phase II clinical trial inrormacion u.ocnure auu consent .jlj
Page, 7

2(3
they

women,

may

nnoying buc noc dangerous side effects

cause

such

as irregular menstrual periods or lack of menstruation.

such

menstrual disturbances were seen in the preclinical studies

in

and

baboons

in

No

Phase I clinical trial of the anti-hCG

the

vaccine.

(b)

The

vaccine

does not involve the insertion of a foreign object,

such as an intrauterine device (IUD), into a woman's uterus.

While

the

IUD

is

women,

in

some

it increases the likelihood of pelvic infection

or

a very good method of birth control for many

menstrual

heavy

No such risk is associated with

bleeding.

the vaccine.

(c)

The

appears

vaccine

to

more

be

effective

other

some

than

methods.
In

preclinical studies in baboons, the antifertility efficacy of

the

vaccine

effective

to

found

was

in excess of 95Z.

be

This is more

most barrier methods, rhythm, or withdrawal.

than

It

is

not

yet known what the efficacy of the anti-hCG vaccine will

be

in

fertile

women

-

is

obtain

this

trial

to

information

obtained

at

as

be

least

so

one of the objectives of this Phase II

information.

However,

from

the

far it is likely that the vaccine will

as

effective

the contraceptive pill in those

women who generate an adequate immune response to the vaccine.

(d)

The vaccine would be easy to use.

It

is

possible

that

vaccine

can

adjusted

woman.

During the period of protection provided by the vaccine,

the

woman

be

would

not

the duration of protection offered by the

to

have

the

child-bearing

plans

of the

take a pill every day, or use a

to

barrier

method

or

Frequent

visits

to a family planning clinic would not be needed

although

this

particular

withdrawal

would

vaccine

depend

selected

detected in clinical trials.

with

on

the

every

act of intercourse.

duration of effect of the

and'the nature of the side effects

Phase II clinical trial Information brochure and consent form
Page 8

10. ’ WHAT IS THE CURRENT STAGE OF DEVELOPMENT OF THE ANTI-HCG VACCINE?

hCG vaccine to be tested in this Phase II clinical trial has-been

The

under

for

development

past

the

During this time it has been

15 years.

prevent pregnancy) in baboons and for

studied

for

efficacy

safety

(lack

of side effects) in several different types of animal and in

to

(ability

women volunteers in a Phase I clinical trial.

Anjmal studies

at the beginning of this brochure [see Question 1], the

mentioned

As

the animal studies is two-fold, to determine the safety of the

of

purpose

vaccine, and to determine the antifertility efficacy of the vaccine.

The

injecting

animal

safety

mice,

rats,

that

studies

have

been

carried

out

include

and baboons with the complete vaccine and

rabbits

No sign of any adverse side effects where seen

its

individual components.

in

these studies even when the vaccine was given in amounts that were many
the amount to be given to women and on a more frequent basis than is

times

being proposed for the clinical trials.

animals;

such

as

gonadotrophin

(CG).

CG is a hormone produced only by monkeys,

Laboratory

chorionic

and humans.

apes

in

The animal efficacy studies were carried out, therefore,

which,

baboons

mice, rats and rabbits, do not produce

like

the

human, require CG for the fertilized egg to

implant

in the womb and for pregnancy to become established.

earlier

in

with

the

with

a

this

[see Question 9 (c)], female baboons immunized

vaccine

had a pregnancy rate of less than 51 compared

anti-hCG

pregnancy

immunized

baboons

adequate

to

continued

normally,

rate

of

provide

70Z

protection.
no .

in nonimmunized baboons.

Occassionally,

their

response was not

pregnant

became

when

immune

Every time this happened, the pregnancy

miscarriages

occurred, -and

normal’babies were

Similar results were obtained in other studies in which a different

born.

type - of

monkeys.

this

As indicated

brochure

anti-hCG- vaccine

was used to Immunize rhesus’monkeys and" bonnet

However, - when marmosets, a smaller monkey, were immunized with

second type of anti-hCG vaccine, they exhibited a higher-than-average

rate of miscarriages as their immune response to hCG began to decline.

Prototype anci-ncG vaccine
Phase II clinical trial information brochure and consent' form
Page 9

2Z7
Phase I clinical trial

Phase

I clinical trial of the anti-hCG antifertility vaccine was

out

1986 and 1987 with women who had previously <’

The
carried

in

sterilized

before

volunteering

took

part

in

women

to take part in the trial.

and were assigned to five different dose

trial

the

. to be

A total of 42 — .

groups.

six

Each

woman

received

two injections of the vaccine at an interval of

weeks

and

provided

frequent

anti-hCG

antibody

tests.

In

examinations

addition,
and

and urine samples for measuring

blood

and for conducting a large number of laboratory

levels

received

volunteer

each

thorough

physical

carefully monitored for side effects throughout the

was

study.

A

of

few

and

site,

a

injections.

the

few

women

had

aches

lasting

of

the

women

none

However

temporary soreness at the injection

developed

muscle

up

to

48 hours after the

considered these side effects

enough to withdraw from the study and no other significant adverse

serious

effects were seen.

at

Women

from all of the vaccine dose groups developed antibodies to hCG

levels

that

These
to

were

estimated

to provide protection against pregnancy.

levels lasted for at least three months in the low dose group and up

six

months

previously

been

antibody

levels

in the higher dose groups.

sterilized,

actually

it

were

was

However, since these women had

possible to determine if these

not

capable

of

providing protection against

pregnancy in these individuals.

11.

WHAT ARE THE GOALS OF THIS PHASE II CLINICAL TRIAL?

principal

The
antibodies

further

produced

information

objective of this Phase II trial.is to see whether the

by

the vaccine- will prevent? pregnancy. - .In addition.

will, be collected about side effects?, associated, with

' the use of the vaccine.

...

'



.....

:

Procotype anti-hCG vaccine
Phase II clinical trial information brochure and consent form
Page 10

WHO IS ELIGIBLE TO PARTICIPATE IN THIS CLINICAL TRIAL?

12.

women between the ages of 18 and 39 who have had at least one

Healthy

All participants should have regular menstrual

eligible.

pregnancy

are

periods,

be

engaged

in

a

capable

of

fathering

a

child, and be using an IUD or barrier methods of

as their sole method of family planning.

contraception

breast-feeding,

for

screened

for

nor

allergies.

severe

sexual relationship with a man who is

steady

in

certain

Women

who

medications,

nor

They should not be

have a history of

to participate will be thoroughly

choose

and other conditions which might make them Ineligible

these

inclusion

taking

the

A total of up to 250 participants will be

study.

needed for the Phase II trial.

WHAT WILL PARTICIPATION IN THIS CLINICAL TRIAL INVOLVE?

13.

who

choose to participate in this Phase II clinical trial will

interviewed

and given a physical examination Including a gynecological

Women

be

examination.

A

carried

These

out.

Pap

smear

will

be

taken and laboratory tests will be

tests require the provision by the participant of a

urine specimen and the drawing of a blood sample from a vein in the arm.

a women meets all screening criteria, she will be given a diary in

If

to record her menstrual cycles, the dates of sexual intercourse, and

which

any

changes in her general health.

She will come to the clinic once every

month for three months for interviews and the drawing of blood samples.

She
of

will

then be given three injections of the vaccine, at intervals

four and six weeks.

Each injection will be given into the buttocks and

will be preceded by a brief physical examination and a skin (prick) test.

Following

visit
At

the

each

injection,

all

participants

in

this

trial will need to

clinic twice each month for_a period of approximately 6 months.
of

sample taken.

these

visits,

participants

will be interviewed and a blood

A urine sample will need to-be provided on some occasions.

Prototype antl-hCG vaccine
Phase II clinical trial information brochure and consent form
Page 11

anti-hCG

antibody levels rise above the level

When

a

participant’s

estimated

to

provide protection against pregnancy, she will be advised to

have

her IUD removed (or to stop using condoms).

fall

below

earlier,

comes

all

When her antlb''4y levels

efficacy level, or after six aonth., -ulchever

estimated

the

women

will

be

given

option - of

the

recommencing

contraception.

the first year, participants will be monitored at three-monthly

After

intervals

for another year.

This monitoring will involve an interview and

the provision of blood and urine samples.

All

participants

and

time

have

the

to withdraw from the study at any

right

for.any reason without in any way affecting their future medical

care.

WHAT ARE THE POTENTIAL RISKS AND PROBLEMS THAT MIGHT BE ENCOUNTERED?

14.

There are three types of risks and problems that must be considered:

Side effects

Temporary

soreness

at

experienced

by

some

of

it

is

likely

that

trial;

the

injection

women

the

the

same

site

and

muscle

aches were

part in the Phase I clinical

taking

events

may occur in this Phase II

clinical

trial.

Although no other significant side effects have been seen

in

the

animal

and human studies carried out with this vaccine so far, it

is

possible

women

receiving

whether

If

that, a new side effect could become apparent as the number of

such

.the

vaccine

increases.

It is not possible to predict

an event will occur or what type of side effect it might be.

a number of women develop serious side effects, the physician in charge

of the trial may decide to stop it.

Any

woman

.

. ..

..

who takes part in the trial and who develops a side effect

will ba offered the appropriate treatment for it.

•»

• ----- .;rC u>.w4.-..wv .<»ccine
Phase II clinical trial information brochure and consent form
Page 12

Irreversibility

Due

to
by

vaccine

recipients

or

the

±ons

in

immune responses

the

anti-hCG antibodies may persist longer in some

than

in others and, in some cases, the antibodies may

Although this has not been seen in the animals studies

Phase I clinical trial human studies, it remains a theoretical

the

in

va>

vaccine,

indefinitely.

last

individual

expected

produced

possibility.

It

an

possible

is

adequate

what

occur,

two

pregnancy

fail

may

to protect some women

Although

no

adverse

effects

on fetal

to

hCG were seen in animal studies, it is not

effects,

if

any,

will be in the human.

If pregnancies

will

be

available to the volunteer.

One will be to

of

antibodies

the

options

with

continue

vaccine

the

response.

immune

development

known

that

even though they had produced what was considered to be

pregnancy

against

pregnancy;

the

terminated

at

the

other

option

a very early stage.

will

be

to

have the

Whichever option is chosen,

the women involved will be offered the appropriate care.

If

two

stopped

or

level

a

above

and

more

participants

become

to

effective,

calculated

all

participants

be

will

pregnant with antibody values
the Phase II trial will be

'be advised to recommence using their

previous or an acceptable alternative method of birth control.

15.

WHAT ARE THE BENEFITS OF PARTI CITATION?

Participants

their

Inclusion

conditions

not

previously

treatment

date.

were

receive a very thorough medical screening prior to

will
in

the

found

been

Phase

II

trial.

In the Phase I trial, medical

in several prospective trial participants that had

diagnosed.

This allowed them to obtain preventative

for conditions that might have caused serious illness at a later

Phase II clinical

information brochure and consent form
Page 13

tr

irticipants may benefit personally

from

the antifertility effects of t

■accine during the efficacy stage of

the

study and will be performing an

..iportant role in the development of a

in

part

taking

By

this

new method of birth control that may benefit women throughout t

Id.

WILL PARTICIPANTS BE COMPENSATED?

16.

Participants
from

lost

will be reimbursed for travel expenses, child care, time
and

employment,

other

trial-related

expenses.

However, no

payments will be made.as an inducement to take part in the trial.

WHO HAS ACCESS TO THE CLINICAL TRIAL RECORDS?

17.

records

All

kept

are

personnel.

trial

When

in

individual

participants.’

will

retained

be

confidential with access limited to

summarized fashion that will not permit Identification of

presented

a

strictly

results of the study are published, data will be

for

Information

many

generated

in this Phase II trial

years, so that contact can be re-established

with volunteers at a later date.

18.

WHO

SHOULD

BE

CONTACTED

IF

QUESTIONS OR PROBLEMS ARISE DURING THE

TRIAL?

Should
during

ext.)

you

require

further

details about the trial, either before,

or after the study, you may contact

......................

(tel. no. and

Phase II clinical trial information brochure and consent form
Page 14

STATEMENT OF INFORMED CONSENT TO PARTICIPATE IN THE TRIAL

are invited to participate in a study entitled "Phase II clinical

You
trial

a

of

a

if

see

pregnancy

preparation

(anti-hCG vaccine) is effective in preventing

in fertile women.

The study will also collect information about

effects

side

of

the

vaccine

anti-hCG

The purpose of the study is to

anti-hCG vaccine".

prototype

new

in women who volunteer to participate.

vaccine

to

promises

fever

have

side

be

to

effects,

An
more

to use, and to be a more effective method of birth control than

convenient

many other current methods.

The

of

procedures

be

will

volunteer

the

study

follows.

as

are

All

women

who

They will have a physical examination,

interviewed.

includes a pelvic examination, drawing of. a blood sample from a vein

which

in the arm, giving a urine sample, and other routine medical tests.

you

are

will take place over a two-year period.

in

the

study

eligible

to

participate,

Participation
If

you will be given a diary to fill

In this diary you will be asked to record your menstrual cycles, the

out.

dates

you

have

sexual

intercourse, and any changes in your health.

will

then

come

to

clinic

interviewed

the

and

again

to

have

once

each

You

month for three months to be

blood samples taken and will be asked to

provide urine samples.

Following

into

your

intervals

you

come

The injections (no more than three) will be given at

back

to

During the following 18 months,

the clinic for follow-up visits twice each mcnth

maximum

six months of the efficacy stage and at three-monthly

thereafter.

At these visits you will be interviewed and a blood

the

intervals

brief physical examination, the vaccine will be injected

five weeks and seven weeks.

of

will

during

a

buttocks.

and sometimes a urine sample will be taken.

When

medical

preventing
method

tests

pregnancy, . you

suggest

that

will

advised

be

the

vaccine

is

effective

in

to' stop using your current

of birth control. f You will be informed when the tests suggest that

the . vaccine

is

no

longer

method of contraception.

effective so that you can start using another


Prototype antl-hCG vaccine *
Phase II clinical trial information brochure and consent form
Page 15
....

and

Risks

effects

of

In

place

side

soreness

may

occur

soreness,

will

disappear

in

the

participation

where

side -effects

that

new

side

bruising

blood

Some
The

icipated

There are no other

antl-hCG vaccine, but there is a possibility

the

There is a small risk of soreness and

effects may appear.

whenever

temporary.

of

follows.

Some women wh<

earlier study of the vaccine felt muscle aches.

an

known

as

vaccine is i"*-"ted.

the

after a short time.

are

is

but those side effects are minor and

drawn,

You will be offered appropriate medical treatment for any side

effects that occur in the course of the study.

There

vaccine

the

some differences among women in the length of time the

be

may

will remain effective.

vaccine

has

remained

Although there are no known cases in which
indefinitely, there is a very small

effective

possibility that this may happen to you.

is

There

possibility

a

that

vaccine may fail to protect some

the

study

participants

against

pregnancy.

If that happens to you, you may

freely

choose

to

continue

with

the

pregnancy or to have the pregnancy

a

very early stage.

terminated

at

Whatever choice you make, you will be

offered appropriate care in accordance with local medical practice.

The

receive
the

is

benefits

benefit

may

more

of

research are as follows.

this

Your general health

from the thorough medical examination and monitoring you will

before

and during the study.

The benefit to others in the future

development

of an alternative method of birth control that may be

and

have fewer side effects than some currently available

effective

methods.



The

of

alternatives

participation

to

are

as follows.

You may choose

to participate in the research and continue to use your current method

not

birth

control

or

use

another

appropriate

method available at your

family planning clinic.

Your

free

to

participation
withdraw

future medical care.

in

this

study is entirely voluntary and you. are

at any time and for any reason without, prejudicing your

Prototype antl-hCG vaccine .
phase II clinical trial information brochure and consent form "
Page 17

zz9
IMPORTANT NOTE TO THE PARTICIPANT

DO

THE

BELOW UNTIL YOU HAVE MET FOR THE SECOND TIME

INTERVIEWER, YOU HAVE DISCUSSED ANY QUESTIONS YOU HAVE ABOUT THE

YOU

AND

STUDY,

STATEMENT

THE

SIGN

NOT

WITH

HAVE

RECEIVED

SATISFACTORY

ANSWERS

TO

ALL

OF

YOUR

QUESTIONS.

have

been

given

adequate

time to read this brochure and feel I understand its contents.

have

had

the

opportunity

ask

to

satisfied

with

the

answers

understand

that

my

participation

voluntary

and

reason

and

that

I

I

questions

have

in

about

the

received to all of my questions.
this

I

study and I am
I

research study is completely

have the right to withdraw at any time and for any

that my withdrawal will not affect my rights to future medical

care.

I

hereby consent to participate in this trial.

Signature of participant

Date

Signature of investigator

. Date

Signature of witness

Date

Name of witness

Relationship to study

This

study

conforms

to ti

requirements stated in The World Medical

Association Declaration of Helsinki.

\

anci-nvu vaccine
Phase II clinical trial information brochure and consent firm’

;?age 16

All

records

will be kept strictly confidential and no participant in

the study will be identified by name in any published reports.

Participants
lost

from

will be reimbursed for travel expenses, child-care, time

employment,

and

other

trial-related

expenses.

However, no

payments will be made as an inducement to take part in the trial.

(88). Animal experiments have linked several drugs given to male mammals before
mating to decreased birthweight and survival of the offspring (89).
These
include Niophrine, Methadone, Propoxyphone, Thalidomide and Caffeine.
Cyclophosphamide, a cytotoxic drug was shown to cause behavioural damage in the
offspring of male rats treated before mating (28).

^1-5.

Investigating Reproductive Hazards

In this review, results from a wide variety of research methods have been used.
These have involved studies on people exposed to hazardous materials:
epidemiological studies and experimental studies where cell cultures or whole
animals have been exposed.
Experimental studies are a means of testing
chemicals without waiting for the damage to be done to exposed people but there
is much controversy about how reliable the various animal experiments are for
predicting reproductive hazards.
For example, thalidomide rarely induces
malformation in rats or mice but is a proven human teratogen (some even argue
that it is the only proven human teratogen). Conversely aspirin for which there
is good evidence that is not a human teratogen is a strong teratogen in rodent
species. On balance, animal data can be assumed as a useful predictor of hazard
to humans. Immense amounts have been written on the various methods used and it
is not proposed to attempt to do justice to the complexity of the different test
systems here or the range of epidemiological methods used in evaluating the
(wide) range of adverse reproductive outcomes.
References 1, 4, 14, 91-98,
represent just a few of the recent references summarising and discussing
methodology for evaluating reproductive hazards.

1.5.1

Epidemiology

In this section a few of the considerations in epidemiological study design will
be outlined; a short questionnaire for following up an example of miscarriage
clusters is provided; the main types of animal test summarised and their use for
extrapolation considered and mutagenicity tests in both people and experiments
are outlined.
Below, some of the weaker and stronger points in epidemiological studies are
briefly reviewed. However, first a general word needs to be said about the
interpretation of epidemiological studies which result in 'negative' or
'positive' results. A positive finding is usually considered as one where thete
is a 'statistically significant' association between the exposure and the ill
effect (low birthweight, risk of miscarriage etc.).
To be statistically
significant, such a finding should occur by chance alone with a probability of
less than 5% (the most common criteria used is 5%). A negative finding is one
that does not meet the above criteria, that is, no significant association has
been detected.

A study may yield negative results because no true hazard exists but other
reasons may also account for the failure to reach statistical significance, such
as poor study design, the high risk group being swamped by a larger group of
non-exposed, or insufficient study size. This last is a very common reason why
studies are inconclusive. They have 'failed to find a hazard' but importantly,
if they are not very large, they have also failed to rule out the possibility of
some hazard existing. In general terms, larger studies should be given more
credence, assuming that their advantage in size is not outweighted by poorer
quality design or data collection.
Consistency between independent studies is
important too, as is evidence of an increasing risk with increasing exposure for
studies with positive associations.
However, because of the fairly stringent
requirements of statistical significance, given studies of comparable quality,
positive findings should be taken more seriously than negative ones.
One
positive and one negative do not 'balance out'.

32

While doubts remain about the reliability of experimental evaluation in the
prediction of human risk, epidemiological studies remain the most sound source
nf evidence of reproductive hazard. Studies fall into two basic designs, the
cohort study where reproductive function is compared between groups each with
similar exposure or type of employment and the case-control study where rates of
past exposure are compared between sets of 'cases' (such as parents of malformed
children) and controls (for example parents of healthy children). In either
study design data can be drawn from routinely collected medical or employment
records, or can be collected by interviewing or examining the individuals. The
interview method is better because more complete data can be obtained but is
potentially more subject to bias.
Bias is one of the major pitfalls in
conducting epidemiological studies, and can take several forms.

For example, a study of spontaneous abortion and chemical exposure at work may
take the form of interviewing women exposed to the chemical about their past
pregnancies and miscarriage and making a comparison with another set of women
not exposed. The percentage agreeing to cooperate may differ between the two
groups and the exposed women with a history of reproductive problems may be
expected to be more likely to participate if they know about the suspected
hazard.
Furthermore, women who have had a miscarriage may remember more
accurately their exposure to potential risk factors, or may be prompted to
remember these things more completely by an interviewer who knows their
reproductive history. Finally, the two groups may differ in respect of some
other risk factor which would either serve to exaggerate or obscure the
association between the chemical exposure and miscarriage rates.
This latter
problem, the presence of 'confounding factors' can be adjusted for in the
analysis if detailed information is available on the potential confounding
factors.
Examples of these risk factors which can confound surveys of occupation and
reproduction include those mentioned earlier in this chapter: social class,
smoking, alcohol, some pharmaceutical drugs and so on. For example, studies
suggest that the risk of miscarriage may be as much as doubled by cigarette
smoking.
i.e. the miscarriage rate amongst smokers would tend to be twice the
rate amongst non-smokers. In a study of the effects of say anaesthetic gases or
solvent exposure on miscarriage risk if the 'exposed' population also smoked
more than the comparison or control population, this would make the effect the
'relative risk' seem larger than it really was.
However, the size of this
exaggerating effect is always smaller and usually much smaller than the size of
the risk of the confounding factor. This can be illustrated in an example.
Assuming that smokers-have twice the miscarriage risk of non-smokers, if the
group exposed to the suspected hazard contains 70% smokers against the average
of 40% smokers in the comparison group, what then is the size of the confounding
effect? Such a difference in smoking habits would give the 'exposed' group a
miscarriage risk 1.21 times the non-exposed due to the (confounding) effects of
smoking alone. An effect but not very dramatic. Thus, if a relative risk of 2
or more is reported, it would have to be a very strong confounding factor to
account for it (90).

Given that bias has been minimised, a problem which plagues many studies is
insufficient size. If the study is small, covering say a hundred pregnancies
with one or two malformations and a dozen miscarriages, it would probably be too
small to detect a risk (unless that risk were massive). Conversely, if no
significant results were achieved, it would be too small to rule out a hazard in
fact being present. Case control studies are more powerful than cohort studies
in investigating the causes of rare events such as congenital malformations
because the size of a cohort needed to get sufficient numbers of cases would be
larger than most occupational groups or would be prohibitively expensive. It
may in all types of study be difficult to disentangle the actual causes when
people are exposed to a mixture of substances.

33

Large studies are needed to investigate the causes of the full fange of adverse
reproductive outcomes, but in many cases, initial investigations can be limited
to studies of infertility, abnormal sperm count and morphology, menstrual
irregularities and miscarriage. These outcomes have the advantage in having the
potential for detecting effects in relatively small occupational groups because
none of the effects are yery rare. They each have methodological problems, for
example getting cooperation from men to provide sperm samples, or women with a
history of infertility or miscarriage being more likely to be still employed
(rather than full time mothers) resulting in apparently high infertility rates
in any employed group. Miscarriage as a measure of reproductive damage has
particular advantages in that it is the most likely result of teratogenic damage
to the embryo in early pregnancy or genetic damage at or before conception (via
either parent).
In the next section an example is given of the use of a
questionnaire for following up a suspected occupational miscarriage risk.

1.5.2

Questionnaire Methods

The amount of systematic investigation into reproductive health among workers is
quite inadequate. Sometimes groups of workers may be worried that they may face
a reproductive hazard either because of hearing from newspaper reports of other
groups of workers experiencing reproductive problems or reports of animal tests.
Alternatively a number of pregnancies among colleagues at work may go badly
wrong, ending in miscarriage or a malformed child, such 'clusters' can give rise
to fears that some aspect of work may be responsible. Until large scale surveys
have been carried out, it is not possible to know whether or not a hazard is
present. As awareness spreads of possible reproductive hazards, the problem of
how to respond to equivocal evidence will loom large. Few pregnant women will
want to gamble with their pregnancy even if the evidence of a risk is weak. On
the other hand if faced with an unsympathetic employer (especially in small
workplaces with limited possibilities of temporary job transfers) pregnant women
will be faced with the choice of the stress (and reduced income) of having to
resign from their jobs or the stress of keeping on the job worried that there
may be a risk. Such stress may of itself pose a threat to a healthy pregnancy.
Thus there is an urgent need to gather more information on the true extent of
reproductive hazards. One such method is to use questionnaire surveys to gather
information about pregnancy outcome. At the end of this section is an example
of a questionnaire and covering letter. It has been drafted to respond to fears,
about VDU safety because ASTMS has received inquiries on this topic, but this is
just to illustrate the specific use of such questionnaires.
It is not advisable to use it in areas where people are not already aware of and
concerned about some potential risk, for fear of causing unnecessary alarm. Its
function would usually be to put into perspective either a cluster of
miscarriage or to investigate fears that there may be a problem. It is a crude
initial investigation and can only give approximate answers.
Such
questionnaires need to be tailored to particular circumstances and the example
given here is for investigating miscarriage and VDUs. An example of a covering
letter is also given but the survey would have to include meetings to explain
the purpose of the survey in order to get good response rates. If everybody
already knows what the suspected risk is then the letter should be
straightforward and the highest response rate should be sought, as in the
example given.
It is preferable though, to minimise bias, to have it as a
'general health survey' with a most general introduction letter. The survey
will be severely limited unless a high percentage (at least three quarters of
the group being looked at) takes part. Secondly a 'control group', not exposed
to the suspect hazard should also take part and similarly be encouraged to
participate to a high degree. However, the 'control group' should be similar in
other respects - age, social class, hours of work, sitting rather than standing
etc.
Such surveys are vulnerable to bias - a higher response rate in the
'exposed' group; better memory of exposure in the group with miscarriage and if
carried out in response to a 'cluster', the cluster itself starts the survey off

34

with a known built-in excess number of miscarriages. However, in spite of the
potential sources of bias, it can be a useful first attempt to evaluate the size
of the problem.
Larger more systematic surveys may be undertaken later.
Because of the potentially severe pitfalls, advice from union health and safety
officers or sympathetic researchers familiar with carrying out such surveys,
should be sought.

Other questions, including malformations or infertility could be included but
many questions can reduce the response rate. Other questionnaires could be re­
worded and used for assessing fertility and miscarriage late in the wives of
exposed male workers. Miscarriage is a good choice because it is much more
common than other reproductive adverse effects and so an effect would be more
likely to be picked up from a fairly small number of pregnancies. Two other
fairly common outcomes can also be evaluated from the questionnaire - low
birthweight and 'irregular periods' though the latter is the most subject to
differences in women's individual perception. However, in spite of miscarriage
being fairly common generally (10-15% of all known pregnancies end in
miscarriage), small numbers of pregnancies can yield inconclusive results. For
example, to detect with some certainty a doubling of miscarriage risk,
approximately 200 pregnancies are needed to be observed in the exposed group and
200 in the comparison group. (More exactly, to be 95% certain of detecting a
doubled risk, i.e. getting a statistically significant excess number of
miscarriage, requires a study population of this size). Smaller study sizes can
still detect a risk, but are less likely to. The smaller the study size, the
more the chance that risks will go undetected (or less likely that spurious non­
significant positive results will occur). Pregnancies before and after the
period of exposure can be included in the control group.
If the age
distribution of the pregnancies varies between exposed and non-exposed groups
this must be allowed for in the analysis by comparing miscarriage rates within
age groups e.g. under 25, 25-35 and 35+. Strictly speaking, the comparison
should also allow for differences in the 'parity' - the number of previous
children (or pregnancies) - in the exposure groups. Many women who have had
children will have left work to look after them so the population of people left
in work may be slightly biased in favour of those who have had some difficulty.
This can be reduced by including recent past employees, but only if they can all
be included (rarely possible).
If it has proved impossible to get sufficient numbers of non-exposed pregnancies
to make an effective comparison, as a rough yardstick one expects 10-15% of all
pregnancies to end in miscarriage. Therefore, if the number of miscarriage
exceeds 20% this may be cause for concern. With small numbers of pregnancies,
less than 100, 20% miscarriage could easily be due to chance and so it cannot be
taken as evidence of a definite hazard. In surveys such as this the number of
miscarriage may be high because of the presence of one or two women who have
suffered several miscarriages eadh.
Evidence of an environmental risk is
stronger if miscarriage incidence is spread across the group rather than
concentrated in a few individuals.

35

1.5.3* EXAMPLE QUESTIONNAIRE SURVEY ON VISUAL DISPLAY UNITS AND MISCARRIAGE

Introductory Lottsr

There have been several reports of apparently high numbers of miscarriage
amongst VDU operators. There is no firm evidence that VDU's cause miscarriage,
but it is not possible) to say that they do not because the right studies have
not been carried out. ' This short survey is designed to see if there is any
evidence justifying a complete survey of the VDU operators here.
Please help us by completing this questionnaire and returning it. YOUR ANSWERS
WILL BE STRICTLY CONFIDENTIAL AND NO INDIVIDUAL WILL BE IDENTIFIABLE FROM THE
GROUPED RESULTS.
We are doing the survey because some members have noted the numbers of
miscarriage amongst VDU operators.
The survey will only work if you all
complete a questionnaire, so please help us and yourselves by completing yours.
Thank you for your help.

[

How to Answer the Questions

Please tick the relevant answer or complete in writing.
If you have never been
pregnant, only answer questions QI, Q2, Q3, Q4 and Q5. For the questions on
pregnancy please answer each question for each miscarriage or child. If you
cannot remember the relevant details or don't know them just write that in. If
you don't know the exact date or age give an approximate date. If you find that
there is not enough room to write a full answer, please add another sheet of
paper with your extra information.
full date of birth?

Month

Day

Q.l

What

Q.2

Arff' you working with VDUs, or have you in the past?

Q.3

If YES, please give the following details:

is your

1

Yes

Year
No

[

[
[

(i)

name of job on VDU

(ii)

brief description of VDU work

(including hours of

use each day)

[
Q.4

Since starting work with VDUs have you noticed any changes in your health e.g
(i)
(ii)
(iii)
(iv)
(v)

more headaches?
Yes .....................
No .....................
more eye-strain?
Yes .....................
No .....................
more backache?
Yes .....................
No .....................
irregular periods?
Yes .....................
No .....................
other changes or improvements to your health?

[
[

[
q.5

Have you ever been pregnant?

Yes

No

If you have not been pregnant, you have now completed the questionnaire. Please
return it. Thank you for your help.

[
[

Q.6

Please give the approximate date of getting pregnant and results of all your
pregnancies by ticking the appropriate box.
Ff try nanCy

Date l/cal «

No.

month if pass.)

Miscarriage

Termination

Birth

1
2
3

4
5
6

Q.7

Please answer the questions below for each pregnancy.

PREGNANCY

1

(i) Did you have a positive pregnancy
test? (Yes or No)

(ii) Was your job the same as at
the beginning of your pregnancy?
(Yes or No)

(iii) If No, please describe it, or the
differences to the Q.3 answer
(e.g.less hours.)
(iv) How many weeks into the pregnancy
did you work?
(v) Did you change your job during
the pregnancy? (Yes or No)

(vi) If Yes, what did you change to
and when (i.e. at how many
weeks)?
(vii) How long was the pregnancy? (i.e.
how many weeks before the
miscarriage,
birth
or
termination)

(viii) What was the birthweight?
(in pounds or kilos)

37

2

3

4

5

6

1.5.4

Experimental Tests

The main experimental tests on animals are conducted on rats or mice, rabbits to
a lesser extent and much less frequently on cats, dogs or monkeys and are as
follows.
In teratogenicity tests animals are exposed during embryogenesis and
the offspring are evaluated for lethal effects or growth retardation and
malformations.
Effects on offspring behaviour may also be investigated.
Effects on male or female reproductive function may be evaluated separately by
observing effects on sperm production in males or oestrous cycle in females.
The effects on the whole reproductive cycle can be observed by exposing one or
both parents from before conception and for a more complete evaluation
continuing the exposure through two or three generations. At each generation
the number of offspring', their size and development would be evaluated. Short
term tests for teratogenicity have also been developed including tl)e exposure of
chick embryos or rodent limb buds and observing effect of exposure on
development but they are less reliable for prediction than whole animal studies.
A problem encountered in some animal studies is that various effects on
reproduction including reduced fertility, embryolethality and the induction of
malformation may be a general response to debilitating effects on the adult
animals of the toxic chemicals. The most powerful evidence of reproductive
effects is where they occur in the absence of other adult toxicity. The hazards
for which there is evidence of reproductive harm in humans are usually matched
by evidence from animal experiments (14). Almost all of the 15-20 known or
suspected human chemical teratogens give positive results in animal
teratogenicity evaluations (98). However, a number of substances, especially
drugs which have undergone more extensive testing, appear to have no effect in
humans but marked effects in some animals (97). Differences in biochemistry
between different species would lead one to expect divergent responses between
different species to the same chemical. Thus there is no guaranteed animal test
of reproductive function that predicts effects on people.
However, such
evidence as exists now points to the value of animal tests in general for
predicting such effects. A recent international meeting of experts convened by
the World Health Organisation to address this question concluded:'The literature on experimental studies in animals indicates
that they are valuable for predicting the impairment of
specific aspects of reproductive function. For example, the
adverse effects of 1,2-Dibromo-3-chloropropane on the testes
were reported in animals before the effects were recognised
in men.

Comparison of the limited data available on the effects of
chemicals on both animals and humans indicates that in
general humans are no less sensitive than animals to adverse
effects on their reproductive systems'.
Reference: WHO Regional Office for Europe. Working Group on the Effects of
Occupational factors on Reproduction. Summary Report 11 August 1983.
We may conclude that in the absence of good quality epidemiological data
pointing to the safety of a particular substance, if there is evidence of
reproductive hazard in animals (preferably in the abse'nce of adult toxicity and
repeated in more than one species) then a similar hazard should be expected in
exposed people. Animal experiments may be able to define a threshold, or no
effect level but in attempting to extrapolate a 'safe' dose for people it should
be borne in mind that humans have been found to be in general more sensitive
than animals to reproductive toxins usually by a factor of at least ten (14).

38

1.5.5

Genetic Damage
There is a connection between genetic damage and reproductive hazard. The high
percentage of chromosomal abnormalities in spontaneous abortuses and the
evidence linking paternal exposure to mutagens to increased risk of spontaneous
abortions and malformations point to a causative role of mutagenic damage in the
development of both lethal and teratogenic effects.
Further a high percentage
(801+) of mutagens have been shown to be teratogenic in animal experiments (99).
Whether or not a mutagen will be a germ cell mutagen, affecting sperm or egg
cells, depends on whether it reaches the germ cells, as does whether or not it
could act as a teratogen depends on whether it can cross the placenta. However,
there is a good reason for suspecting that any mutagen (causing either point
mutations or damage to chromosomes - more precisely a clastogen) may pose a
reproductive hazard. There are various experimental systems for detecting
mutagens from bacterial mutagen tests like the Ames test to dominant lethal
tests in fruit flies or rats. The latter.test assess the embryolethal effects
of paternal exposure to a mutagen and indicates that the chemical has reached
the sperm cells.
In addition there are several tests of the presence of chromosomal damage that
are used to assess occupational exposure to mutagenic substances. Some involve
the observation of damage to chromosomes, usually in lymphocytes - blood cells.
Others specifically look at damage to sperm cells and may offer good potential
for predicting reproductive hazard. One, the YFF test involves counting the
number of sperm cells with an extra Y chromosome by means of using a dye which
shows up the Y chromosome as a fluorescent dot under ultraviolet light.
Another, picks up mutations in a protein found on sperm tails, so called LDH-X
variants. This latter test is very new and its reliability for monitoring
mutagenic effects in people has not been evaluated.
The number of mutagens identified in the battery of tests that have been used to
identify them is really quite large and is not reproduced here. Many of them
may turn out to be germ cell mutagens and teratogens as well as carcinogens
(which is well established as a correlate of mutagenicity). Mutations it should
be remembered need not have an immediate effect. Recessive mutations may wreak
some havoc in two or more generations from now. Although not given the same
degree of seriousness as evidence of teratogenicity or carcinogenicity, the very
minimum response to evidence of mutagenicity should be an awareness that they
may pose severe reproductive hazards.

39

NATIO.NALCOMMUNOW

FOR

WiB1UWHHK & tin
HHKH.HMWT

GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
DEPARTMENT OF FAMILY WELFARE
IEC DIVISION

CONTENTS

Introduction

Part-I - The Strategic Framework

Part-II - a)

The RCH Communication Challenge

b)

Matrix on Behaviour Change Objectives

c)

Notes on the Matrix

INTRODUCTION:
In 1997, the Government of India launched its new Reproductive and Child Health
(RCH) program. This program, represents a marked shift in the Government’s policy,
moving as it does, from its past pre-occupation of meeting sterilization targets, to the
introduction of a decentralized participatory planning process based on community needs
assessment. The countrywide RCH program, covers an extended range of services for
unwanted fertility, maternal health, RTI/STI infection, child health and adolescent health.
The new paradigm embodied in the RCH program, echoes the deliberations of the
International Conference on Population and Development (ICPD) held in Cairo in 1994.

Information, Education and Communication (IEC) has always been a significant
component of the Government of India’s family welfare program. The accent, so far, has
been on awareness generation about the program and service facilities, with the presumption
that this would ensure increased utilization. However, it is now evident, that the time for
awareness generation is past. If change in behavior is desired, a specific program that
promotes behavior change will be required.
In order to achieve the objectives set out for the National Population Policy 2000,
also, it has been stated that family welfare messages must be clear, focused and disseminated
everywhere, including the remote comers of the country, and in local dialects.
The Ministry of Health and Family Welfare, Government of India, started the process
of defining the strategy for communication of the country’s RCH program last year. The
Ministry invited experts from the fields of communication, management, obstetrics and
gynecology, pediatrics, training, international donor agency representatives and NGO
partners to deliberate with Government officials on articulating a strategy for communication
which would advance the new paradigm for reproductive and child health care. A new
strategy that would make the leap from awareness generation to behavior change, from being
instructive to being empowering, and from taking the generic approach and to taking the
individualized approach.
Such shift in emphasis would require localized communication efforts so that diverse
needs of different audiences in varied socio-cultural contexts can be meaningfully addressed.
It would require decentralized planning to facilitate better quality and access, and interaction
with audiences to improve service delivery as well.

As a first step, it is proposed to change the name of the IEC Division in the Ministry
of Health and Family Welfare to ‘Communications’ Division. This is essential so that the
focus shifts from information dissemination and awareness generation to communication for
behavior change. This is as per the recommendations of the Media Advisory -Group of
MOHFW and acceptedhvJthe-Ministrv.
The RCH paradigm shift - towards client - centered, demand driven services - needs
strategic communication to work as a tool to create demand for quality services. The

1

communication challenge for RCH is one of demand creation and this requires understanding
of media opportunities, professional procedures and use of marketing approaches.

among priority audiences, research the social norms that act as barriers as well as
opportunities and bring in the enabling factors in terms of professionalism and structural
change in communication management. What follows is the Communications Strategy that
has been evolved through many consultations and discussions among experts and with State
level lEC/Communications officers.

The first part of this strategy lays down the goal and main strategy tenets and suggests
an operational framework for communications at the Central, State and District levels. The
latter part identifies the major behavior change objectives that have to be achieved for the
success of the RCH program.

2-

PART-I

Stratetic Framework for Communication for the Reproductive and Child Health
Programme

Goal:
The goal of the communication strategy for the RCH Programme is to

encourage individuals, families and communities to make informed decisions concerning
reproductive and child health through a programme of health communication -which
facilitates behaviour change.

This will be achieved in a systematic and participatory manner through capacity building of
all partners and convergence of services among different sectors.

Changes in Strategy direction :
A general consensus emerged on the direction that the new communication strategy for RCH
should take, in order to meet its stated goal. The time horizon within which this strategy is
expected to be valid is 7 - 10 years and will thereafter require review. Mid-course
corrections will be required from time to time.
The key tenets of the strategy are :
1.

Interpersonal communication for behaviour change will be the mainstay at the field
level, and will encourage greater dialogue on issues of reproductive and child health
between individuals within families and communities;

2.

Advocacy interventions based on normative research, including through the use of
mass media, will be needed to promote societal change with regard to behaviour
norms on RCH issues;

3.

This will require decentralization of some responsibilities for IEC to States and
districts from the Centre and consequently the articulation of new roles for each of the
three levels;

4.

There will be need for increased engagement with the NGO and private sector for
social mobilization and IEC for RCH;

5.

As roles change, there will be a critical need for capacity building at all levels to
undertake the newly defined tasks and enhance the image of RCH functionaries.

Components of the new framework;
The changing attributes of the IEC strategy for RCH within the country will require a change
in responsibilities for IEC actions at the Central, State and District levels of Government.

The role of Central Government in advocacy of national population and women and child
issues will gain importance. The Central Ministry will take the lead in estabilishing
necessary capacity building and research capability support to the States. States will assume
greater responsibility in addressing State specific societal behaviour norms as well as for
planning support for district based efforts in IPC and local publicity. They will also ensure
support for communication efforts undertaken by self-governing urban areas within their
boundaries. Districts will become the natural focus for convergence of Government and non­
governmental efforts for behaviour change through participatory planning, and inter-personal
communication. They will also assume the lead in initiating local (rural and small town)
publicity efforts within the context of RCH objectives and goal.
The Central, State and District administrations will perform complementary roles within IEC
to permit service providers and frontline workers to achieve their goal of delivery of demand
driven, quality RCH services.

Responsibilities of districts:
The changed responsibilities for IEC at the district level will enable frontline workers to
respond to identified RCH needs of individuals within the community, facilitating the use of
community specific, local knowledge and practices to promote behaviour change. They will
actively work to influence the normative behaviour of local communities (including small
urban communities) through the involvement of local self-government and opinion leaders
within the area.

The action plan of districts will make provisions for :
>
>
>
>

Timely distribution of IEC materials
Utilization of folk media and other local channels of communication
Convergence of the efforts of related Departments and
Enhancement in the capabilities of relevant staff within the district.

The district, will thus be the Central point for the development of an appropriate andflexible
action plan to support the communication needs of the community. The plan will be backed
by the development of capacity to undertake supportive supervision and monitoring, and
simple tracking techniques to assess progressive changes in the knowledge, attitudes, beliefs
and practices (KAPB) among the communities.

Responsibilities of States:
In the new organization of responsibilities,k the States will take charge as an important focus
of IEC activity. On the one hand, States will be responsible for facilitating IEC actions by
districts and self-governing urban communities. The development of State plans would be
informed by the plans of its constituent communities. The States will monitor actions
undertaken by them and track the effects of such actions on the changing picture in response
to delivery of RCH services and communication efforts.

Jn the other hand, States will develop plans to also •






Timely distribution of materials
Draw together State-local expertise from Government and non-governmental sectors
in the areas of research studies, training, health care, advocacy and management
support.
Undertake a concerted State specific communication campaign for population and
women and child health issues and other components of RCH.
Converge the efforts of relevant Departments.
Enhancement in the capabilities of relevant staff within the State.

The State will thus, become the hub of specific campaigns to address the communication
needs of its populace. The plan will be backed by the development of capacity to undertake
supportive supervision and monitoring , to contract agencies for KAPB studies, media
tracking and evaluation and to support production of materials which address the specific
needs of communities local to the State.
^he State will also co-ordinate its plans within the national policy framework for IEC in RCH
and with directions indicated by Government of India, from time to time.

Responsibilities of the Centre:
The Centre will take responsibility for the overall policy development process for IEC within
RCH with the full involvement of and co-ordination with State administrations. The Centre
will have oversight of IEC actions undertaken by the States and will monitor actions
undertaken by States and track the effects of such actions on the changing picture in India in
response to delivery of RCH services and consumer education.
On the other hand, Centre will develop plans to —



Undertake concerted communication campaigns to draw attention to such population
and maternal and child health issues which require changes in societal behaviour
norms.
™ • Undertake approaches to introduce newer concepts of issue (such as concerns within
■ gender sensitivity, adolescent health) to national attention.
• Draw together national expertise from Government, voluntary and private sectors in
the areas of research studies, training, health care, advocacy and management support.
• Converge the efforts of relevant Departments.
• Support a clearinghouse for issues related to population and women and child health
and other components of RCH, which will be a resource for research and materials
development within States and Districts.
• Enhance the capabilities of relevant staff within the Central Ministry.
The Centre will thus assume responsibility for development of appropriate capacities at State
level, development of capabilities within the Central unit to contract agencies for KAPB
studies, media tracking and evaluation and to support centrally sponsored mass media efforts
which address overarching issues within population and reproductive and child health.

PART-_U

THE RCH COMMUNICATIONS CHALLENGE
There are three principal components of the RCH programme:




Meeting Unmet need for Contraception;
Improving Maternal Health; and
Raising Chances of Child Survival.

Achieving improvements in maternal and child health, in meeting unmet need for
contraception and creating a need among couples with less than 2 children are seen as
milestones to ensure that India’s population is stabilized.

In order to achieve the goals of the RCH Programme, the communication
interventions have to introduce behavioural change by addressing social norms, cultural
pattern and create a supportive environment.

Matrix of Behaviour Change Objectives

RCH Issue

Indicators (objectives) of
Expected Behavior Change

Barriers to Behavior
Change: Communications
Challenges

Opportunities to trigger
change

Communications
Priority

Unwanted
Fertility

Arrest fall in contraception
use in some States ***

Social and religious disapproval.

Availability of easier, safer
methods

Inform and motivate
regarding
availability of both
spacing and terminal
methods, especially
in those states with
fall in use ***

a) Unmet
need for
contracepti
on

Perceived costs/risks of
Effective contraceptive
contraception
coverage by 75% couples **
Increased use of contraception Husband’s lack of support
among couples with less than and/or fertility preference
two children **

NSV for men

Reach out to men about
NSV and male
responsibility **

b) Unsafe
abortion

Drop in Illegal abortions *

Social stigma, fear and lack
of counseling/guidance

Improved husband-wife
communication

Focus on spacing
between first and
second child **
Widely publicize legal
provision and hazards of
illegal abortion **
Promote counseling

And reach out to
adolescents **
Address son preference *

End Illegal Abortions *

Ambivalence towards
further child-bearing

Promote gender
equality*

Promote responsible
parenthood*

RCH Issue

Indicators (objectives) of
Expected Behavior Change

Barriers to Behavior
Change: Communications
Challenges

Opportunities to trigger
change

Communications
Priority

Maternal
Health

Reduce Maternal Mortality/
Morbidity**

No perception of pregnancy
as a time for special care.
Skewed gender relations

Motivate service providers
through RCH'training
Reach out and involve
private practitioners

Communicate
essential ANC
schedule***
Communicate risks
and dangers of
pregnancy and
importance of early
registration***

a) High
Maternal
Mortality

At least 3 ANC visits during
pregnancy**
Reduce delivery by untrained
persons**

Inadequate knowledge of
risks during pregnancy
Care-seeking behavior not
internalized

Address RH issues with
women’s self-help groups,
MSS etc

Inform about
availability of ANC
and other services
and timings to
pregnant women,
husbands and other
members of
family***

b)High
Maternal
Morbidity

Universalize registration of
pregnancies in all districts*
Improve registration of
pregnancy in remote and
tribal areas*

Lack of information
regarding available facilities
and service delivery
Inadequate service delivery
staff and lack of motivation

Improved husband-wife
communication
Involvement of
community in primary
health care through PRI

Motivate service
providers, women’s
groups and other
community groups
to early registration
of pregnancy**

Strengthen Male
Involvement*
Improve maternal nutrition**
Reduce nutritional anemia
among pregnant women**

Lack of knowledge and
concern
Negative cultural norms and
dietary practices during
pregnancy

Address RH issues and
family responsibility to
men’s gatherings/groups

Build on men’s
approval of family
planning**
Reach out to young
unmarried men**
Counter myths and
negative cultural and
dietary practices**

c)
Adolescent
Reproducti
ve Health

Increase knowledge and
awareness on RH issues
among adolescents**
Delay age at marriage*

Cultural Norms

Non-formal education and
health camps for
adolescents

Improve knowledge
and awareness of
RH issues among
adolescents**
Engage community
on issues of early
marriage, women’s
health and status in
the family*

d) RTI/ STI
Care

Make RTI/STI a public health
priority among medical
practitioners**
Increase in number of cases
reported and treated*

Lack of knowledge and
perception of illness among
women
Indifference and
misapprehension among
medical practitioners

Peer education through
women’s groups
Address issues with
medical associations
Family Health Camps

Bridge the
knowledge gap
among private
practitioners***
Encourage husband­
wife communication
on RH issues**

RCH Issue

Indicators (objectives) of
Behavior Change

Barriers to Behavior
Change: Communications
Challenges

Opportunities to trigger
Change

Communications
Priority

Child
Health

Reduce/eliminate neo-natal
mortality (focus on girl­
child)***
Eliminate incidence of
polio***

Lack of information
regarding risk and failure to
recognize danger signs and
promptly seek care
Lack of information
regarding availability of
service
Lack of motivation

Care givers respond to
issues that relate to the
health of their children.

a) 1MR
rising in
some
districts

Reverse drop in 1MR***

Lack of information and
motivation
De-motivated staff

Inform and educate
mothers on risks and
danger signs and
availability of
services***
Persuade family and
community to end
unequal treatment of
girls and boys**
Motivate service
providers***
Motivate family and
community on child
survival risks and
availability of
essential services***

b) Drop in
immunizati
on
coverage^

Arrest drop in immunization
coverage***
Universalize registration of
births**
Increase percentage coverage
of measles immunization**

Failure to complete the
schedule within time-frame
Lack of information
regarding necessity of
registration

Widely publicize
information on
complete
immunization
schedule***
Motivate service
provider and
community to
register births in
remote (poor) areas*

c) Child
care,
especially
. new-born
care

Increased number of children
with severe ARI being treated
and reported**
Diarrhea treatment and
prevention***

*** Immediate

ARI not seen as risk to child
survival
Girls get less care and
attention than boys
Failure to hydrate sick child
adequately

** Medium term * Long term

Improve knowledge­
base of service
provider and
community
regarding risks of
ARI **
Communicate home­
based treatment of
diarrhea***
Address issue of
equal treatment to
girls and boys with
couples and
families**

xQtes on the Matrix
1 ■ Column 1 represents the broad areas of concern in the {National} RCH Programme.

2.

Based on the data from NFHS 1 & 2 and RCH Household Surveys the RCH
Programme objectives and/or expected behaviour change indicators are set down for
the broad areas of concern in Column 2.

3.

The Barriers to Behaviour Change and Opportunities to trigger Behaviour Change
(Column 3 & 4) are based on empirical evidence from various studies across the
country on prevalent social and cultural practices. Regional variations which may be
there have not been highlighted.

4.

An attempt has been made to order priorities for Communications in terms of
Behaviour Change that need to be addressed urgently (within one year) and those that
will require some more time to become effective (3-4 years). Certain societal,
normative issues like preference for sons and early marriage of girls need to be
addressed at a deeper level of social and cultural values which change slowly over a
long period of time.

5.

While the results of the Communications endeavour in the three cases may show up at
different points in time, the effort has to be initiated simultaneously. The
communications planners have to ascertain the relative cost-effectiveness of the
suggested interventions and allocate budgets and assign responsibilities for designing
messages and message delivery accordingly.

6.

While the National RCH Communications Strategic Framework has outlined the roles
of the Districts, States and the Centre, the behaviour change issues are to be addressed
at all levels. The Centre may be better placed to take up the long-term societal issues
or advocacy interventions (policy issues) through mass media in a cost-effective
manner. The States are more suited to address regional specificities and plan
campaigns accordingly. Similarly, Districts are in a better position to match
communications with service delivery (supply side factors) and reach out to
individuals, families and the community through IPC, traditional folk and other local
media channels, and, group interactions/processes.

7.

It is understood that all effort at different levels should support one another and there
should be no dissonance in the messages that go out from different sources.

8.

In the 5 States (Rajasthan, Madhya Pradesh, Bihar, Orissa and Uttar Pradesh) where
the problems are acute and urgent action is required, the Centre shall provide
additional financial and technical support in planning and execution of
Communications activities.

I

9.
This paper is based on discussions, research and other background material which is
available with MOHFW.

I 2-

Briefing Kit I
<S">

(

gfcg
teg

7

Population & Reproductive Health Facts on India

HOW DO I USE THE KIT?
What is advocacy? Advocacy is the promotion of public debate and the influencing of public
opinion on a particular issue on a sustained basis through various audiences and channels.

The United Nations Population Fund (UNFPA), fully endorses the principles and
recommendations of the Programme of Action of the International Conference on
Population and Development (ICPD), held in Cairo in 1994.The Cairo document, ratified
by more than 180 countries of the world, puts quality of life and welfare of individuals at
the centre stage of development.
UNFPA promotes and invests in reproductive health and population programmes and
encourages advocacy in these areas to multiply the positive impec . these programmes
on the quality of life for both men and women. The briefing kit prt . ed by vNFPA, Indie
can be used as in many situations. Here are some suggestions
a)

b)

For Elected Leaders:
i. Include the issues contained in the briefing kit in your ~
ii. Relate these issues to your constituencies
iii. Address them in your party's mandate
iv. Monitor them in your area of responsibility

ForTeachers/lnstructors in Adult Education:
i. Organise debates, essay competitions and group discussions around these
issues
ii. Propagate these issues among the teacher community
iii. Raise these issues during parent-teacher meetings
iv. Develop primers and material for neoliterates based on the information included
v.

c)

f)

Relate these issues to field-level coverage

For Policy-makers:
W
i. Assess whether or not the local policies/programmes address these issues

ii.
iii.

e)

in fact sheets
Generate discussions on these issues during group meetings in community

For Media Persons:
i. Understand the issues contained in the briefing kit
ii. Reflect these issues in your features (articles, electronic media stories, etc.)
iii.

d)

o sps oches

Initiate discussions on these issues with the community
Allocate more resources and attention to the issues mentioned in the kit

For Corporate sector:
i.
Include interventions for addressing these issues in welfare programmes
ii. Promote private sector participation through available channels
ForNGOs:
i.
Include advocacy initiatives/service delivery programmes on these issues in
ii.

organisation's mandate
Empower community in monitoring the progress

The key to successful advocacy is a solid basis of empirical fact. This
meets that need by summarising fact on key issues as they pertain to the
context.The kit serve as a quick introduction to many topics on population, reprod
health and gender. Each individual sheet in the briefing kit highlights, one SP®0'
t
m this broad area. Each sheet is designed to help people engaged in advoc y
marshall facts and figures in order to create convincing presentations.

CONTENTS
ICPD - The Programme of Action

Reproductive Health Approach

Quality of Care for Reproductive Health
Gender Inequalities and Reproductive Health
Family Planning
Safe Motherhood

Abortion
Reproductive Tract Infections

IMPORTANT NOTE
All these materials may be reproduced freely

Infertility
Demographic Trends
Population and Environment
Adolescent Reproductive Health

Male Responsibility

Trends in the Total Fertility Rate

United Nations
Population Fund

Message from Dr. Michael Vlassoff, UNFPA Representative, India
The United Nations Population Fund (UNFPA) is the world's largest multi-lateral funding agency
for population and development. The major share of UNFPA's assistance focuses on reproductive
health including family planning. UNFPA's assistance to India began in 1974 and has increased
continuously since then. India is the largest recipient of UNFPA assistance in the world. The
current programme proposes to spend $100 million during 1997-2002.

In line with the International Conference on Popui
1994. UNFPA emphasizes expanding choice to >r
indiviG rsis and couples over their entire life span. UNFPA-Supported p
national governments to operationalise the Programme of Action endor
I

ion and Development (ICPD) held at Cairo in
:si the changing reproductive health needs of
grammes are designed in collaboration with
id by the ICPD.

UNFPA recognizes that, with the ICPD paradigm shift, there is a need for a better understanding of reproductive health
issues, demographic trends and their linkages to sustainable development. Several issues impacting on reproductive
health status and quality of life require serious advocacy initiatives in order to mobilize society, change attitudes and
trigger appropriate actions.

The briefing kit in your hands is an effort towards meeting the need for information to build a better understanding of
reproductive health and population issues in the Indian context. Each fact sheet provides an overview of one specific
topic along with up-to-date information and a succinct analysis. Some comparative data from other countries are also
included. Hopefully, the fact sheets will stimulate a more informed debate on policy and programmatic options at many
different levels in Indian society.
UNFPA believes that good advocacy begins with good information. I sincerely hope that the kit will be useful in
broadening the participation of stakeholders in the crucial task of achieving population stabilization in India through
provision of quality reproductive health services.

New Delhi
July 11,2000

Michael Vlassoff
UNFPA Representative

international conference on population and development THE PROGRAMME OF ACTION
ICPD....
The International conference on Population and Development (ICPD) was held at Cairo, Egypt, during September
1994. Delegations from 179 countries took part in neyutriions to finalise a Programme of Action on population and
development for the next 20 years.

■presents the international consensus on population
■ ' - . '
)A recommends a!
. .
population and development objectives, including
both quantitative and qualitative goals that are mun . • ,
-.:ve and are of critical importance to these objectives.
Countries have been guided by the POA in planning appropriate policy changes and programmatic responses. In
nutshell the POA calls for:
a

Raising quality of life for all people through population and development policies and programmes that seek to
eradicate poverty, sustain economic growth in the context of sustainable development to achieve sustainable
patterns of consumption and production, and to develop human resources and guarantee all human rights
including the right to development.

a

Achieving equality and equity between men and women and enable women to realise their full potential, to
involve women fully in policy and decision-making processes, including establishing mechanisms for women's
equal participation and representation at all levels of political and public life, and enabling men to take the full
responsibility for their sexual and reproductive behaviour as well as in their social and family roles.

a

Supporting the institution of family, contributing to its stability and taking into account plurality of its forms;
promoting equality of opportunities for family members, especially women and children; and mobilizing socio­
economic support and more effective assistance to indigent families.

a

Facilitating demographic transitions in countries where there is imbalance between demographic growths and
socio-economic and environmental goals, so as to make progress towards stabilisation of the world population.

a

Striving to make reproductive health accessible through the primary health care system to all individuals of
appropriate ages as soon as possible and no later than 2015. This will require actions to increase accessibility,
availability, acceptability and affordability of health care services and facilities, with special emphasis on child
survival, women's health and safe motherhood, and HIV/AIDS prevention.

a

Fostering a more balanced distribution of population in urban and rural areas by promoting economic, social
and gender-equitable sustainable development.

a

Addressing root causes of migration, by taking appropriate measures with respect to resolution of conflicts,
promotion of peace and reconciliation, respect for human rights and territorial integrity and sovereignty, so that
remaining in one's country becomes a viable option for all people.

Stressing the importance of valid, reliable, timely, culturally relevant and internationally comparable population
data for policy and programme development, implementation, monitoring and evaluation.
Emphasising the importance of sustained national commitment for making population and development
programmes successful.
Increasing commitment to and stability of international financial assistance as well as domestic resources in the
field of population and development.

Promoting effecti'
in the discussions :
programmesrefe-' ■

-s between governments, NGOs
• ?. re design, im
development and



community groups and the private sector
. iination, monitoring and evaluation of

ICPD + 5: in 1999.t
rational community enjn
s?.r review of the Programme of
Action. The
<i!<en with a view ■.
.. .;ss made till date, examine the
obstacles remaining and produce practical re
at making the ICPD's twentyyears goals as reality. The five-year review showed that implementation of the recommendations
of the Programme of Action had made good progress. Many countries had taken steps to integrate
population concerns into their development strategies. A broad-based definition of reproductive
health had been accepted by an increasing number of countries and steps are being taken to
provide a comprehensive range of services. In many countries civil-society organisations are
contributing to the formulation and implementation of policies, programmes and projects on their
own or in partnership with Governments as well as the private sector. The five- year review also
emphasised the need for services for prevention and treatment of HIV/AIDS as an integral
component of reproductive health programmes at the primary health care level. To accelerate the
implementation, it was agreed that Governments should make every effort at the highest political
level to mobilise financial resources required from all sources.
A set of key actions for the further implementation of the Programme of Action was adopted by the
Special Session of the UN General Assembly and, in particular, added benchmarks in areas that
had not been specified with quantitative goals in the Programme of Action. These include:

A

A

At least 95 per cent of young men and women aged 15-24 years should have access to
information, education and services necessary to develop the life skills required to reduce
their vulnerability to HIV infection.
By 2005, where the maternal mortality rate is very high, skilled attendants will assist at least
40 per cent of all births, 50 per cent by 2010 and at least 60 per cent by 2015.
Reduction in the gap between contraceptive use and the desire to space or limit families by
at least 50 per cent by 2005, 75 per cent by 2010 and 100 per cent by 2050.

Stressing the importance of valid, reliable, timely, culturally relevant and internationally comparable population
data for policy and programme development, implementation, monitoring and evaluation.

Emphasising the importance of sustained national commitment for making population and development
programmes successful.

Increasing commitment to and stability of international financial assistance as well as domestic resources in the
field of population and development.

Promoting effective partnerships between governments, NGOs, local community groups and the private sector
in the discussions and decisions on the design, implementation, co-ordination, monitoring and evaluation of
programmes related to population, development and environment.

ICPD + 5: In 1999, the international community engaged in a five-year review of the Programme of
Action. The process was undertaken with a view to assess progress made till date, examine the
obstacles remaining and produce practical recommendations aimed at making the ICPD's twentyyears goals as reality. The five-year review showed that implementation of the recommendations
of the Programme of Action had made good progress. Many countries had taken steps to integrate
population concerns into their development strategies. A broad-based definition of reproductive
health had been accepted by an increasing number of countries and steps are being taken to
provide a comprehensive range of services. In many countries civil-society organisations are
contributing to the formulation and implementation of policies, programmes and projects on their
own or in partnership with Governments as well as the private sector. The five- year review also
emphasised the need for services for prevention and treatment of HIV/AIDS as an integral
component of reproductive health programmes at the primary health care level. To accelerate the
implementation, it was agreed that Governments should make every effort at the highest political
level to mobilise financial resources required from all sources.
A set of key actions for the further implementation of the Programme of Action was adopted by the
Special Session of the UN General Assembly and, in particular, added benchmarks in areas that
had not been specified with quantitative goals in the Programme of Action. These include:
x

*

A

At least 95 per cent of young men and women aged 15-24 years should have access to
information, education and services necessary to develop the life skills required to reduce
their vulnerability to HIV infection.
By 2005, where the maternal mortality rate is very high, skilled attendants will assist at least
40 per cent of all births, 50 per cent by 2010 and at least 60 per cent by 2015.
Reduction in the gap between contraceptive use and the desire to space or limit families by
at least 50 per cent by 2005, 75 per cent by 2010 and 100 per cent by 2050.

reproductive health approach
The Approach...
The International Conference on Population and Development
has, in its Programme of Action, adopted principles placing
individual needs and choices at the centre of the
reproductive health agenda. States are called upon to
observe the principles of gender equality and equity,
and women's empowerment while providing universal
access to reproductive health care without any form of
coercion or discrimination.
The reproductive health approach is central to the paradigm
shift. In essence, the approach:
a

Places individuals and couples (i.e. clients) at the centre of efforts
to improve family health. It focuses on assisting individuals to meet their personal reproductive goals. This
means people have ability to reproduce and regulate their fertility, women are able to go through their pregnancies
and bear children safely, the outcomes of pregnancies are successful in terms of the survival and wellbeing and
couples are able to have sexual relationships free of fear of pregnancies or contracting infections.

a

Emphasizes on provision of quality services in meeting essential reproductive health needs.

a

Focuses on decentralized planning and management, as operating at the local level will allow greater coordination
and cooperation across sectors, which is often not possible at the central level.

In operational terms the reproductive health approach entails...
a

Service delivery mechanisms that cater for articulated client's needs, not based on targets imposed from the top
or decided arbitrarily by the service providers. The emphasis is on bottom-up planning based on the client's
needs. Subsequently, monitoring implementation of these plans on the basis of selected indicators will help in
assessing the performance of service providers.

a

Establishing standards for provision of quality reproductive health services, measuring adherence, improving
quality, all working towards client satisfaction. It is envisaged that emphasis on quality will also boost utilisation
of services and thus meet unmet demand for health services. Clients' perspectives on quality should also be
taken into cognisance in order to foster accountability in the system.

a

Strengthening capacities for decentralised programme management. Devolution of financial and administrative
powers to the local level is already underway in the country. Decentralised programme planning, implementation,
monitoring and evaluation are likely to be more responsive to the needs of the clients, be more resource efficient
and be firmly rooted in the socio-cultural milieu, compared to top-down monolithic programme management
practiced in the past.This will also entail strengthening of programme management capacities. Right to information
and transparency in public systems is also likely to be fostered.

REPRODUCTIVE HEALTH APPROACH (Contd...)
Operationalisation of the reproductive health approach: concerns and priorities
x

District and facility-level public health management is quite weak in planning and budgeting. There is a multiplicity
of institutions at district-level to manage several schemes/projects and programmes.

x

Motivation to perform is considerably lacking. Measurement of quality is perceived by Government personnel to
be a threat.The morale of field functionaries is quite low. They do not feel as part of the process of change and
have little sense of ownership.

x

Implementation of service delivery plans pre-supposes adequate staff, buildings, equipment, drugs and other.
supplies. Decentralization should be coupled with authority to use available resources flexibly for better productivity.

x

Improvements in the reproductive health are probably best achieved by a mix of public and private efforts.
Subsidies should be targeted at the poor to make services affordable.

A

User fees are increasingly common in developing countries. While they can generate resources and spur efficiency,
these should be carefully evaluated and implemented with caution.

A

The State of Kerala has made the pioneering move to formally devolve 40 per cent of development funds in
favour of Panchayati Raj Institutions at the block level. There is need for more informal debate and mobilization
of the people around relevant issues so as to fully operationalize the various provisions of 73rd and 74th
constitutional amendments.

QUALITY OF CARE FOR REPRODUCTIVE HEALTH
Whither Quality?
Quality of care has emerged as a central issue in
reproductive health. The ICPD Programme of Action states
"Reproductive health programmes must make significant
efforts to improve quality of care". Access to good quality
reproductive health services has been seen as a key element
in enabling individuals and couples to attain a measure of
control over their health and for ensuring the well being of
their families. It is increasingly recognised now that quality
leads to client satisfaction. As a first step towards ensuring
quality, removing method-specific contraceptive targets has
been hailed as a turning point. The challenge to shift the
programme focus from merely increasing coverage to quality
is, however, formidable.

Commonly accepted as quality services are those services that meets the needs of clients. While the client perspective
focuses on individuals, the providers and managerial perspectives are equally important. Access for quality reproductive
health services should be also seen within the framework of reproductive rights.

What are the common concerns?
a

A critical reason for under-utilization of services is that clients perceive the quality of services to be too poor to
merit use. Perception of quality influences clients' decision-making regarding utilization or non-utilization of a
specific service from a particular source. As per the NFHS findings utilisation of antenatal services remains
abysmally low in many states. In the state of UP only 31 per cent pregnant women received any ANC outside
their home.
Another key component affecting quality is the attitude of the service providers. Insensitive treatment and
stigmatising behaviour on the part of service providers is a major barrier in utilisation of services. The attitude of
health functionaries is often patronising, distant or bordering on unfriendly, thus increasing the "psychological
costs" of services to unaffordable levels.

-*■

Many studies have shown that major reasons for not accepting contraception includes fear of side effects,
limited access, and lack of knowledge about contraceptives. Informed decision-making a hallmark of quality is
seriously compromised in such situations.

a

Frequency and duration of client-provider interactions also influence service quality. Any barrier (e.g., distance,
rushed provider, language) is detrimental to service quality. The usual lack of audio-visual aids during these
interactions diminishes the effectiveness of communication.

a

Quality of care is often considered unaffordable for programmes with scarce financial resources. However,
programmes lacking in quality are extremely costly, because they waste human and physical resources.
Investments in quality are actually cost-effective in achieving better health outcomes.

QUALITY OF CARE FOR REPRODUCTIVE HEALTH (Contd...)
Lack of basic facilities at the health-care institutions (e.g. water supply, cleanliness, and availability of toilets and
electricity) affects client satisfaction. Similarly, inadequate attention for ensuring privacy remains a major concern.
Technical knowledge and competence on the part of service providers is of crucial importance for achieving
better quality, as sound technical expertise leads to reduced incidence of side effects associated with particular
procedures/contraceptives.

Client follow-up mechanisms need to be in place for maintaining quality of care. Preliminary findings from the
NFHS II survey indicate that a significant proportion of children were only partially immunised because of high
drop out rates. This results in wasted resources and a false sense of protection among parents.

An ICMR multi-centre study in 1989 covering 398 Primary Health Centres in 199 districts revealed shortages of
female paramedics (19 per cent fewer Lady Health Visitors and 6 per cent ANMs), further compounded by their
being unevenly distributed with respect to population. Shortages of essential drugs ranged from 4 to 31 per
cent. There were poorly equipped labour rooms (25 per cent), operating theatres (16 per cent) and wards (54
per cent). Assessment of the family planning component revealed deficiencies in updating records (75 per cent),
in screening and preoperative care of clients (up to 72 per cent), in ensuring privacy (14 per cent) and sterilisation
of equipment (60 per cent).These findings reinforce the view that a large-scale provision of additional inputs is
required to address these gaps.
A study of sub-centres during 1996-97 in the state of Rajasthan indicated that 30 per cent of sub-centres are not
housed in the own buildings, 37 per cent were without electricity, 41 per cent without water supply and 57 per
cent without space for conducting deliveries.

Method-specific targets, coupled with variable client incentives, have been most significant hurdles in improving
the quality of family welfare services in the past. Lack of any appreciation for importance of quality of care in
public systems has resulted in violation of laid down standards in the past.

Failure to monitor and reward quality has been a major lapse in the family welfare programme. Non-availability
of standards, protocols, manuals and recording systems have contributed to non-measurement of quality.

Improvement in quality begins with a process of defining frameworks, setting standards, measuring deviations,
diagnosing causes of such deviations and taking corrective actions.

gender

inequalities and reproductive health
Despite the advances made by Indian women since Independence, the life of
an average Indian women from birth through infancy, childhood, adolescence,
marriage, motherhood and widowhood is a long battle against discrimination
and deprivation. The complex socio-cultural determinants of women's health
and nutrition have cumulative effects over their life time. Gender inequalities
in India stem from three important sources: differences in men’s and women's
economic roles (and power), cultural traditions restricting movement and
autonomy, and marriage and family practices.

The empowerment of women and the achievement of gender equality and
equity are pivotal for the improved reproductive health. Increasing access to
education, health and economic participation will lead to greater female
autonomy and thereby create an enabling environment for faster decline in population growth and accelerated socio­
economic development.

p

Gender Inequalities
One indicator used to assess women's status is the population sex ratio. The sex ratio in India has seen a downward
trend throughout the 20th century, reaching 927 woman per 1000 men in the 1991 census. There is a case of around
50 million missing females in India that needs explanation. Adverse sex ratio can be attributed to number of factors,
most striking being preference for sons in many areas of India. Determination of sex of the foetus for the sole purpose
of female foeticide (abortion of the female foetus) common in many parts of India despite being a criminal offence
under Prenatal Diagnostic Technique (Regulation and Prevention of Misuse) Act, 1994.
Discriminatory child-care practices in certain areas also leads to impaired growth and development of the girl child.
Education inequalities between females and males are pronounced. Though school enrolment rates are rising, high
drop-out rates for girls still continue to be a cause for concern. Girls have lesser chances of being admitted to school
and have higher chances of dropping out from school. Recent data show that 59 per cent of girls are retained in the
primary education, compared to 62 per cent of boys.

Although mean age at marriage for girls is rising, a significant number of girls are still married off below the statutory
age at marriage (i.e. 18 years) through arranged marriages. Women are forced to have children soon after marriage in
order to prove their fertility and their worth.

Adolescent marriage is synonymous with adolescent fertility. Teenage pregnancies are not safe. Adolescent mothers
are twice as likely to die from complications during pregnancy as are women 20 years or older.
Malnutrition, frequent pregnancies and infections contribute to a high maternal mortality ratio in India, estimated at 407
maternal deaths per 100,000 births in 1997. The extent of maternal mortality is an indicator of disparity and inequity in
access to appropriate health care and nutrition services for women.

GENDER INEQUALITIES AND REPRODUCTIVE HEALTH (Contd...)
Women and Violence
Violence against women is any gender-based act or conduct that results in, or is likely to result in, physical, sexual and
psychological harm or suffering to women. This includes threats of such acts, and all forms of coercion or arbitrary
deprivations of liberty in both public and private spheres. Available statistics from around the globe suggests that one
out of every three women has experienced violence in an intimate relationship at some point in her life.
J-

According to a survey during 1998, spanning seven Indian cities and covering both rural and urban populations,
45 per cent of women have been subjected to at least one incident of physical or psychological violence in theic
life time. Women are most at risk of violence from men they know.
"

-*■

Gender violence cuts across all socio-economic groups and regional variations.
Violence leads to high-risk pregnancies with adverse outcomes. Sexual violence also results in unwanted
pregnancies and sexually transmitted infections.

A

In India today:
One dowry death takes place every 102 minutes
A rape occurs every 54 Minutes
Molestation occurs every 38 Minutes
A crime against a woman occurs every seven minutes (National Crimes Record Bureau).

a

Nearly 7,000 complaints of domestic violence against women are reported annually in Delhi. Barely 10 per cent
of these complaints are translated in to first information reports.

a

The disability adjusted life years (DALY) of women in the age group 15-44 lost due to domestic violence ana|
rape is estimated to be 9.5 million years.

Violence against women impairs or nullifies the enjoyment by women of human rights and fundamental freedoms.

Women's Empowerment
Women's empowerment is the process by which unequal power relations are transformed and women achieve greater
equality with men. At the Goverment level, this includes the extension of all fundamental social, economic and political
rights to women. On the individual level, this includes the processes by which women gain inner power to express and
defend their rights and greater self esteem and control over their lives so crucial for positive reproductive health.

FAMILY PLANNING
Family Planning is a Rights Issue....
The reproductive rights framework recognises the right of men
and women to be informed and to have access to safe,
effective, affordable and acceptable methods of family planning
of their choice. These rights stem from recognition of the
basic right of all couples and individuals to decide freely and
responsibly the number, spacing and timing of their children
and to have information and means to do so. It is important
that quality reproductive health programmes are in place so
as to help individuals and couples in realisation of these rights.
Inaccessibility of quality services denies couples the ability
to achieve their personal reproductive intentions on one hand,
and on the other hand is likely to delay the goal of population
stabilisation, so crucial for improving the quality of life.

Unmet Demand
a

Unmet demand for contraception has been estimated to be 30 per cent. National level surveys (e.g., NFHS II)
indicate that unmet demand (currently married women who want no more children but are not using a method of
contraception), both for limiting and spacing, continues to remain high in many states. In the state of UP, 38 per
cent of couples have expressed unmet demand for limiting and nearly 18% want to postpone birth of their next
child for another two years, but are still not using any contraceptive method.

a

Nearly two in five couples in the reproductive age currently use a method of contraception. Amongst users, nineout of ten couples are protected by the female sterilisation method. As a result, young and low-parity women
remain unprotected from repeated and closely spaced pregnancies: only 16 per cent of women below 30 years of
age practice contraception.

a

Male participation in accepting responsibility for contraception is woefully negligible. Programme statistics show
that only 1.9 per cent of total sterilization acceptors adopted vasectomy in 1997.

Health Benefits
a

Reducing the number of unintended pregnancies promotes reproductive health mainly by reducing the number of
times a woman is exposed to the risk of childbearing in adverse circumstances.

a

Unintended pregnancies also affects children's health, because often these pregnancies occur disproportionately,
among women in high-risk categories including very young, the old, those with short pregnancy intervals, and
those with many births. About 37 per cent of live births occurred within two years of a previous live birth (1992).

FAMILY PLANNING (Contd...)
Access and informed decision making
Though there is nearly universal knowledge about limiting methods (e.g.,female and male sterilization), knowledge
about spacing methods is inadequate and patchy. Lack of knowledge breeds and perpetuates myths and
misconceptions.

Access to contraceptives appears to be limited, especially in rural areas. Non-availability of service provider
denies access to dependable sources of contraceptive supplies so crucial for certain spacing methods e.g., oral
contraceptive pills). Alternative service delivery systems (commercial, social marketing, community-based
distribution) are yet to make an impact in remote rural areas.
Follow-up care for family planning acceptors is extremely important, especially for spacing methods. Lack of
proper follow up, especially for the management of side effects leads to high rates of discontinuation.
Per cent of currently married women (15-49 years)
using modern contraceptive methods
State

Contraceptive
Prevalence Rate

Oral Pill

IUD

Condom

Female
Sterilization

Male
Sterilization

40.3
66.6
24.5
59.0
59.6
53.8
52.0
47.5
28.1
44.3

1.5
9.2
1.1
1.5
0.5
9.5
0.3
0.9
1.2
1.0

1.2
1.4
0.5
3.1
0.6
5.6
2.5
1.9
1.0
0.8

3.1
2.9
0.7
3.5
0.7
1.5
1.5
4.9
4.2
2.9

30.8
32.0
19.2
43.0
52.7
22.4
45.2
27.8
14.9
35.7

1.5
1.8
1.0
2.3
4.3
2.4
0.8
0.4
0.7
2.2

Rajasthan
West Bengal
Bihar
Gujarat
Andhra Pradesh
Sikkim
Tamil Nadu
Goa
Uttar Pradesh
MadhyaPradesh

Source: (NFHS-2 Survey)

Expanding Choices
Experiences from other parts of the world indicate that introduction of a new contraceptive method increases
overall contraceptive use significantly. In general, the range of contraceptives should accommodate the diverse
needs of limiters, spacers, breastfeeding mothers and those requiring prevention of sexually transmitted diseases.
No scalpel vasectomy is new technique for performing vasectomy. The incidence of side effects and complications
is much less as compared to conventional vasectomy. No stitches are required and the procedure is faster and
less intrusive.
Use of oral contraceptive pills, as emergency contraception appears safe and effective for women who need a
backup to regular contraceptive use. Though not a substitute for regular contraception, emergency contraception
is an appropriate choice for women who are victim of coercive sex, who have occasional sex or who experience
rupture or slippage of condoms.

SAFE MOTHERHOOD
A Neglected Tragedy
Worldwide nearly 600,000 women die every year as a result of complications arising out of pregnancy and childbirth.
The tragedy is that these women die not from diseases but during the normal life enhancing process of procreation.
Safe motherhood is seen as a human rights issue and there is increasing recognition that it is possible to reduce
maternal mortality significantly with limited investment through effective policies and programmes.

Problem at a glance
x

It is estimated that India, which contains about 15 per cent of the world's population, accounts for nearly 20 per
cent of maternal deaths. Nearly 1,12,000 maternal deaths are estimated each year in India. Improved maternal
care could save the lives of these women and allow them to lead productive lives.
Four mothers die for every 1000 live births each year in India. There are vast regional and rural-urban differences.
For example, in the state of Uttar Pradesh seven mothers die for every 1000 live births whereas in Kerala the
ratio is only one fourth as high.

Selected Maternal Mortality
Ratios in India

The Maternal Mortality Ratio (MMR) is defined
as the number of maternal death (during
pregnancy, childbirth and the purperial period)
per 100,000 live births. By comparison MMR is
6.1 in Japan, 8.3 in USA and 5.4 in Germany.

Kerala

87

Bihar

451

Madhya Pradesh

498

Rajasthan

607

Sri Lanka

30

Uttar Pradesh

707

China

115

Orissa

739

Thailand

200

Pakistan

340

Maternal Mortality Ratios
In Asia

Indonesia

390

India

407

Bangladesh

850

Nepal

1500

Every five minutes a woman dies as a result of a complication attributable to pregnancy and childbirth in India.
It is estimated that for each woman, who dies as many as 30 other women develop chronic, debilitating conditions,

which seriously affect quality of life.

JE>
SAFE MOTHERHOOD (Contd...)
Determinants of the tragedy
Lack of access and inadequate utilisation of essential emergency obstetric services is a crucial factor. In India,
skilled personnel attend only 35 per cent of deliveries. In some districts only 5-10 per cent deliveries are
attended by skilled personnel.
It is estimated that nearly 7 million induced abortions takes place annually in India. For each legal abortion, it is
estimated that another 10 illegal abortion take place but go unrecorded. Studies indicate that nearly 12 per cent
of all maternal deaths are attributable to abortion-related complications. Anemia is the underlying cause for 20
per cent, toxemia for 13 per cent, purperial sepsis for 13 per cent and bleeding during pregnancy for 23 per cent£
maternal deaths.
Average weight gain during pregnancy is around 6.5-7 kg, in India, while average weight gain for women in
Thailand and Philippines is close to 9 kg, and 12 kg in developed countries. Anemia among women in India is
rampant. For instance, around 55 per cent of women were found anemic in the state of Madhya Pradesh in one
recent survey.

Maternal mortality is high in those states where fertility is high, simply because women there are having more
births. Maternal mortality is also high in those states where children are born to very young women to older
women and to women who have multiple, closely spaced pregnancies.
The lack of male participation results in poor utilisation of prenatal, natal and postnatal services by pregnant
women. Several reports indicate that men do not give much importance to the health problems of women. Either
they are unaware about the importance of seeking preventive care or they are simply indifferent.
Women need support in obtaining access for essential obstetric care. Raising awareness of the need for women
to reach emergency care without delay if complications arise during pregnancy is particularly critical. Studies
have shown that in 25 per cent of maternal deaths family members were not aware of the seriousness of
woman's condition and took no action towards obtaining assistance.
a

A diet that provides sufficient calories and micro-nutrients is essential for a pregnancy to be successfully carried
to term. Proper nutrition will reduce the likelihood of a pregnant woman experiencing serious complications
during pregnancy and childbirth.

Prevention of unwanted pregnancy through effective contraceptive use is the most cost-effective of all interventions.
Enabling women to choose whether, when, and how often to have children is central to safe motherhood.
Reducing the likelihood of a woman getting pregnant by providing quality family planning services would make
a significant impact on maternal mortality.
Prevention and management of unsafe abortions are key interventions for safe motherhood. All women deciding
in favour of terminating their pregnancy as per the provisions of the Medical Termination of Pregnancy act have,
access to quality abortion services.

Empowering Women
Strategies to empower women and enhance their choices need to be put in place. This means promoting women's
understanding of their needs and assertion of their rights in general and reproductive rights in particular, fostering
community education about pregnancy and childbirth, and making health services more responsive to the needs of
women. Such interventions will go long way in helping women seek services with confidence and without delay.

abortion
Complications attributable to unsafe abortion are a major public
health problem facing women in developing countries. Unsafe
abortions are a leading cause of maternal mortality and contribute
significantly to the maternal morbidity. In India, abortion is legal
and women are legally able to access safe abortion services
from trained medical providers at certified facilities.

What is abortion?
Abortion is termination of pregnancy before the foetus becomes
viable or capable of living independently (extra-uterine), which
has been defined by the World Health Organization as twentytwo weeks menstrual age. Abortion may be spontaneous and induced. Spontaneous abortions, (sometimes called
miscarriages) occur at the rate of approximately one in every fifteen pregnancies. Induced abortion is a deliberate
termination of pregnancy, and may be legal or illegal.

Magnitude of problem
While the prevalence of abortion in India is unknown, the most widely cited figures suggest that around seven
million abortions taken place annually.
As per service statistics compiled by the Government of India, about one million abortions are performed annually
under the MTP act.
Around six million illegal abortions are performed by a variety of medical and non-medial practitioners, most of
whom are unqualified/untrained and induce pregnancy termination at uncertified places using dubious methods.
Illegal providers can include trained doctors and nurses, "Indian Systems of Medicine" practitioners, traditional
birth attendants and village health care workers and even elderly women in villages.
The six states that have highest numbers of abortions mirror the states that have fewest facilities as per norms.
These states are Assam, Bihar, Madhya Pradesh, Orissa, Uttar Pradesh and West Bengal.
Indian women seek abortion throughoui the reproductive period. Adolescents, both married and unmarried seeks
abortion services in significant numbers. A substantial number of unwanted pregnancies among adolescent’s
result from forced sexual intercourse.

As adolescents have less access to reproductive health information and services compared to older married
counterparts, they are more likely to delay recognizing pregnancy and seeking care. They are more likely to seek
care from unsafe providers.
India’s second trimester abortion rate, i.e. those of foetuses 12 to 20 weeks old, is thought to be among the
highest in the world. It is estimated that over 10 per cent of all abortions in India are second trimester abortions.
Women in the second trimester are more likely to access illegal providers as it is difficult to obtain legally. The
risk of complication following second trimester abortion is much higher for physiological reasons.

ABORTION (Contd...)
x

Common methods of abortion used by the illegal providers include both vaginal and oral methods. Sticks, roots,
herbs and foreign bodies are introduced in the vagina to induce abortion. Orally ingested abortificients include
indigeneous and homeopathic medicines, choioroquine tablets and high dose progestrogens and estrogens, papaya,
carrot seeds, etc. Abdominal message, witchcraft and heat application is also used to induce abortion.

-*■

The main complications that can occur during induced abortions are excessive bleeding due to injury of the
genital organs and incomplete abortion. Post-abortal infections are also very common especially if abortions are
induced in unhygienic settings. Where safe abortion services are not available or accessed, treating abortionrelated complications may consume a significant amount of the available health service resources including
medical staff time and supplies.

x

In the Indian cultural context, sexuality, reproduction and abortion are sensitive issues and are not discussed
openly. It is widely believed that abortion is a sin and even today only a small proportion of Indians are aware that
abortion is legal. According to a ICMR multi-centric study, 31 per cent women in Tamil Nadu and 75 per cent in
Uttar Pradesh and Haryana believed that abortion is illegal.

The Reasons for Seeking Abortions
The reasons why women in India abort are many and varied. The principle underlying reason, of course, is unwanted
pregnancy.
x

Financial reasons, too many children, becoming pregnant after too short a birth interval, health problems during
pregnancy, pregnancy at older age, becoming pregnant too soon after marriage, suspecting husband's infedility,
extra-marital pregnancy and pregnancy on account of rape or incest are all conditions that can lead to unwanted
pregnancy.

x

Sex-selective abortions are also commonly sought. Strong son preference and easy availability of cheap prenatal
diagnostic techniques have resulted in increased use of prenatal sex-determination tests even among rural poor.
Many private clinics offer both sex determination and abortion services. Despite the Prenatal Diagnostic Techniques
Regulation and Prevention of Misuse) Act 1994, the practice is rampant.

It is clear that for the most women, the most proximate determinant of unwanted pregnancy is lack of access to
appropriate contraception.
Contraceptive failure can also lead to unwanted pregnancies, and these can be aborted legitimately. However,
reports indicating a high proportion of women requesting on account of contraceptive failure may well be
exaggerations, as contraceptive failure is one of the reasons whereby a women can legally request an abortion.

reproductive tract infections
Reproductive tract infections (RTIs) including sexually transmitted infections
(STIs) were not recognised as a problem until recently. Research conducted in
the India over the past decade to document the magnitude of reproductive
morbidity in India, has made these infections more visible and brought them
onto the reproductive health agenda. Concerns about the spread of the HIV
epidemic and recognition of the role that RTIs plays in the transmission of HIV
have also drawn attention to the problem. Men also experience RTIs, particularly
STIs, but the prevalence and the consequences for women are much more
severe.

What are Reproductive Tract Infections?
RTIs include a variety of bacterial, viral and protozoal infections of the lower
and upper reproductive tract of both sexes. Many RTIs are sexually transmitted. RTIs originate in the lower reproductive
tract and in absence of treatment can spread to the upper reproductive tract (i.e. the womb, the fallopian tubes and the
ovaries).

What are the common causes of RTIs?
a

Latrogenic infections, which are related to inadequate medical procedures, such as unsafe abortions, unclean
deliveries and other diagnostic and therapeutic procedures.

a

Endogenous infections, which may be associated with inadequate personal, sexual and menstrual hygiene practices.

a

Sexually transmitted infections (STIs)

Magnitude of the problem
Nationwide estimates for the prevalence of RTIs are not available in India. However an annual incidence rate of 5 per
cent is generally accepted. All community-based prevalence studies that have been conducted in India indicate that
rates of RTIs are very high.
a

In a study conducted among women in two villages in Maharashtra, the prevalence of clinically diagnosed RTIs
was 46 per cent of the women surveyed.

a

In other studies conducted in four different sites (rural West Bengal and Gujarat, and urban Baroda and Mumbai),
the prevalence of RTIs ranged from 19 to 71 per cent.
In a study conducted in rural Karnataka, over 70 per cent of women had clinical or laboratory evidence of RTIs.
Men suffer from RTIs as well. A substantial proportion of men does have problems such as uretheritis and genital
infections.

REPRODUCTIVE TRACT INFECTIONS (Contd...)
Consequences
There is substantial unmet need among women and men for the treatment of these infections. There is a culture of
silence regarding RTIs, as women do not discuss such illnesses even with their husbands. Similarly, access of Indian
women and men to non-stigmatising health services in the public sector is a major problem.

Untreated, RTIs and / STIs take their greatest toll through complications resulting from the spread of microorganisms
from the point of infection to another part of the reproductive tract or other organs of the body.
A major complication, infertility is a source of psychological distress and family disruption.

-*■

Other complications, such as ectopic pregnancy (pregnancy outside the uterus) and cervical cancer, represent
significant causes of mortality.

x

Some infections may cause fetal wastage or affect child survival by causing pre-term deliveries, low-birth weight
babies or by infecting newborns during delivery.

The relationship between RTIs and HIV/AIDS
A

First, RTI and HIV infections are associated with the same risk behaviour that is unprotected sexual intercourse
with multiple partners. Thus, the same measures that prevent STIs also prevent sexual transmission of HIV.
Secondly, the presence of RTI has been found to facilitate the acquisition and transmission of HIV. A ten fold
increase in the risk of HIV transmission has been associated with infections that cause genital ulcers, such as
syphilis, chancroid and herpes. The risk associated with diseases causing discharge, especially gonorrhea,
chlamydial infection, trichomoniasis and bacterial vaginosis, is increased by a factor of four.

x

There is mounting evidence that some RTI pathogens are more virulent in the presence of HIV- related immuno­
deficiency.

Prevention of RTIs
RTI prevention intervention requires three levels of action:
<*■

Primary prevention - preventing the acquisition of infection through safe sex practices, clean deliveries, abortions
and other procedures and genital hygiene.

-*■

Secondary prevention - early diagnosis and treatment of established infections, screening for asymptomatic
infections and mass treatment approaches.

A

Tertiary prevention - Minimizing the adverse consequences of such infections.

infertility
Women's status in India still primarily rests on her success in bearing children. Infertility is
almost always considered to be wife's problem - as the possibility that the husband
is not fertile is seldom considered Infertility is usually a major disaster for the
women who may face divorce and ostracisation as a result. Since the
reproductive health approach envisages helping couples in achieving their
reproductive intentions, it is appropriate that efforts are made to address
the problem of infertility.

What is Infertility
Infertility refers to a diminished (or absent) capacity to produce offspring where the
possibility of achieving conception is not completely ruled out. A couple is considered infertile if one year of
unprotected coitus of average frequency does not result in pregnancy.
Primary infertility occurs when a woman has never conceived, despite cohabitation and exposure to pregnancy.

-*•

Secondary infertility occur when a woman has previously conceived but is subsequently unable to conceive
despite cohabitation. An extended definition of infertility includes women who can conceive but cannot carry a
pregnancy to full term, that is, women who suffer repeated or habitual spontaneous abortions.

Magnitude of Infertility
Globally, the number of infertile couples is estimated to be 60-80 million. Between 8 and 12 per cent of couples around
the world have difficulty conceiving a child at some point in their lives. The prevalence of primary infertility in India is
given as 3 per cent and secondary as 5 per cent. Thus currently there are estimated to be 8-10 million infertile couples
Un India.

Causes of Infertility
Around 38 per cent of infertility is due to female causes, 20 per cent due to male causes and 27 per cent due to causes
in both partners. No clear-cut cause can be ascertained in the remaining 15 per cent of couples.
A common cause of infertility in women is occlusion of the tubes that carry the egg from the ovary to the womb. The very
high prevalence of asymptomatic and untreated reproductive tract infections in women results in scarring of the tubes
leading to obstruction. Tuberculosis of genital organs is also very common in India which results in tubal occlusion. If
proper cleanliness is not observed during abortion or after delivery, disease-causing germs migrate to the womb and
reach the tubes which may also cause occlusion.

Worldwide, there seems to be a core of about 5 per cent of couples who suffer from anatomical, genetic, endocrinological
and immunological problems that cause infertility. Hormonal levels also influence the production of eggs in the women
and any disturbance in hormonal production leads to an-ovulatory cycles, when the egg is not produced and/or released
from the ovary. Sometimes congenital abnormalities affecting the reproductive organs may also impact on the fertility
status of women.

........... )
INFERTILITY (Contd...)
Knowledge of the male contribution to infertility lags behind knowledge of the female contribution. The leading causes
include genital tract infections, varicocele, testicular atrophy and hormonal abnormalities.The causes of male infertility,
as reported in WHO studies, show that in India as many as 73 per cent of infertile men had no demonstrable cause of
infertility. Infections in the prostate gland was the most common cause of infertility (8.8 per cent).
Perceived causes of infertility are different. According to a community-based study in rural Gujarat, women are usually
blamed for infertility. Excessive "heat' in the body, consumption of "hot food", haunting by evil spirits, the evil eye, prior
use of contraceptive methods and Karma from past lives result in infertility.

Influencing Factors
Factors known or strongly suspected to affect the probability of conception include:

A

Age of the woman: age effects do not begin until a woman reaches her late 30s.

x

Lack of understanding of reproductive biology: Coital timing and frequency can affect the probability of conception.

*

Exposure to heat: Men working in occupations where a lot of heat is generated or wear tight undergarments [may
experience diminishing the quantity and motility of sperms. Exposure to potentially toxic substances in the diet
or environment such as arsenic or pesticides, work in the semi-conductor industry, mining, and exposure to lead
are suspected contributors to infertility.

There may be societal pressure on young couples to prove fertility immediately after marriage. Sometimes the
couples seek treatment from self-styled experts in infertility management, only leading to serious complications
which may render them infertile for rest of their lives.

Socio-cultural factors: for example, close consanguine marriages
A high level of infertility may often drain the limited resources of the health care system. However, many conditions
contributing to infertility are preventable. Foremost among these is preventing sexually transmitted diseases. Unfortunately,
men seldom feature in investigations for the management of infertility. Although there is a proliferation of new reproductive
technologies promising "test tube babies", the simpler option of adoption is yet to become popular.

W? '''

Under the MTP Act, termination of pregnancy can be sought under the following conditions:
Termination of Pregnancy is permissible up to 20 weeks duration, if opinion is formed by the one registered
medical practitioners( for pregnancies up to 12 weeks) and by two registered medical practitioners (for
pregnancies up to 20 weeks) in good faith:

A
a

a

continuation of pregnancy would involve a risk to the life of the pregnant women or grave injury to
her physical/mental health.
there is substantial risk that the child would suffer from physical or mental handicaps.
pregnancy resulting from rape or contraceptive failure.
actual or reasonable foreseeable socioeconomic environment could lead to risk of injury to health
of mother.

Furthermore, the procedure shall not be performed in any place other than a hospital established or
maintained by the Government or a clinic approved for this purpose.

Why women seek illegal abortions?
a

a

a
a

a

Ignorance about dangers of unsafe abortions.
Urge for secrecy due to stigma attached to abortions.
Lack of access to certified facilities.
Lack of privacy and confidentiality.
Insistence by service providers to accept family planning as a condition for performing abortion.

Sometimes women have no choice about the provider. Inadequate care, lack of privacy and confidentiality
drive many women to seek abortion services from illegal sources.

DEMOGRAPHIC TRENDS
India's population has crossed one billion on May 11,2000. The population of India quadrupled during the 20th century.
Though there has been a slight decline in population's growth the rate in the decade 1981-90, as compared to the
previous decade, it was much less than expected. The growth rate estimated for 1997 is 1.83 per cent.
India consists of 25 states and seven union territories.The states vary enormously in size and population. At one end of
the spectrum is the mountainous state of Sikkim with a population of 0.47 million in 1996, and at the other end, the state
of Uttar Pradesh with an estimated population of 160 million. There are only four other countries in the world - China,
USA, Indonesia and the rested India itself-which have populations that exceed the population of Uttar Pradesh. The
states vary not only in their geographical size and population count but also in terms of population density, socio­
economic conditions, cultural practices, social norms regarding marriage, the status of women in society, and many
other factors that influence the living conditions of the people, especially the reproductive health of women, and men, of
children.

Fertility Scenario
a

a

a

a

The crude birth rate has been declining slowly in India. For 1998, CBR has been estimated to be 26.4 births per
1000 population, down from 36.9 in 1971.
The total fertility rate(TFR), which represents the average number of children a woman would bear if she experienced
current fertility rates throughout her reproductive years is estimated at 3.3 children per women. In 1971 it stood
at 5.2 children per women.
Child-bearing in India is concentrated among younger women. More than three fourths of total fertility is contributed
by mothers aged 15-29 and 23 per cent is accounted for by births to adolescent women aged 15-19.
There are wide variations in fertility levels and trends among the states (see graphs). Using 1997 SRS data, Tamil
Nadu (2.0), Kerela (1.8), and Andhra Pradesh (2.5) have TFRs below 2.5 children per women, i.e., close to the
replacement level of fertility (2.1). Uttar Pradesh (4.8) has the highest fertility among the states of India.
The median interval between births is 32 months. One in every eight birth occurs within 18 months and 27 per
cent occurs within 24 months. These are high-risk pregnancies which lead to depletion of the mother's body, lowweight births and higher levels of infant mortality.

Age at Marriage
a

Marriage is an universal phenomenon in India. Nationally, 39 per cent of women aged 15-19 and 95 per cent of
women age 25-29 are married.The percentage of women in 15-19 married is more than 50 per cent in Bihar and
MP as compared to 3 per cent in Goa.

a

The mean age at marriage has increased steadily over time in India 16 years in 1961 to 20 years in 1992-93 for
females and from 22 years to 25 years in the same period for males.
According to the Child Marriage Restraint Act of 1978, the minimum legal age at marriage in India is 18 years for
women and 21 years for men. A large majority of women are not aware of the legal minimum age at marriages and
child marriages continue to take place in rural India in large numbers. According to a 1992 survey, at age 15-19
more than 50 per cent of women in Madhya Pradesh and Bihar were already married, compared with only 3 per
cent of women that age in Goa.

a

Infant Mortality and Child Mortality Rates
Infant mortality refers to the probability of an infant surviving up to age one year.The IMR declined in India from
101 per thousand live births during 1978-82 to 72 in 1998.
The infant mortality rate is higher in rural areas than in urban areas and declines sharply with increasing education
of the mother

Infant Mortality Rates, 1998 (infant deaths per 1,000 live births)

Rural

Urban

Total

India

77

45

72

Tamil Nadu

58

40

53

Uttar Pradesh

89

65

85

West Bengal

56

41

53

Madhya Pradesh

103

56

97

Kerala

15

17

16

Source: SRS 1998

-*•

The child mortality rate (deaths of children aged 1-4 age group per 1000 children) has declined to 23 in 1997
from 52 in 1971. Despite this decline, one in every nine children in India dies before reaching age five.
Mortality risks are higher among infants born to women under age 20 and where birth intervals are less than 24
months.

Contraceptive Prevalence
x

(

Knowledge of family planning in India is still from being universal. Although knowledge of one contraceptive
method (usually sterilization) is nearly universal, general knowledge of say four or more methods is still very low.

Knowledge of sterilization is high, but knowledge of modern non-permanent spacing methods (IUD, pills, injectables
and even condoms) is surprisingly low. For instances, in the 1999 NFHS-2 survey in Andhra Pradesh, only 74
per cent of women knew about IUDs, 78 per cent about oral pills and 75 per cent about condoms.
a

Almost one-quarter of currently married women do not know any modern temporary methods. Knowledge about
where to obtain contraceptives is also very limited.

x

In India 44 per cent of currently married women aged 15-49 practice family planning.
Despite women's strongly expressed desire to space their children, modern spacing methods are still not popular
because of low effective access to them and poor images.
If the current unmet need for contraception -which is around 30 per cent- can be met through programmatic
interventions, then India’s total fertility rate can be brought to 2.1 children per women (replacement level) by
2010.

x

Worldwide, the number of cities with a 1-5 million inhabitants increased from 75 in 1950 to 327 in 1995 and is
expected to reach 463 by 2015. In India, in 1991 there were 19 such cities. In 2015 there will be 22 cities of this
size. Eight cities will be over five millions by 2015 in India.

Population size and Growth
The following table depicts the UN projections regarding the age composition of population in a few selected countries.
India still has a young population, lowering its productive potential.

Age Composition (percentage) of selected populations in 2000
Population aged 0-14

Population aged 15-59

Population aged 60+

India

33.3

54.1

12.6

China

24.9

58.2

16.9

Brazil

28.8

58.3

12.9

USA

21.5

49.6

28.9

Germany

15.5

44.9

39.6

Source: World Population Prospects, United Nations (1998)
If current trends continue, India may overtake China in 2045 to become the most populous country in the world.

UN Population Projections for 2000 and 2050: India and China (billions)

Low variant projection

Medium variant projection

High variant projection

India (2000)

1.01

1.01

1.02

India (2050)

1.22

1.53

1.90

China (2000)

1.28

1.28

1.28

China (2050)

1.25

1.48

1.55

Source: World Population Prospects, United Nations

POPULATION AND ENVIRONMENT
The population-environment linkage is not a simple relationship, but a complex,
multi-dimensional one. Population acts through such variables as social
organisation, government policy, dominant technology and personal
consumption behaviour.The connections are complex, indirect, and
variable by location and time.

India's population is expected to be one billion by May 2000. It
took sixty years for the population to double from 1901 to 1961.
The next doubling took little over thirty years. This clearly implies
that the Indian population has grown exponentially in the last few
decades. If current trends continue, India may overtake China in
2045 to become the most populous country in the world. The large
population base continues to challenge and constrain efforts for sustainable
development. India's current annual increase of population of almost 16 million is large enough
to neutralise efforts to conserve the resource endowment and environment.
Let us examine the impact of population growth on natural resources highlighting population and environment linkages.

Water Resources
About 200 million people in India do not have access to safe drinking water and nearly 1.5 million children under
5
die each year due to water-borne diseases. The country loses 200 million person-days of work each year
because of water-borne diseases.

Eighty per cent of domestic water demand is met through ground water sources. There are more than 8.5 million
electric and diesel pumps drawing ground water across the country. Water tables have been falling in many areas
of India. Falling water tables increase the salinity, arsenic and fluoride pollution rendering water unsafe for
drinking purposes.
There are reports that ground water resources in some districts of West Bengal have been contaminated with
arsenic. Survey findings from the affected districts indicate that about 1.75 million people consume arseniccontaminated water and around 0.2 million were suffering from arsenic-related diseases.
The impact of habitation on contamination of water reservoirs is very well documented, leading to an increased
burden of morbidity and mortality in communities served by these water sources.
Rapid industrialization is considered to be central to economic development and improved prospects for human
well-being. Routine discharge of effluents from industries in to water sources, however, have severe consequences
on quality of water.

Demand for water is increasing rapidly due to agricultural, industrial and population growth.The average consumption
of water per person is now 680 cubic meters per year for all uses. This is projected to double by the year 2050.

POPULATION AND ENVIRONMENT (Contd...)
Forests
x

In the decade of the 1980s, India lost forest cover at the rate of almost 1.5 million hectares per year. Currently no
more than 10-15 per cent of country is forested and much of this remaining forest is degraded.

x

The per capita forest availability is only 0.08 hectares in India which is very low compared to situation in other
countries - Indonesia 0.85 hectares, Malaysia 1.45 hectares and United States 1.2 hectares.
Indigenous populations, earlier farming in villages, have shifted from fertile to the fragile areas for cultivation due
to severe pressures on land.

A

Dependence on forest areas for household fuel and timber needs, and supplementing income by sale of fuel wood
and other minor forest produce has caused biotic pressures. Women have to spend long hours in trekking for fuel,
and other daily needs.

Land Resources
x

With a growing population, the pressure on land is intense in India. With 16 per cent of world population, India has
just have 2.4 per cent of world land area. As the rural population grows, average farm size falls considerably. The
population density has increased from 77 in 1901 to 274 person per square kilometer in 1991.

-*>

The average size of land holding in India is shrinking. The average size of all land holdings has gone down from
2 hectares in 1976 to 1.57 hectares in 1990.

Average size of land holding In India (Hectares)

A

1976

1980

1985

1990

2.00

1.84

1.69

1.57

Pesticides use has risen constantly in India and nearly 70 per cent of pesticides used in India have been banned
or severely restricted for agricultural use in other countries.

Energy
a

40-50 per cent of total energy consumption in India is accounted for by households. The bulk of the energy
consumed by households consists of such traditional fuels of fuelwood, animal dung and crop residues, which
contributes to domestic air pollution and impacts on health.

Air
a

a

Quality of air has deteriorated considerably in India's urban areas as population has grown at a rapid pace.
Inhalation of polluted air has serious health effects, including respiratory, cardiac and nervous disorders.
In most of the 23 India cities with a million plus population, levels of suspended particular matter are dangerously
higher than the limits recommended by WHO. Vehicles are a major source of pollution.

ADOLESCENT REPRODUCTIVE HEALTH
Adolescents constitute an important segment of society.
Yet until recently, the special needs of this group have not
been sufficiently addressed. There is increasing recognition
now that reproductive health needs of the adolescents have
to be articulated in terms of information and services so
that they can make informed choices leading to improvement
in their health status.

Who are adolescents?
Adolescence is a period of physical, psychological and social
maturity from childhood to adulthood extending from the
onset of puberty to the attainment of full reproductive
maturity. "Adolescence" has been defined as including those between 12 and 19 years of age, "youth" as those
between 15 and 25, and "young people" as a term that covers both age groups. Adolescent reproductive health refers
to physical and emotional well being of adolescents and includes their ability to remain free from unwanted pregnancy,
unsafe abortions, sexually transmitted infections including HIV/AIDS and all forms of sexual violence and coercion.

Why the focus on adolescents?
a

In India, adolescents account for one fifth of the population. With an estimated 200 million population in this age
group, constitute a significant group meriting separate attention. Adolescents represent a major potential human
resource for the overall development of a nation.

a

In the past, adolescents have been largely neglected in both health and family planning programmes. Most
programme interventions are aimed at married adolescents. The needs of unmarried adolescents are not recognised
and hence not catered for.

a

Actions taken during adolescence can affect a person's life, opportunities, education and health status.

Adolescents in India : Issues at glance
In India, the legal age at marriage is 18 years for females and 21 years for males. Nonetheless, early marriage
continues to be the norm. There is some evidence of decline in adolescents marriages, but regional variations
continue to persist. In the states of Rajasthan, Bihar, Madhya Pradesh and Uttar Pradesh more than 50 per cent
of girls are married before they are 16 years old. On the other hand, the increase in the age of marriage, despite
regional differences, has led to an extended period of adolescence, leading to a new set of concerns related to
sexual norms and behaviour.
Adequate nutrition is critical for adolescents. The major measure of nutritional or health status is the daily
average intake of energy and proteins against the recommended daily intake (RDI). While all ages and both sexes
fall short of the RDI, the difference is greater for adolescent girls, suggesting the continuation of the bias that
begins even before birth. The most visible manifestation of nutritional deficiency is the high prevalence of anaemia
and stunting among adolescent girls. The situation is worsened with pregnancy and often results in obstetric risks
and reproductive failures.

ADOLESCENT REPRODUCTIVE HEALTH (Contd...)
-*•

Adolescent fertility rates are high in India. As per NFHS-I survey findings (1992), the age specific fertility rate
(15-19 years) is 116 births per 1000 women of that age. By comparison, the corresponding rates in Japan and the
United States are only 2 and 19 per cent respectively.

x

Nearly 23 per cent of all births in India occur to adolescents mothers in the age group 15-19 years.
Infants born to teenage mothers are at higher risk of low birth weight, pre-maturity and stillbirths. Incidence of
obstetric complications is also very high among adolescent mothers.

-*■

The magnitude of adolescent sexual activity is significant, and is higher in boys than girls. There is under­
reporting of non-marital relationships by adolescent girls due to fear of social disapproval. Therefore, the magnitude
of the pre-marital sexual activity is not known. Commercial sex workers usually serve as partners for first-time
sexual encounters.
Knowledge of sexual and reproductive issues is extremely poor amongst adolescents. In some studies, 50 per
cent of female adolescents did not know about menstruation, and their limited knowledge was based on social
factors (such as not being permitted to cook) rather than the actual physiological changes.

J-

Invariably, information on sexual and reproductive issues sought from peers can be misleading and inaccurate.
Parents and teachers play a minor role in giving information, and are usually reluctant to impart such information.
Sexual and reproductive decision-making by adolescents is constrained by age and gender factors. Adolescent
women have little choice on whom and when to marry, and are usually not in a position to negotiate contraceptive
use. Service providers also tend to be judgmental while catering to needs of the adolescents. This varies slightly
with’age, with an older wife more likely to make such decisions.

-*•

Unwanted pregnancies and induced abortions are a common feature in India. Induced abortions are often sought
at uncertified places and performed by untrained providers th'us jeopardising the life of women. Risk further
increases when abortions occur in the second trimester, which is the case for the majority of adolescent pregnancies.
Young people are at greater risk of contacting sexually transmitted diseases including HIV/AIDS due to the early
onset of sexual activity, reluctance to use barrier methods, and frequency of partner change.

-*■

It is estimated that most drug users in India are between the ages of 16 and 35, but the actual use of drugs may
begin at an early age, sometimes as young as 10 years. In the North- eastern states, drug abuse among young
people has become a major social problem, threatening the social fabric and structures of society.

A

The available data indicate that a high incidence of rape occurs in the 10-16 year age group. Sexual abuse
appears to be prevalent in India.

•x

Trafficking of adolescent girls is a problem that can be traced to poverty, migration, tourism and low levels of
education. The Central Social Welfare Board survey in 1991 indicated that 40 per cent of commercial sex workers
were inducted when they were less than 18 years old. The problems of young girls in prostitution and the demand
for young girls is linked to social and cultural held beliefs relating to virginity (it is commonly believed that sex with
a virgin is a cure for STDs including HIV/AIDS) and gender relations.

male responsibility
As population programmes are making the transition towards becoming
comprehensive reproductive health programmes, one of the most important
items on the agenda is the issue of men. Chapter IV of the Programme of
Action endorsed during the International Conference on Population and
Development (ICPD) says that in most societies men exercise
preponderant power in nearly every sphere of life, ranging from personal
discussions on the size of families to the policy and programme decisions
taken at the level of Government1’ and therefore men are key to bringing
about gender equality. Putting men on the agenda is not at all in contradiction
to the promotion of women's empowerment.

What is male responsibility?
There is no universally accepted understanding of what it means to include men; rather, a variety of interpretations
exist of the concepts of 'male involvement' and ’male responsibility'. Men are involved in reproductive health through
their multiple roles as sexual partners, husbands, fathers, family and household members, community leaders, and
gatekeepers to health information and services. Including men as partners has a variety of meanings. There are many
different ways to involve men appropriately and constructively in reproductive health. The universal concern must
simply be that the calculation is one of addition, not subtraction: that is, in adding services for men, we must ensure that
women's needs are not sacrificed or jeopardised in any way.

Why men now?
a

Men do have reproductive and sexual health needs of their own. Studies indicate that a significant proportion of
men have problems related to sexual dysfunction, infecundity and other urological problems.

a

With HIV/AIDS and other Sexually Transmitted Infections now spreading faster among women than among
men, attention has been focused on the health consequences of men's sexual behaviour. Also, prevention of
HIV/AIDS largely depends on condom use (besides abstinence and fidelity).

a

Millions of pregnancies are unintended, and each year many thousands of women die as a result of these
pregnancies which could be prevented through increased contraceptive use. Contraceptive use must often be
negotiated with the male partner.

a

There is now greater recognition that men make decisions that affect women’s reproductive health as well as their own.

a

Including men in reproductive health programmes could contribute to more equitable relations between partners
and improved communication regarding reproductive goals.

Current Scenario
a

National level survey findings indicate that unmet demand both for limiting and spacing methods of contraception
continues to remain high in many states. In Uttar Pradesh, 87 per cent of women with unmet need said that the
decision to use contraception ultimately rests with the husband.

a

Male participation in accepting responsibility for contraception is woefully negligible. As per programme statistics,
over 97 per cent of sterilisations are tubectomies.

*■

Reproductive health services for men remain inadequate. Many services in hospitals and clinics focus primarily
on female clients, sometimes to the exclusion of men.

x

According to some studies conducted in rural Uttar Pradesh, the majority of the men were not aware of their
wives' pregnancies, antenatal care received, pre and post-natal complications or reproductive problems. The
reason for this lack of awareness was limited nature of inter-spousal communication, and little involvement of
men in matters that they considered purely of interest to women.

x

Indian men do engage in risky sexual behaviour and thus do transmit infections to their spouses. Men do have a
somewhat "liberal" attitude towards pre or extra-marital sex. Further, men do not consistently protect themselves
and their partners while engaging in sex with commercial sex workers and rarely while engaging in sex with their
spouses.

A

A large proportion of men who live in monogamous marriages tend to abuse women both emotionally and
physically.

A

According to the study done in Uttar Pradesh 9 per cent of men reported having a sexually transmitted disease,
but only 45 per cent of them had consulted an expert for treatment.

Socio-cultural Obstacles
x

Men perceive the practice of discussing and sharing decision-making on family size and contraceptive use as a
personal loss of control.

A

Society sanctioned roles, which strictly segregate roles and responsibilities by gender, discourages husband-wife
communication particularly on reproductive health.

x

Traditional beliefs may conflict with men's participation in reproductive health.

Lack of Services and Provider Bias
A

The assumption that men are disinterested in family planning, or are not of concerned fortheir wives has resulted
in services not generally being men-friendly.

x

In the area of service delivery for reproductive health, programmes have traditionally focused on women via
maternal and child health programmes.

A

There is very scanty information on men's knowledge, attitudes and practices with respect to their reproductive
health goals, sexual behaviour and fatherhood.

Applied to the management of reproductive health programmes, the goal should be to redress the biases that
have evolved in the staffing of services. This has led to men dominating the upper levels of the bureaucracy and
women being largely absent from the higher paying roles where decision-makers' opinions shape the philosophy
of the programme.
x

Also, the past orientation of many service providers placed the responsibility for contraceptive decisions solely
on women and impeded efforts to promote male responsibility in family planning decisions. This provider bias
favouring female methods may have also deterred contraceptive use by men.

TRENDS IN THE TOTAL FERTILITY RATE

- - - Maharashtra

- -•— Madhya Pradesh-------- Gujarat —e— Rajasthan

Andhra Pradesh

Kerela

Karnataka -e— Tamil Nadu

TRENDS IN THE TOTAL FERTILITY RATE

O-UNHM
United Nations
Population Fund

55, Lodi Estate, New Delhi - 110003, India
Phone : 4628877, Fax : 4628078
Email: india@unfpa.org, Website : www.unfpa.org.in

MH' &

Report of the Regional Consultation on
Responding to the Target Free Approach
Held in Pune on January 31 & February 1, 1997
519, Prabhu Darshan, S S Nagar, Amboli, Andheri (W), Mumbai - 400 058
Tel: (+91)(022)6250363, Fax : (+91)(022)6209203
E-mail : admin@cehat.ilbom.ernet.in
2/10, Swanand, Aapli Sahakari Society, 481, Parvatidarshan, Pune - 411 009
Tel/fax : (+91)(0212)497866
E-mail: admin@punecehat.ilbom.ernet.in

Centre for Enquiry into Health and Allied Themes (C EH AT)
The Centre for Enquiry into Health and Allied Themes, CEHAT is a non-profit research
collective/organisation set up with the primary objective of conducting research on topics of relevance to
the health and well-being of the disadvantaged and the poor. It functions as an interface between
progressive and pro-people movements and academic expertise.

CEHAT represents the outcome of a long process of debate and discussions on the increasing need to create
a structure which could in a disciplined manner enquire into the many troubling questions thrown up by and
within people’s movements and provide a data base and well-substantiated answers. Some of these topics
may involve quantification and estimation, for instance, the volume of resources wasted on irrational drugs.
Others may extend, deepen and influence currently'applied norms of medico-legal jurisprudence such as
research on domestic violence, torture or rape. Some may impinge on medical ethics and may raise further
questions as in explorations of the responsibility of the medical community towards patients. Studies and
surveys on women’s experience with abortion or contraception or their perceptions of health and illness will
seek to inform mainstream analyses, while those on psycho-social trauma of populations forcibly displaced
or the concept of social wage and what it implies, will reveal what is hidden even as they influence the
process of change towards a more sustainable and equitable society.
How we function

On principle, CEHAT does not regard society either as a ground for experimentation or as unexplored
terrain for data-gathering for intellectual exercises. Given this, all CEHAT’s projects endeavour to create
space for the participation of people in the study without compromising on academic rigour. All CEHAT’s
projects include ethics committees and are committed to return the results of research to participants and
respondents, in an appropriate manner.
OBJECTIVES

1. Conduct research and action-research on topics of importance or interest
from the point of view of people’s movements in the country.
2. To interact with progressive movements, in related areas, such as
women’s groups, trade unions and campaigns or organisations involved
in human rights issues and provide research inputs.
3. To identify research priorities in health at local, national or international
levels, the findings of which will directly or indirectly benefit oppressed,
marginalised or silent sections in society.

The emphasis in CEHAT is on a democratic and participatory mode of decision-making. An external social
audit group periodically evaluates CEHAT’s performance in collective management and the relevance of
research directions of the centre.
At present CEHAT functions on a project to project basis. At some point in the future, a corpus fund will be
raised to ensure a degree of continuity in the institution. At all points of time CEHAT will aim to provide its
staff with a just pay on scales comparable to UGC scales, and a participatory and conducive work
environment.

CEHAT is a research activity of ANUSANDHAN TRUST whose trustees are Dr. Amar Jesani (who
presently coordinates the activities of CEHAT), Dr. Anant Phadke, Dr. Anil Pilgaonkar, Dr. Dhruv
Mankad, Ms. Manisha Gupte, Dr. Mohan Deshpande, Ms. Padma Prakash, Mr. Ravi Duggal and Dr.Vibhuti
Patel. The trustees have multidisciplinary academic training and experience in the fields of medicine,
economics, sociology, journalism, biochemistry and microbiology. Most of them are currently engaged in
full-time research in health and related issues and women’s studies.

REPORT OF THE REGIONAL CONSULTATION
ON
RESPONDING TO THE TARGET-FREE APPROACH

CEHAT
Centre for Enquiry into Health and Allied Themes
January 31 & February 1,1997

519 Prabhu Darshan, 31 S. Sainik Nagar, Amboli, Andheri (West), Mumbai - 400 058
Tel: (+91)(022) 6250363, Fax : (+91)(022) 6209203
E-mail: admin@cehat.ilbom.emet.in

2/10, Swanand, Aapli Sahakari Society, Parvatidarshan, Pune - 411 009
Tel/fax : (+91)(0212) 497866
E-mail: admin @punecehat.ilbom.ernet.in

ACKNOWLEDGMENTS
We thank all the participants for their valuable contributions, thereby

making the regional consultation meet a success. We are grateful to the

Health-Watch network for sponsoring this meeting. We would like to convey
our thanks to BAIF (Bharatiya Agro Industries Foundations) for making

available their premises for the meeting. We are grateful to all those who
looked after the nitty-gritty of organising, without whose unfailing and

sustained efforts the meeting would not have been such a comfortable
affair. We take this opportunity to thank Ms. Maya Nadar for providing her
secretarial assistance for the meeting.

We express our gratitude to

Dr. Sharadini Rath for shouldering the responsibility of writing this report

and to all those who have facilitated the report writing by their articulate,
and prompt comments on the interim report, helping us out to bring out this
report for wider dissemination.

PREFACE
Women’s health has for too long been seen within the narrow confines of maternity. The family
on the one hand pushes women to produce sons and the government health services on the other
hand coerce women to limit the size of the family through provider controlled and long acting (or
terminal) methods of contraception. Maternity is over-valued in Indian society to the extent that
childless women are stigmatised, deserted and are rendered more vulnerable to violence and
bigamy on the husband’s part. The State, with an overt bias towards population control treats
fertility as a disease with poor women as it’s carriers.

No wonder then, that the public health services reflect these biases too. In the first place, the
public health infrastructure is poor, the personnel inadequately trained, resources including drugs
and equipment rarely available - even at primary health centres. Poor developmental
infrastructure such as lack of pliable roads and transport services make these (often ill-placed)
services even more inaccessible. Linking vital services such as abortion or childbirth with
sterlisation or contraceptives adds insult to injury for most poor women. The private sector, with
it’s expensive and often irrational (or even harmful) treatment then becomes the ‘choice’ for
most people who incur vast amounts of debt for the much needed curative services.
In this light, the Indian government’s attempt towards humanising the family planning campaign
by making it target-free is a welcome step. It is certainly a better thing to do than coercing people
into permanent methods of contraception (remember the Emergency?). For over two decades
now the women’s movement as well as health activists have demanded that targets be removed
from the family planning campaign and in a sense, this official move will certainly give some
respite to community based health workers, especially the over-worked Auxiliary Nurse
Midwife (ANM) as well as to women in the reproductive age group.

Having said this much, one needs to examine the reasons and the strategies of the government
visa a visa the target free approach. With women becoming vocal over the years through being
organized by women’s groups and Non-Governmental Organisations (NGOs) it is now hardly
possible to launch an anti-woman campaign without creating an uproar. To supplant it, an ‘unmet
need’ of contraception has been identified among Indian women and the launching of a soft
approach in contraception is expected to work better at this stage than coercion ever will. The
basic fact that population policies (whether pro or anti-natalist) are in themselves eugenic and de­
humanising or that women have many other unmet needs as well, (such as poor access to legal
rights, to housing or decent jobs, for example) is not the main political debate, now. Giving the
population policy a human face by linking it to development is the current slogan.
Whatever the reason be, the fact that reproductive health needs of women are being articulated in
government and NGO quarters is in itself a positive sign. The role of progressive groups would
be to create pressure for expanding the existing policy on reproductive and child health into a
much broader policy on women and health that encompasses other vital and hitherto neglected
areas such as work and health, emotional health, violence, abuse, medico-legal jurisprudence,
impoverisation and so on. A demand for answerability within the public sector and regulation of
the private sector so as to make health care universally available to every one would have to be
raised once more.

Rather than accept ‘packages’ of health care, it would be worthwhile to press for a
comprehensive public health policy that provides good quality health care for all people,
including women, irrespective of their capacity to pay. In real terms it would mean an
overhauling and reinforcement of the existing health care infrastructure and making it accessible
in physical and financial terms for all Indian people. Gender sensitivity within such a policy
which takes serious cognizance of the special needs and socio-economic position of women is a
must.
With a view to debate and clarify some of the above issues, CEHAT, being a founder member of
the ‘Health Watch’ network, decided (in collaboration with ‘Health Watch’) to organise a
consultation with health activists, NGO representatives and Government officials from
Maharashtra-Goa region for two days in Pune. Though the participants came from varying
backgrounds and experiences, they agreed on certain basic issues - namely that the target free
approach as defined in the government manuals was inadequate and that reproductive health
services would not be of much value unless they were contextualised within the broader frame­
work of people’s right to basic health care in India, of which women’s health concerns would be
an integral part.

We have great pleasure in circulating this report to all of you who have been concerned with
issues related to women and health. The dialogue that started in this consultation needs to be
strengthened in a way that the target-free approach is certainly not abandoned by the state in a
haste, and that the myopic definition of ‘women and health’ evolves beyond the understanding of
maternity and fertility.

Ms. Manisha Gupte.

Member, Governing Board,
CEHAT.

Introduction
Participants at the regional meeting of health workers, researchers, and activists from
Maharashtra and Goa deliberated upon the merits and implications of the Target Free
Approach (TFA) to Reproductive and Child Health (RCH) put in place by the Ministry of
Health and Family Welfare since April 1996, at a two-day meeting which concluded on
February 1, 1997. This consultation was jointly organised by the Centre for Enquiry into
Health and Allied Themes (CEHAT) and Health Watch.

It was felt that the new 'target-free' approach to reproductive and child heath care marks a
much needed and long awaited first step towards a complete revamping of health policy.
This approach tries to move away from counting sterilisations as an indicator of reproductive
health, to providing real reproductive health care through the public health services.
However, there was a strong consensus that the new policy as outlined in a manual to be used
by public health functionaries at various levels falls far short of taking care of real health care
needs of people, and women in particular. It continues to think of reproductive health and
'family planning' synonymously, while virtually ignoring most rational reproductive health
indicators. It makes no efforts to offer good quality curative care. As a result, while
abandoning the target approach is appreciated, it is highly unlikely to make any real
difference in this essential area of health in the present form.
It would be far more rational to integrate reproductive and child health into a comprehensive
package for delivering quality basic health care to the people. Such a health package should
be available to all, independent of their ability to pay and must take into account the socio­
economic conditions of communities while delivering care. Given women's poor access to
health care, there might still be the need to have a special women's health programme within
such a package, but it should be considerably more comprehensive than simply taking care of
their reproductive health in the 'family planning' mode.

The participants also came up with criticisms and suggestions for improvements in the
development of human resources, the training and other needs of health workers, public
health infrastructure, the quality of the care it delivers, and ways to evaluate its efficiency
and effectiveness.
All these deliberations and recommendations are reported in detail in the following sections.

Major Topics

Reproductive and Child Health approach and health care
The strongest criticism of the RCH programme was that a separate and stand-alone
reproductive and child health package was the wrong policy to follow. There must be a
basic package of comprehensive health care available to all, which covers not population
control driven targets, but addresses the basic health care needs, such as curative care for
common diseases, dental care, mental health, occupational health, for both men and
women. Such care must be provided with an acknowledgment and understanding that
social and cultural factors affecting men and women are different, and therefore there
must be gender sensitivity in the care as well. In this regard, many times the view was
expressed that a special programme for women's health needs still remains necessary
since they have been excluded from such care for far too long, having had only their
reproductive capacity under the lens. In fact, even within the purview of reproductive
health mostly women have been targeted, only during their child-bearing years, and only
from the viewpoint of population control. This must change. It iriust be recognised that
women have reproductive health care needs that fall outside the limits of family planning
and child care, and as long as these are not treated by a routinely accessible and efficient
system, there is little chance of having a healthy population, small or large. Right to basic
health care must be made fundamental and it must be made available to all irrespective of
people's ability to pay.
A large number of suggestions were made to concretise this view of a comprehensive
health policy. A list of services which should be covered in such a programme was as
follows:
. general practitioner/family physician services for personal health care,
. first referral hospital care and basic specialist services (paediatrics,
gynaecology and obstetrics, general medicine and surgery, occupational and mental
health, dental services and ophthalmology, special diagnostics),
. immunisation services for vaccine preventable diseases,
. maternity services for safe pregnancy, abortion, delivery and post-natal care,
. pharmaceutical services, including laboratory services, surveillance and control
of major diseases with the aid of continuous surveys, information management
and public health measures,
. contraceptive services,
. health education and information,
. ambulance services.

There was discussion of the referral system. It was pointed out that with the rapid growth
of the private sector in both rural and urban areas, coupled with insufficient public
services, most first contact care was handled by this sector. An estimated 1.2 million
qualified and as many unqualified doctors were involved. This is an important area of
consideration for the state in designing the comprehensive health system. However, the
integration of the private practitioner into a health care package must be well regulated
under the single umbrella of a national health authority. There should be rationalisation of
resource distribution, an efficient referral system and insurance plans available.

2

state in designing the comprehensive health system. However, the integration of the private
practitioner into a health care package must be well regulated under the single umbrella of a
national health authority. There should be rationalisation of resource distribution, an efficient
referral system and insurance plans available.
In a study on factors affecting health seeking and utilisation of curative care, it was presented
that even in rural areas, private care was preferred at first contact. This was based on a
perceived notion that the quality of this care was better than that in the Primary Health
Centres (PHCs). Also, socially and economically dominant groups used private care, while
deprived and marginalised communities used the PHCs, only because they could not afford
private care. At the PHC level it was found that the ANMs were so burdened with family
planning work that they hardly provided any curative care, leaving the underprivileged
communities with no choices for such services. It was felt that the now defunct Community
Health Volunteer scheme should be reinstated to un-burden the ANM and rationalise the
contact between communities and the PHC that serves them.

Regarding finances, it was pointed out that in the existing system of health care, the
distribution of resources between urban and rural was rather skewed. 15 percent of the
budget of the health ministry goes towards family planning, .and 40 percent towards hospitals
and medical care. However, 80 percent of the 15 is spent in rural areas while 85 percent of
the 40 in urban. An estimate based on current use and an average morbidity rate of 2 percent
suggests that Rs.500-600 per capita needs to be spent in order to give quality basic health
care. This is about four times the present spending. It was pointed out that utilisation of such
a universal care package will be high initially, rising geometrically, and then fall and level
off as health needs reduce to optimal levels.
In order to do a needs assessment study for planning resources, it was pointed out that much
of the first contact care in the private sector was completely undocumented. In rural areas
where people were using PHCs, the driving agenda of population control and family planning
under which the public health workers operated meant that there was no information about
general health care needs from this area either. Such studies need to be done in order to
identify priority health care areas specific to communities. NGOs should contribute by taking
up such studies.

Health care for women
This topic pervaded all the discussions. This section gives an overview of the breadth of
concerns studied and expressed. Details of recommendations for improvements within the
target free approach and the RCH programme are given in subsequent sections. As
mentioned in the previous section, there was a strong feeling among many participants that
even within a structure such as a comprehensive basic health package, there was a necessity
for a women's health programme. Such a programme must be aimed at expanding the health
services available to women a great deal. There was broad consensus on the details of what
such services should include. It was felt that the planned RCH package must incorporate
these to make it effective in the long term.

3

It was agreed that instead of devising family planning policies, the need of the day was to
empower women to take charge of their basic health care, with efficient and accessible
support from the state system. If this was done, family planning would become a matter of
rational, but personal choices. Lowering of birth rates would then follow as the natural
consequence.

Given the stated policy of the ministry to abandon population control targets, there was a
very strong need to put into place assessments of women's reproductive health indicators
based on a broad picture of the social, economic, and health environs of women. That such a
picture can be very complex was stressed in several presentations.
A study of women as disadvantaged in access to health care, with specific reference to
abortion presented the view that the woman suffers from her ability to bear children in both
spheres; the family and the state. The state sees her fertility as something that must be
regulated, and she gets selective services and counseling according to that aim. So she never
has the freedom of informed choice in planning her reproductive life. However, maternal
mortality is very high and flies in the face of the stated policy. Even within the family, her
ability to bear children, and sons in specific, only gives her security of sorts without ever
giving her real control over when and how she wants to have them, and she remains
dispensable.

If she is infertile for some reason, she becomes virtually invisible to the state, but suffers
greatly at the hands of family and community, and is proven to be dispensable.
With so much emphasis being placed on their fertility alone, women are often seen to be
unable to seek care for gynaecological illnesses that are not directly related to pregnancy.
This is even more understandable since the public health workers at PHCs are known to be
callous, insensitive, and often intimidating. This is especially true of abortion services. The
quality of care indicator changes according to the social and economic status of the women.
Unmarried women have even less power of bargaining and must seek such abortions in the
expensive private sector. There is also the frequent demand for the husband's signature. This
is not included in the Medical Termination of Pregnancy (MTP) Act. Its an interpretation
governed by the existing social values, which makes it even more difficult for women to get
such services on demand. Further, women are pushed to accept provider controlled and
invasive contraception following an MTP. This further reduces women's access to safe
abortions.

There are absolutely no services available for occupational health problems, domestic abuse
alleviation , and mental health. Older women are deemed to be permanently fit, and no
counseling is done about menopause and its side effects.
Given such complex social and economic constraints on the care of the reproductive health
of women, there were a number of issues which the participants agreed must be taken into
account to make the RCH programme effective. The following outlines an expanded
reproductive health package.
. Safe child bearing, with access to appropriate health services.
. Care of gynaecological disorders.

4

. Access to safe and affordable abortion services.
. Capability to reproduce (infertility).
. A safe sex life without fear of disease, coercion and unwanted pregnancy.
. Safe, effective, affordable and acceptable methods of family planning, with informed choice
being emphasized.
. Special attention to adolescents, girls and boys.
. Mental health.
. Domestic violence issues.
. Occupational health, including housework.
There must be efforts made to raise awareness within the community about these, including
how to spot symptoms and where care for them may be sought. Legal rights and wrongs must
be clear regarding age of marriage, abortions, etc. The right to informed choice must govern
all such efforts of education. Special efforts need to be made to bring women into the circle
of health care, given their poor access. Service providers must be aware of cultural
constraints on adolescents seeking care for gynaecological problems.

Recommendations regarding Target Free Approach
The following sections deal with recommendations that were suggested by the participants
for improving health care in the target-free approach as outlined in the manual. There was
repeated discussion on what exactly ‘removing targets’ entails. The view was expressed that
as far as providing clear unambiguous guidelines to the care providers at various levels of
service was concerned, there had to be indicators of some sort. They must be used to both
motivate the health workers, as well as evaluate their performance. The meeting was
informed that Maharashtra was trying to put in ‘target free targets’ by making up their own
manual. It stressed self-generated targets, set up by community representatives and health
workers together. This would take into account their specific health needs in their social and
cultural contexts, instead of being imposed on them in a top down fashion. Sterilisation
targets have been put at the end of the list and current evaluation is being done comparative
to last year, without any demand on meeting those levels.
It was also pointed out that health workers who have been trained for the past four decades in
chasing sterilisation targets were not going to be able to make a fast transition to not having
them. So what should the new targets be, if any? What roles should various public health
workers play in the new system? How should they be evaluated? There were detailed
discussions on these questions and the following sections present them, along with specific
recommendations.

The human workforce
The ANM turned out to be the fulcrum around whom revolved all the changes in human
resource management that were required if the system was to serve the purpose of broad
based provision of reproductive health care. Research presented showed a dismal state of
affairs as far as the ANM’s position in the system, both state and social, was concerned.

5

It was found that the TFA assumed that the ANMs are independent and confident planners.
However, on close examination it was found that most ANMs operate under no professional
supervision. They are usually women from disadvantaged classes. This makes them
vulnerable in both ways, the sexual and the social. They have no bargaining powers in either
contexts in times of pressure. Most of the times they are stationed in villages away from their
homes and cannot take advantage of family support in times of need, nor can they count on
social support from their environs. They do outreach programmes to identify care needs and
travel extensively among surrounding villages. This raises the issue of their security and
comfort. They also work with very poor infrastructure at the subcentre, while they are held
responsible for its performance. ANMs typically take care of child and reproductive care
work, and as such are seen more as dai's than as trained medical personnel. On the other
hand their men co-workers as the Multi-Purpose Workers (MPWs), tend to. be seen as
'doctors', even though they do the same amount of curative care as the ANMs. They are
mostly malaria workers, collect TB slides, chlorinate wells, and so on. So the ANM is
marginalised both socially and professionally, while having the maximum responsibility on
her shoulders in terms of running the subcentre, in which the MPWs have no share.

It is also on the ANM's shoulder that the entire grass-root implementation of family planning
policy has rested for all these years. Finally, it is her performance in pushing contraceptives
and doing immunisations that reflects in the targets being monitored. Now that these targets
are being removed it is imperative that she be given a clear job description. Some of the
suggestion made for improving the ANM's role are as follows :

. The role of the ANM has to be substantially strengthened. She must be given clear
responsibilities in terms of the care she is to provide. The strongest consensus on this point
was that she should not be asked to do 'family planning' work, but should simply take care of
family health in general, more specifically women's reproductive system morbidities and
child care. In fact, she can maintain family registers of health histories. They can be used
both as means of monitoring her work, and also to draw a complete health picture of the rural
families. At this point in time, no such data is available.
. In order that she is able to carry out these duties efficiently she must be backed up by a
more curative care oriented subcentre than what exists now. She must be trained to look for
symptoms of gynaecological morbidities and in cases where she cannot treat them, be able to
refer them to PHCs with the confidence that they will be treated promptly and properly. This
is a vital link in making her position within the community strong. People must have
confidence that she is indeed the link between them and quality care at larger centres.
. She must have team support from the MPWs. Outreach work should be done more by the
now defunct Community Health Volunteers(CHVs), rather than having the ANM traveling
over large geographical areas. The CHV scheme should be re-examined and re-instated.
While outreach work is necessary for identifying care needs, this work is best suited to the
CHVs since they can do it for their own respective villages. It gives them the advantage of
being physically and socially accessible within the community. It also makes them
accountable to the community. The ANM cannot, and should not be asked to, do this work
for a large number of villages.
. The ANM must be motivated by prospects of promotion. If it is found that she cannot be
promoted to higher posts within the medical care set up, she should be considered for

6

managerial positions. Stagnating her in the same position for years will breed indifference to
the work she must do, along with discontent.
. In the new TFA, she should be encouraged to interact with the community to find priority
areas of health care needs and set up targets to improve the health picture in that locality. For
all this, she needs training in leadership, communication, and personality development.
. If the ANM is to be the first and most accessible link between the people and the state
health system, she must be given the necessary tools, both medical and human, to sustain that
position effectively. Along with responsibilities, the ANM’s decision-making power
has to be
substantially strengthened.
Among other suggestions for improving the efficiency of the health workers, there was a lot
of emphasis placed on re-training. It was felt that from the ANM/MPW upward, including
the Medical Officers (MOs), the District Health Officers (DHOs), and all the managerial staff
at the PHCs and RHs, needed gender sensitivity training. It is not correct to assume that all
illnesses, even those outside of the reproductive system of the woman, affect men and
women similarly. As pointed out in an earlier section, the woman is very constrained in
socio-economic ways as men are not and needs appropriate consideration when providing
care. The health workers must be made aware of it and. given training to deal with the
situations.
MOs and DHOs should be given periodic re-training in diagnostic skills using medical
college hospitals. RHs should have a regular woman gynaecologist on a visiting basis. It was
also felt that there should be an effort made to attract women to take up jobs as MO/DHOs.
Incentives such as seat reservation in local schools for their children could be offered. In
general, the presence of professional women in the state medical care system should be
greatly enhanced.

Another area of discussion was the inclusion of the private sector into the health system.
Although it was agreed that this was a good idea, there was apprehension expressed that this
would be done in haste, without doing a thorough study of the quality and range of care that
they provide and how it should be regulated in a collaboration with the state. Such a study is
absolutely necessary. Professional bodies with consumer groups and thie government should

evolve standards and accreditation systems before any effort is made to integrate the private
sector in the RCH programme.

Infrastructure, quality of care, and evaluation
The ramshackle state of the public health infrastructure was reflected in a study of drug
supply in Satara district. Various PHCs and RHs were surveyed. It was found that no one
single drug was available in the PHCs throughout the year. Only about 3 percent of the total
supply was available on a regular basis, and 55 percent were effectively not available. The
situation in the RHs was not noticeably better, 38 percent of the drugs being available only
very irregularly. The total supply to the public sector was about 56 lakhs, while an estimate
of the use by private sector was about 21 crores, which is closer to the estimate of drug
requirement in this area for an extrapolated morbidity load. This shows very strongly that

7

there is no facility for curative care, even for common ailments, within the public health
system. The entire budget and supply is geared for immunisations and family
planning/contraception activities. This trend continues in the TFA manual. The manual
mentions only some 7-8 drugs to be supplied to PHCs, while the drug kit is supposed to have
some 80-90 drugs. There seems to be complete confusion on this issue. As a national health
policy this goes against common sense. Poor people in rural areas must have basic curative
care access to their PHCs, not just for contraception and family planning.
While drug supply is one aspect of the issue of access, other severe problems regarding
infrastructure were pointed out by participants. All these directly affect the quality of care
issue. Physical locations of PHCs serving a given geographical area was of great importance.
If people have to spend an entire day traveling back and forth to the PHC, the incentive for
doing so is going to be very low, and quacks and other unqualified ‘doctors’ will then be
used. Reliable state transport services which are extremely necessary , as a back-up to
utilisation of public health facilities are also not available in remote rural and tribal areas. If
only 15 people from each village go to the PHC every day, the existing state bus service will
not be sufficient. Universal access to basic health care must be the guiding principle in
planning these resources, backed up with development infrastructure.
It was felt that this bad planning for infrastructure also reflects the poor state of data
collection for both need assessment, and the quality of care being provided . There is no data
on the former, since public health has been synonymous with family planning and
contraception. General health care has been dealt with on ‘campaign’ basis once in a while
for mostly highly communicable diseases such as tuberculosis, leprosy, etc. However, even
care for these is not available on a regular basis, much less for other common ailments. The
evaluation of the quality of care is again family planning oriented, with health workers being
asked to fill out forms with this focus. Unfortunately this policy continues even in the new
manual of the TFA.

With this background, the participants came up with strong recommendations for improving
the infrastructure, with the help of relevant data collection based on rational indicators of
health, that would then help the care providers at the PHCs and RHs improve their quality of
care.
. Since all infrastructural changes can be made only on the basis of data on need assessments,
this should be started immediately. What data should be collected from which health
functionary and how should it be used? Collection of sensitive and intimate information
about people's lives or about NGOs/social action groups raises ethical and political concerns
since this data is centralised, globalised, and used to draw conclusions for the purposes of
policy making that then directly affect the services being provided at grass root level.
There was also consensus among the participants that there was too much data being
collected. This issue raised concern among participants because excessive data collection
would create resentment among people as their time and energy would be unnecessarily
consumed . Even the ANM was asked to provide so much data that there was little time left
for her to actually do health care work. Since it was agreed that the basic function of the
PHC was to provide basic curative care, it was felt that maintaining family health registers
would give far more information about health needs in a community than only keeping

8

records of contraception and other family planning indicators. This data can then be pooled
together at the district levels for planning finances, drug supplies, training requirements for
personnel and infrastructural changes. This means that such data needs to be processed fast.
Decentralising this process will help tremendously in a fast response to the health needs of a
community. Updating of this kind should be a continuous process, instead of being done
once in several years.
. There needs to be rationalisation of both the drug supply to PHCs, and their locations.
Locations should be governed by time taken by the community being served to access the
PHC, and not by the political clout of a particular village. The drug supply should be based
on the health needs of each locality. Curative care for common ailments should be available
on a regular basis, rather than in fits and starts.
. What indicators should be used to survey both the health picture of a community, and the
performance of its care provider? The most strong recommendation was that these indicators
should be evolved with the consensus of the community. Mahila Mandals, panchayats and
other bodies within the villages should be involved in the process. They should be asked both
about their care needs, as well as how they are being served in their alleviation. User reports
should be collected on a regular basis? Removing population control targets should not leave
the health providers with the feeling that there is no more work to be done. They should be
motivated to set up their own targets with the help of the community and be evaluated on that
basis.
. Women's reproductive health indicators should be evolved keeping in mind, as outlined in
the section on Women's Health, that they have morbidities other than those related to child­
bearing, and that care seeking for these is a strong function of their social and economic
status. If regular data is collected for all these even at the level of family registers, it would
be possible to draw correlated pictures for health needs of women in different socio­
economic and age strata. Again, their access should also be taken into consideration by
updating outreach programmes and providing them with spaces in which to discuss these
issues without feeling either pressured or threatened.
. All these tie directly back into the issue of training of health care providers. It should be
made gender sensitive and this is a point on which there should be regular evaluation,
especially from the user's point of view.
. The whole system of infrastructure, along with evaluation, and assessments of health needs
should have in place some measures to assess and apportion responsibilities in case of
failure. That something does not work should not be reduced to a piece of paper which is
nobody's responsibility. There should be clear guidelines for taking care of such situations
promptly.
It was felt at various stages of the discussion that provision for trained and motivated
personnel who are actively involved in the health issues of the community is the minimum
necessity of the infrastructure. It is not a good idea to ask them to fill out forms for indicators
that have been prepared with the national agenda of family planning in mind. No single
community can be forced to tow a national policy to the exclusion of their other, most often,
more immediate and demanding health needs. Empowerment of the communities to have a
say in the health services they require is of primary importance. For this, a revamping of data
collection, its decentralisation, fast processing, and subsequent planning of resources both
material and human is now a pressing need.

9

Concluding Remarks

The target free approach came in for a great deal of detailed scrutiny in this meeting. Both its
policy level foundations and its implemetational effectiveness were thoroughly examined.
The main broad issues on which there was consensus are the following.
. Public health workers must be used to provide basic curative care which is client oriented.
They must not be used to chase population control targets, or family planning agendas of
various sorts.

. The reproductive and child health package should be part of a general basic health care
plan, whose driving aim should be to have a healthy population, not a 'family planned'
population that does not even have access to basic curative care for common ailments. The
operative word in health policy should be health, family planning being a part of it, instead of
being the other way round.
. Women's health must be taken out of the family planning bracket and put firmly into a more
comprehensive health plan. Their needs must be assessed in terms of their socio-economic
situation and care delivery must be appropriately tailored.
. Decentralising the need assessment system will be so much more logical if such a health
policy was put in place. This can then be used to make the delivery of health care far more
rational in terms of both; what people need and how efficiently they can access it.

10

LIST OF PARTICIPANTS
1. Dr. Leela Visaria
Healthwatch
C/o Gujrat Institute of Development
Research,
Near Gota Char Rasta, Gota,
Ahmedabad - 382 481
®: (0) (079)474809
® (079)6423410
Fax: (079)474811
Present Address:
A-4, Institute for Economic Growth Flats,
Institute for Economic Growth campus,
University Enclave,
New Delhi - 110 007
S: (O) (011)7256118
2. Dr. Dhruv Mankad
Vachan,
Vasundhara, Shivajinagar, Pune - Nasik rd.,
Nasik - 422 006
a: (O) (0253) 562520,562379

3.

Dr. Kranti Rayamane
Shodh, 440, N-3, CEDCO,
New Aurangabad - 431 003

6.

Dr. Shashikant Ahankari
Halo Medical Foundation,
Janaki Hospital, Andoor, Tai: Tuljapur,
Dist: Osmanabad

7.

8.

Dr. Jyotsna Deshpande
Janarth
(Regd. Society for Development Activity)
19, Samadhan colony, Post box no. 127,
Aurangabad - 431 001
3: (O) (0240) 337479,335062

9.

Bailancho Ekvott
C/o Ms. Auda Viegas,
Margoa - 403601, Saleete Goa

10.

5.

Dr. Vrinda Kale
Janarth
(Regd. Society for Development Activity)
19, Samadhan colony, Post box no. 127,
Aurangabad - 431 001
B:(O) (0240) 337479, 335062
Ms. Eulalia A Alvares
The Other Indian Press I Third World
Network Features,
Above Mapusa clinic, Mapusa
Goa - 403 507
®: (0)263305
Fax: (O) 263305

Mr. Roland Martins

GOA DESC
No.ll, Liberty Apts., Feira Alta,
Mapusa - 403 507, Goa
a: (O) (0832) 252660

S: (O) (0240) 485693
4.

Dr. Subhash Doshi
Medical officer,
Primary Health Centre, Parinche,
Tai: Purandhar, Dist: Pune
Pin-412 311

11.

Dr. Madhuri Rao
Bailancho Saad,
Prema bldg., Rumadi Orem, Panaji - 403 001
® :(O) (0832) 232460

12.

Ms. Usha Joshi
Bailancho Saad,
Prema bldg., Rumadi Orem, Panaji - 403001
®: (O) (0832) 232460

11

13.

14.

15.

16.

Ms. Jayashri Velankar
IWID,
A - 201, Vasant View,
D’monte lane,
Orlem, Malad (W), Mumbai - 400 064

19. Dr. Anil Pilgaonkar
34 B, Nausher Bharucha rd., Grantrd., (W),
Mumbai - 400 050
3: @3688608

®: @8886237
(0)8811573

20.

Dr. Malini Karkal
4,
Dake colony, Andheri (W),
Mumbai - 400 053
®: @6260469
Dr. Shireen Jeejeebhoy
Settminar, 16-A, G.Deshmukh Marg,
Mumbai - 400 026
@3864421,3862110
Fax: 3822418
E-mail: shireen.jej@axcess.net.in
Mr. Ravi Duggal
SWISSAIDIndia,
301-B, Sai Niwas, Subhash Road,
Vile Parle (E), Mumbai - 400 057
®: @(022)6286865
Tel/fax: (O) (022)8203868
E-mail: admin@swissaid.ilbom.ernet.in

17.
Ms. Aditi Iyer
Gold Finch, 514/C, R.P.Masan rd.,
Matunga, Mumbai - 400 019
18.

Ms. Padma Prakash
Senior Assistant Editor, EPW
19,
June Blossom Soc.,
60 A, Pali rd., Bandra (W)
Mumbai - 400 050

(0)2696072/73
® 6421265
E-Mail: epwl@shakti.ncst.ernet.in

Ms. Sonia Gill
27/43, Sagar Sangam, Bandra Reclamation,
Bandra (W) Mumbai - 400 050
®: @6405829

21.

Dr. Laxmi Lingam
Tata Institute of Social Sciences,
Sion-Trombay rd., Deonar,
Mumbai -400 088
(0)5563290
® 7701742

22.

Prof. Tara Kanitkar
Apt. 10, E 3 building,
Girija Shankar Vihar
Karve Nagar
®: (0)342731,342436

23.

Dr. Madhuree Talwalkar
State Demographer,
State Family Welfare Bureau,
Pune-411001
®: (0)624914
Fax: (O) 621766

24.

Dr. Anant Phadke
50, LIC Quarters, University rd.,
Pune-411016
S: @355728
.

25.

Dr. Hemant Apte
Social Scientist,
KEM hospital and research centre,
Rasta Peth, Pune - 411 011
(0)625600
® 327698
Fax : 625603

12

26.

Dr. Bela Ganatra
KEM hospital and research centre,
Rasta Peth, Pune - 411 011
®: (0)625600
Fax: (O) 625603

27.

Ms. Seema
Indian Health Organisation,
Ranjeet complex, first floor,
R.no.l & 2,428, Mangalwar peth
Pune-411011
®: (0)633996
Pager no.: (O) 9628566936

28.

Dr. Deepti Chirmulay
BAIF Development and Research
Centre,
Dr Manibhai Desai Nagar,
National highway no.4,
Pune-411029
®: (0)365494,365496
Fax: 366788

29.

Ms. Nishi Singh
KEM hospital and research centre,
Rasta Peth, Pune - 411 011
®: (0)625600
Fax: (O) 625603

30.

Ms. Nandita Ambike
KEM hospital and research centre,
Rasta Peth, Pune - 411 011
®: (0)625600
Fax: (O) 625603

31.

Ms. Manisha Gupte
CEHAT/MASUM,
11, Archana Apts.,
163, Solapur rd., Hadapsar,
Pune-411028
®: 0(0212)675058
Tel/fax: (O) 611749

32.

Ms. Chandra Karhadkar
MASUM,
11, Archana Apts.,

163, Solapur rd., Hadapsar,
Pune - 411 028
®: (O) (0212) 675058
©531819
Tel/Fax :(O)611749

Participants from CEHAT 33.
Dr. Amar Jesani
34.
Mr. Sunil Nandraj
35.
Mr. Quazi K.A.
36.
Ms. Kanwaljeet Singh
CEHAT
519, Prabhu Darshan, S S Nagar,
Amboli, Andheri (W), Mumbai - 400 058
®: (O)(022)625036
Fax: (022)6209203
E-mail: admin@cehat.ilbom.emet.in

37.
Dr. Sunita Bandewar .
38.
Ms. Hemlata Pisal
39 Ms. Mugdha Lele
CEHAT,
2/10, Swanand,
Aapli Sahakari Society,
Parvatidarshan, Pune - 411 009
Tel/fax : (O) (0212) 497866
E-mail: admin@punecehat.ilbom.emet.in

13

Select list of publications of CEHAT

A)

Health care services and financing

Studies, reports and books:
(RA.04) “Patient satisfaction in the context of socio-economic background and basic
hospital facilities: A pilot study of indoor patients of the LTMG hospital, Mumbai", Iyer
Aditi, Jesani Amar, Karmarkar Santosh: CEHAT., October, 1996, pp.56
(RA.01) “Special statistics on health expenditure across states”, Duggal Ravi, Nandraj Sunil,
Vadair Asha: Economic & Political Weekly, vol. XXX, Part I in No.15, April 15, 1995,
pp.834-835, and Part II in No.16, April 22, 1995, pp.901-908

Papers and essays:
(PA.24) "From Philanthropy to human rights : A perspective for health activism in India",
Jesani Amar (Paper presented at the Diamond Jubilee Conference on “Social Movements”
organised by the Tata Institute of Social Sciences, Mumbai on November 3, 1996): CEHAT,
November 1996: pp.24.
(PA.20) “Market reforms in health care”, Jesani Amar: Radical Journal of Health (New
Series) Vol. I No.3, July-September 1995, pp.171-3 (Editorial)
(PA.19) “Public health budgets: Recent trends”, Duggal Ravi: Radical Journal of Health
(New Series) Vol. I No.3, July-September 1995, pp. 177-82.

(PA.17) “Health expenditure patterns in selected major states”, Duggal Ravi: Radical
Journal of Health (New Series), Vol. I No.l, January 1995, pp.37-48
(PA.14) “Population meet: Poor impact of NGO’s”, Duggal Ravi, Economic and Political
Weekly, Vol. 29 No.38, September 17,1994, pp.2457-8
(PA. 13) "Population and family planning policy: A critique and perspective”, Duggal
Ravi(Paper presented at International Conference on Population and Development, Cairo,
September 1994). CEHAT, August 1994, pp.6
(PA. 10) "Peoples economy: context and issues from India", Duggal Ravi (Paper presented at
Seminar on “Market Economy Also for the Poor”, Berne, Switzerland, May 1994), CEHAT,
May 1994, pp.14.

(PA.09) "For a new health policy : A discussion paper”, Duggal Ravi (Paper presented at
the study circle organised by the MFC/FMES/ACASH, Mumbai, on August 21, 1994):
CEHAT, August 1994, pp.13.

14

(PA.06) “Resurrecting Bhore: Re-emphasizing a universal health care system”, Duggal Ravi:
MFC Bulletin, No. 188-9, November-December 1992, pp.1-6

(PA.01) “Private health expenditure”, Duggal Ravi, MFC Bulletin, No.1’73-174, July-August
1991, pp.14-6

B)

Health legislations, ethics and patients’jights

Papers and essays:
(PB.ll) ‘The unregulated private health sector”, Jesani Amar, Nandraj Sunil: Health for
Million, Vol.2, No.l, February 1994, pp.25-28.
(PB.09) “Patients rights: A perspective”, Jesani Amar, Nadkami Vimla: The Indian Journal
of Social Work, Focus Issue: Patients’ Rights, Vol: LIV No.2, April 1993, pp. 167-71 (Guest
editorial)

C)

Women’s health

Studies, reports and books:
(RC.01) “Vyatha Streechi, Katha Garbhapatachi",
Bandewar Sunita, Slide show in Marathi, CEHAT.

Gupte Manisha, Pisal Hemlata,

Papers and essays:
(PC. 15) “Women's role in decision making in abortion: Profiles from rural Maharashtra",
Gupte Manisha, Bandewar Sunita, Pisal Hemlata. Paper tabled in XIV International
Conference of the Social Science and Medicine at Peebles, Scotland, September 2-6, 1996.

(PC.14) “Abortion needs of women : A case study of rural Maharashtra”, Gupte Manisha,
Bandewar Sunita, Pisal Hemlata, Reproductive Health Matters: May 1996 Special issue :
Abortion : The Unfinished Business

(PC.13) “Women’s perspectives on the quality of health care and reproductive health care:
Evidence from rural Maharashtra", Gupte Manisha, Bandewar Sunita, Pisal Hemlata
(Scheduled for publication in a book to be brought out by the Ford Foundation): CEHAT,
December 1995, pp.28

(PC.12) “Umaltya Kalyanche Prashna", Gupte Manisha, Pisal Hemlata (article for
AFARM): CEHAT., December 1995, pp.4 (In Marathi)

15

(PC.08) "Abortion: Who is responsible for out rights", Jesani Amar, Iyer Aditi, Karkal
Malini (ED) Our lives, our health (Book) New Delhi: Coordination Unit, World Conference
on Women, Beijing, 1995, August 1995, pp.114-130.

(PC.07) ‘Women, health and development”, Karkal Malini, Gupte Manisha, Sadgopal Mira:
Radical Journal of Health (new series), Vol:l, No.l, January-March, 1995, pp.7-8.
(PC.05) “New approaches to women’s health: Means to an end?”, Prakash Padma: Economic
and Political Weekly, December 18, 1993, pp.2783-6 (A background paper for the MFC
meet on “Social construction of reproduction”, at Wardha, January 13-15,1995).
(PC.04) “Women and abortion”, Jesani Amar, Iyer Aditi: Economic and Political Weekly,
November 27, 1993, pp.2591-94 (A background paper for the MFC meet on “Social
construction of reproduction” at Wardha, January 13-15, 1995).
(PC.03) “On being normal (whatever that is)”, Gupte Manisha: MFC Bulletin, No. 197-201,
August 1993, pp.4-6. (A background paper for the MFC meet on “Social construction of
reproduction”, at Wardha, January 13-15,1994)

(D) Investigation and treatment of psycho-social trauma

Studies, reports and books :
(RD.01) "Will truth prevail? A report of the investigation team on the murder of Sr. Sylvia
and Sr. Priya at Snehasadan, Jogeshwari", Jesani Amar and others, Mumbai: Solidarity for
Justice, April 12,1991, pp.31.

Papers and essay:
(PD.10) "Health of child labourers in India", Sinha Roopashri: CEHAT, December 1995,
pp.6.

(PD.06) "Violence and the ethical responsibility of the medical profession", Jesani Amar,
Medical Ethics, Vol.3, No.l, January-March 1995, pp.3-5.

Copies available at Mumbai and Pune office of CEHAT.

16

medico friend circle

Bldg. 4, Flat 408, Vahatuk Nagar,
Amboli, Andheri(W), Bombay - 400 058.

Ravi Duggal, Convenor.

Date : 17.6/94

To All mfc members and sympathisers

Dear friend,
Greetings from the new convenor's office ’ On 31st March 1994 Manisha's tenure as the mfc convenor
ended and I have stepped into her shoes.
Manisha conveys her thanks for the affection and cooperation she received from all friends during her
convenorship.
My convenorship coincides with my new job which involves a lot of travel, especially in the states of
Rajasthan, Gujarat, Maharashtra and Andhra Pradesh. This means both, that all friends must provide the
necessary support to the convenor's office more actively than before, as well as must be more tolerant if
there are delays in communication ! But this also means that wherever I am travelling and I know about
mfc friends in that area I will make a special endeavour to meet them. Please make a note of the new mfc
address at the top right hand comer.

My immediate agenda for the remaining part of the year is :

1.

Increase members of our friend circle, for which all of you must put in some effort. If your own
membership is due for renewal, please send in your money order/demand draft immediately in
the name of'medico friend circle'.

2.

Increase the number of subscribers for the mfc bulletin, especially life-subscriptions. If most of
you can become life-subscribers (only Rs.300/- for individuals and Rs.500/- for institutions) it will
be good for the bulletin's health in the long run. Please also encourage your interested friends to
become subscribers/life-subscribers.

3.

Finally, the agenda for the 'Annual Meet' of 1994/95 has to be worked out. For this I need your
soggestions immediately.

I close with my best wishes and a hope that with your support and affection we can together strengthen
the role that mfc can play in the health movement.

In solidarity,

Ravi Duggal
mfc Convenor.

Encl: 1. Report of the Annual Meet
2. List of Participants.

I

REPRODUCTIVE HEALTH: STATE, SOCIETY AND FEMINIST PERCEPTIONS
XX ANNUAL MEET OF THE MEDICO FRIEND CIRCLE

In February 1983 the medico friend circle made a pioneering attempt at defining the problematic of the relationship of women
with the medical system, a relationship whcih was becoming increasingly tense in the context of a emerging women's
movement. For most of the patticipants, witlun tire mfc and outside it, the meeting has always stood out as having been
fraught with somewhat desperate attempts at arriving at a minimum understanding, at finding a common language which
could address both tire concerns of a burgeoning feminist moveemnt and a progressive medical fraternity critically aware of
the limitations of medicine and its practice. A report of Hie evaluation of lire meet (compiled painstakingly by Mira Sadgopal)
points out that among the major drawbacks was firstly, tire lack of a common oriention among participants, and secondly, the
lack of an attempt to clarify the issue of what sexism actually is and to lay out generally acceptable assumptions as well as to
delineate areas of controversy between the expected participants points of view. Much has happened in the decade after that
meet. But it would seem from tliis meet that we have at last found a language, an understanding of the different perspectives
which inform people's point of view.
The focus of tire meet evolved out of our common concern about the different
meanings that were being given to the concept of reporductive health. We felt that there was a need to define through dialogue
and discussion why our understanding of reproductive health was different from the way it was being projected now. To
arrive at a common platform from wliich we could discuss, we decided to devote an entire day of the three day meetto discuss
social construction of reproductionand how different agencies, the state, society,and feminists have perceived it. Swatija
presented a discussion paper written by the forum for women's health. What do we mean by reproductive health ? While
biology’ mediates and determines the man-woman relationship, reproduction is very much a social construct and an
understanding of reproductive health moves between these two arenas of pour lives. When we talk of reproduction, tire first
issue that comes to mind is a woman's fertility,cycle which has for ages generated awe. And yet this biological phenomenon
has received a social construct-and reproduction has been identified as a woman's responsibility, by the same logic, the
expression of sexuality is also tailored to suit the definiion of normality prevalent in society, thus normal sexuality is
heterosecuality leading to reproduction and to the begetting of a male cliild thus in order to control a woman's fertility her
sexuality and its expressioiun had to be tailored . Automatically, contraception becomes a woman's responsibility. At the
other end, all sorts of sexual abuse of women gets condoned because these get associated with a man's virility which
is'normal'. Following from this a woman's reproductive health gets defined only as awomen's health in their role as
reproducers witlun marriage. All other aspects of women's lives are totally negated and so, by definition the health of a large
number of women who do not fall in tliis 'normal' category gets neglected.

In reality women are producers and reproducers and therefore the contradictions of their lives as producers must necessarily
comprise a component of women's reproductive health. Similarly, we have to define reproductive health to include the health
of women in all age and Status groups in society such as the very old and the very young, the widows, the uunmarried/or the
unmarriageable.
Science, medicine and health care system have contributed to and adopted society's notions of reproductive health and have
in consequences neglected a large area of the health of women, this norm has also further strengthened the trend to intervene
in normal processes of the human body to manipulate and change the fertility status incorporating the same anti-woman
biases . this also influences the type of research which is done, for instance, while the phuysiology of reproduction is
researched, th ebiochemical and other changes which occur intlie course of reprocution are not so well understood.

A consequence of this is that in our minds today, questions of contractption controlling fertility and handling infertility have
become questions of teclinology of getting the right method, with the social aspects becomeing secondary. This
understanding pervades the entire biomedical sphere as well as the programmes such as family planning and MCH
programmes. This invasive attack of technoogy together with the taking over by the state of all the terminology and concepts
with which women have begun to unite and to redefine themselves are detrimental to women empowerment and must be
critically understood. We have to look and redefine reprocuctive health in a way which empowers women.

Also contributing to the discussion were two background papers : one published in the me bulletin (August-December
1993)by Veena Shatrugna and the other in the EPW (December 18, 1993) by Padma Prakash. Veena's paper reports on a
study exploring the relationship between women's work for income, access and utilisation of health care and women's health
status and comes up surprising findings.For instance, that incomes alone do not affect women's utilisation of health care
facilities even though working for an income increases women's morbidities. This cannot be tackled unless the roots of
women's illness and the social construction ofgender changes such that the man-woman roles and expectations change along
with socio-economic status. Padma's paper presented a background to the evolution of the new reproductive health being

proposed as a model for women's health, what it comprises and the consequences of its implementation for women's health.
The presentation was followed by parallel group discussion aimed at arriving at an understanding some of tile issues raised in
Swatija's paper. Not surprisingly, the discussion were wide ranging depending on the composition and the inclination of the
group. And while the reporting of the groups at the end of the session could hardly be said to have contributed to a general
clarity on tlie various issues, it was apparent that participants took off whatever particular glasses that they nonnally wore to
consider issues anew and come to tenns with the tensions witliin the given dominant social construction of reproduction and
hence of sexuality or man-woman relationship and of women's staus. It would be impossible to capture the nuances and the
depth of discussions in some of the groups. Here we touch upon the more concrete points of discussion: construction of
manhood’womanhood; concept of normalcy related to reproduction and sexuality; role of science and technology in
structuring these gender roles; impact of medicalisation and commoditisation on gender roles and relationships; social class as
a factor in the social construction of gender.
Tlie given stereotypes we internalise and are conditioned into accepting are of the woman as being non-aggressive, nurturing
and men as being aggressive. These stereotypes are institutionalised not only in day to day living but in academic enquiry as
well. For instance, in econoomics these stereotypes of'natural family" have led to concepts of subsistence family wage which
accept as correct the unequal distribution within the family. Or for instance, the concept of minimum wages which are
unequal for men and women. The internalisation of these stereotypes has lead to a disastrous lack of appreciation of
women’s bodies being different. Medicine assumes that women are different only in relation to the sex organs and to an
extent their psychlogical make-up.,, but when it comes to diseases in general, it is always assumed that the course is the same
in man and woman and therefore the intricacies of how a certain therapy works is also the same. For instance, there are
studies wliich now show that perhaps the effect of certain drags may be very different in mane and women. But these roles
are not sturctured by biology. Biology is a convenient tool to reinforce social norms. More important than biology is the
social class which is at the root of the construction of normalcy. The construction of normalcy puts a burden on women. As
Manisha Gupte's background paper (mfc bulletin, Auugust-December 1993) pointed out women are fso often plagued by
questions of whether they are normal: is white discharge normal ? Is a menstrual cycle of more or less than 28 days normal ?
If I don't have sons am I normal ? and so on. Whereas there are so many millions of women who are outside the realm of
'normal': the deserted, post- menopausal, infertile, tlie depressedk the single, the lesbian, those without sons, sex workers, the
self-confident, the dark skinned the polygamous and so on. These strong notions of normalcy now operationalise and justify
the use of technology to attempt to alter, what is thoughht of as being her destiny. For instance, childlessness previously a
social phenomenon is now a medical problem with a technical solution. Contraception is increasingly a medical issue with
little comprehension of the social aspects which leads to the development of contraceptives which put low value on
women'ssocio-psychological factors. This brought up the question of science and technology and their role in reinforcing the
norm. There were strong opinions expressed in most of the groups on this topic. While there is an increasing dissatisfaction
and disillusionment with the fact that technology is being sought to be used as a substittue for social action, the corrolary
which seems to be arising that all technology per se must be rejected cannot be accepted. For instance, ultrasound, has had a
tremendous impact on medical advances. Appropriate technology which is culturally and practically more compatible is
often ignored in favour of high tech and super specialised applications. As an illustration, the neglect of herbal medicine and
older methods. Moreover, the use of technology once it is developed cannot be looked at as a matter of individual choice,
because the developmental costs of any technological innovation are borne by society.
Another issue that was raised was whether men and women behave in the same way vis a vis technology ? Is technology
itself not designed with a bias against women ? Does the social organisation required for the incorporation of technology
itself favour men rather than women ? There is also the issue of technology abuse especially with reference to minorities and
the under class. The preofessional class is more sympathetic to the middle class so the use of technology for women of this
class is bound to be different than in the case of poor women. The question of whether technnology itself discriminates
expectedly led to very vocal opinions in most groups.

With this as a background the meet went in for group discussion on the following topics: Contraception; Maternal and Child
Health; Infertility, in the first half of the second day and Abortion,Population Policy, Sexualityand Menopause-HRT in the
second half. Group reports are included elsewhere. Here we will pick out the highlights of these discussions.

Contraception: An important concern is the increasing trend towards discussing contraception as if it were only a
technicahmedical issue. The urgent need to focus attention on the socio-cultural factors which determine contraceptive
practices and inform a whole range of issues concerning contraception.(See Sundari Ravindran's paper in EPW November 1320, 1993) It is within this framework, issues such as the female bias in contraceptive research, the increasing tendency to view
contraception as a female problem, a and yet at the same time promote the use of contraceptives which are not womencontrolled , the de-emphasising of non-hormonal methods of contraception, such as for instance barrier methods, the

3

unetliical clinical trials of long acting contraceptives (see background paper in mfc bulletin August Decmber 1993) need tb be
examined. Moreover the gender bias in promoting contraception also leads to distortions . for instance, advertisements for
male methods (condoms) focus on sexual pleasure while those for female methods on responsibility and protection, further,
the promotion of condoms today is linked not so much with women's health as protection for the mak in the face of the real
or imaginary threat of AIDS and as a means of controlling numbers A cautionary note was sounded on how feminists too
were becoming caught up in a reductionist view of tire human body and focus exclusively on women's reproductive functions
and organs to the detriment of a process towards developing an alternative view of what women's health constitutes.

Maternal and Child Health: Two important issues which were liighlighted were tire concern over the fact that the maternal
mortality rate had not shown significant improvement and second, the unreliability of data on either maternal mortality or
maternal morbidity What are the reasons for maternal deaths ? Are they due to high risk factors, socio-economic factors
including nutrition, lack of ante natal care or lack of supportive medicare ? Or were they extraneous to the state of pregnancy
and its outcome ? Several studies, notably the Columbia University study and collective experience at the field level indicates
that tlie availability institutional facilities for delivery is a crucial factor in preventing maternal deaths. Availible SR.S data
indicates that states and districts which have a liigh proportion of institutional deliveries (Punjab. Kerala. Ratnagiri district in
Maharashtra) also a decline in maternal mortality rates. But the solution is not to put all efforts into providing institutional
care. In fact the provision of institutional care without (a) adequate knowledge about the possible risks of pregnancy and what
is to be done in an emergency, or in other words education (b) a concern for the pregnant women’s health and not just the
health of her baby or in other words a better social status for women and (c)reliable and efficient means of communication
and transportation and the means to use these or in other words adequate infrastructural socio-economic development would
be counterproductive becausee facilities would remain unutilised while Women would continue to die from lack of facilities. In
the west maternal and child health services comprise good obstetric care, high risk approach and a well developed ANC
component. This is not so in the third world The long debate that ensued on what aspects of maternal and antenatal care are
the most crucial or what should be emphasised over others are indicative of changing perceptions on MCH programmes. The
government's proposal to cut down on maternity benefits for the fourth cliild and onwards came in for sharp criticism from all
sides.
Infertility: Discussioons on infertility centred around an effort to understand fertility and motherhood. Does a woman have a
personal need to have a biological child or is the desire for motherhood socially defined? Parenthood was determined by
people’s capacity to love and care for others and was not determined by blood ties. Infertility was socially constructed: for
instance, women who do not fall into the category of marriage may be fertile yet be considered 'infertile'in the eyes of society.
On the other hand infertility is seen as a consequence of a woman's behaviour in the past. Women's ownershipof material
resources or tire lack of it was a factor in determining how womanliness itself becomes defined in terms of a woman's capacity
to bear children. Another factor in defining infertility is the medical system which is gender insensitive: just as it pushes
women to limit the size of their families regardless of their own desires and needs, it is also unconcerned with the anguish of
women who have not been able to conceive. What role does and should technology play in the treatment of infertility and
what stand can we take on research on technology for treating infertility ? No consensus emerged on this issue, but a common
understanding was that in the context of lack of resources for so many clearly relevant areas of health care, research on such
technology cannot be considered a priority concern.

Abortion: What are the factors which make a woman decide to go oin for an abortion ? to suggest that it is the lack of safe
contraception does not make for a full understanding of the forces which operate. A major underlying factor is the unequal
and often distorted man-woman relationship, one consequence of which is men's insensitivity towards abortion. In the Indian
context abortion, the services available and why women go in for it cannot be understood except in the context of the history
of the legalisation of abortion in the country. (See Amar Jesani and Aditi Iyer's background paper published in the EPW,
November 27 1993). The legalisation in India was not an outcome of women's needs or the demands of the women's
movement. It was consequent upon the state's need to limit population growth Legalisation, has meant especially in tge recent
context of the growth of private sector in health care, has meant commercialisation of the service such that there is little
regualtion on their quality .This has further lead to the increasing insensitivity with whcih women 'patients' are dealt with
where they feel humiliated and shamed. On the issue of foetal right it was felt that this cannot be considered a civil right and
abortion is a woman's right. Even though this right has been coferred on women without their demanding it, every effort
should be made to preserve it. the need of the hour is to provide women-centtred abortion centres though this should not lead
to a sort of ghettoisation but to a changed perception of the need for such services.

Population Policy: Increaingly in the current context, the need for population control is being projected as a primary factor in
ensuring women's health. In reality the emphasis on population control policy infact derails all other programmes making the
situation all the worse for women. For example, with the focus on reducing numbers, the lack of people's access, especially

women's to resources is sidelined, this danger is liiglilighted in the case of Tamil Nadu. To talk of women's reproductive rights
has no meaning in the context ofthe complete lack of survival rights for women has no meaning, (see Malini Karkal's paper in
mfc bulletin August-December 1993) It is only if these: that is, education, employment, food, child care, and a better social
status in society are ensured that women's reproductive health can be a matter of special concent. For instance, in Kerala the
fact that there are few births among women in the ages 15-19 is attributable to better education and also leads to better health,
perhaps. Sri Lanka has been able to bring down birth rates because of a policy which ensures that women have access to
education and employment.
The basic plrilosophy of population policies being encouraged in tliird world countriesy has been that the poor are
eugenically inferiour and therefore should not be allowed to breed. Lidia has been in the forefront not only in adopting
population policy but in implementing it throught a state family planning programme and has contributed significantly to the
growth of demography as a serious discipline (See mfc bulletin May-July 1993). Unfortunately these are not achievements
we should be proud of Today the situation is such that demographers are defining people's needs, setting targets for family
size etc without taking into account sociological, cultural economic factors which determine family size. While
contraceptives, safe, effectiveand women controlled are a widely felt need, a directly or indirectly coercive family planning
programme directed only at controlling numbers will shift the focus away from issues of development. The statements being
circulated by different groups on the population policy were mentioned but not discussed at length.
Sexuality: Only in recent years, especially in the context of the reproductive health agenda is sexuality ebeing sought tobe
defined and explored. Thw way women perceive sexuality is probably very different from the way a patriarchal society seeks
to define it and its expression. For instance, activities which give sensual pleasure such as singing and dancing are also
expressions of sexuality. Unfortunately the expression of sexuality becomes narrowly defined even as a girl is growing up:
society places certain limits on her movements and places taboos on some types of expression, and restricting others. Society
hs conferred different limits of expression of sexuality for men and women. For example it is permissible for a man to be or
to aspire to be polygamous, but not for a woman who is supposed to remain chaste for her husband and remain faithful. As a
logical follow through of this is the fact that homosexuality is considered aberrant behaviour and not to be tolerated. But
whether in heterosxual relations or homosexual, there was always a power relation involved which is rooted in the way
society is organised. A major part of the discussion focussed on the fact that progressive and left movements had never
examined the issue very seriously or challenged existing notions. Women who come into these groups often expecting a more
enlightened gender sensitive attitude, have had to contend with the same patriarchal notions of man-woman behaviour and
constraints on the expressions of sexuality as they have to outside these movements. It is only in more recent times that
women from these movements have asserted themselves and sought to highlight the often exploitative relationships which
have developed within the movement. From this is coming about a newer understanding.

Menopause and HRT: With the current emphasis the focus of health interventions appears to be entirely on women in the
reproductive age group. However, with an ageing population and the lower mortality among women in the older age group,
there will be a growing number of older women who will have special health needs. While a lot of problems are common to
both men and women, there is a dearth of information on older women and their social, cultural and physical needs. Ther has
for instance been very little documentation of women entering menopause, although these experiences may be very different
from that of an older generation when a larger proportion lived in extended or joint families, the health needs of older women
are increasingly being defined as being osteoporosis, depression etc which are dealt with at the primary health care level by
prescribing hormone replacement therapy or tranquilisers. However, they may infact need access to simple surgical facilities
to resolve problems such as incontinence, prolapse of the uterus and specialist services such as oncological for detecting and
treating cervical cancers, etc. And yet no comprehensive change is occurring in the primary health care set up to reflect the
changing needs of the population consequent upon the changing demographic characteristics.

The discussion were thus in the nature of explorations rather than focussed and in-depth. What the meet brought out most
emphatically is the dearth of an alternative comprehension of what constitutes women's health, what are women's health and
medicare needs and how best these can be met. A beginning perhaps can be made with Thelma Narain's background paper in
the mfc bulletin August-December 1993) Unless we arrive at an understanding of these, we will fall into the trap of merely
critiquing policies and programmes which are motivated by a different agenda, and be reduced to offerring limited alternatives
within a framework which is neither gender sensitive nor even pro-people.
Compiled by Padma Prakash. Group reports by Nagmani Rao, Aditi Iyer, Annie George, Swatiji, Padmini Swaminathan,
Asha Vadhera.

5

Resolutions passed/Stands taken at tlic medico friend circle annual meet on Reproductive Health
In January 1994 at Sevagram, Maharashtra

Population Policy

We oppose the population policy primarily because:

a.
Its basic premise is that we are overpopulated and therefore need to control our population which in turn means almost
solely, control of birth rate.;
b.
Translation of this premiseinto policies to control the bodies the fertility and the lives of women because it is women who
bear children;
c.
Population policies have in-built eugenic ideologies through the process of selection of the ones who have the right to
survive. In India translation of this ideology consists in targetting particular populations such as the dalits, tribals, minorities
and the poor in general, who bear the brunt of population control policies;

d.
Population policies represent and endorse the interests and lifestyles of over-consumption in the countries of the north as
well as of the elites in the third world. These lifestyles are built on a growth model that is directly responsible for severe
environmental degradaton in most parts of the world which have in turn, undermined people's security and livelihoods. We
reject the prevalent notion that the so-called third world's overpopulation has a causal connection with environmental
degradation.
e.
Birth control mechanisms have over the period become so complex and hi tech that control over bodies have passed into
the hands of population controllersrapart from becoming the sites of questionable and dangerous research.

f.
Population policies are dilinked from socio-economic development: the budget for population policy at the national level
has increased substantially at the expense of general health policies. Budget cuts have also characterised the minimum needs
programme which directly affect the poor in the rural areas.
We demand respect for the integrity of women's bodies and restoration of control over their bodies. Women's basic needs for
food, education, health and work should be addressed on their own merit. Meeting women's needs, including the need for
contraception and the like should be de-linked from population policy including these expressed as apparent humanitarian
concerns for women.

Women should have access to safe contraception and legal abortion under broader health care. These needs can only be met
if all life is respected and accorded dignity.
For all these reasons we state that we oppose population control policies in all forms. Also there cannot be a feminst
population control policy. Our voices cannot be used to legitimise an anti- women, anti-poor, anti-nature policies.

Abortion Services

1.
Abortion should be placed on the agenda of the health sector as an essential part of the entire women's health package
(women's health package = health education of women about their own bodies, sensitisation of men to gender issues in
women's health, health services for women through their entire life cycle).

2.
Health and women activist groups should activel campaign for accessibility to 'quality1 abortion services ( quality sensitive,
safe, women-centred, confidential, non-hierarchical, non-patriarchal, humane).
3.

Abortion services should be provided as a part of a comprehensive women-controlled women's health programme.

4.

The practice of inserting CuTs immediately after MTPs especially in government health facilities should be stopped.

5.
Mushrooming of commercial and assembly line abortion facilities should be opposed and regulatory mechanisms
effectively enforced.

Barrier Methods

Awareness about and availability of barrier contraceptives like the diaphragm and condoms must be ensured by the
government through the public health systems, other government and non- government agencies and the media. Use of such
low-hazard effective contrceptive methods will also help in minimising the spread of sexually transmitted diseases including

AIDS. Hence we endorse barrier methods as opposed to the new hazardous hormonal and immunological methods. Support
to both women and men to use barrier methods successfully requires educational inputs for which the government must
ensure the necessary infrastructure and budgetary allocation, the government must hold responsibility for ensuring quality
control of barrier contraceptive products.
Access to Health Care

The access of the Indian people to health care is grossly inadequate. The reasons, we feel are:(i) Unanswerability of public
health services, (ii) Overemphasis by the public health services on population control.(iii) Increasing dominance of the
unregulated private health sector, which further aggregate inequities, (iv) Privatisation (v) Very low investment of resources in
the public health sector and the skewed concentration of existing resources in favour of-urban areas.

Taking into account the poor health status of the Indian people, we strongly assert people's right to universal access to rational
and humage health care as defined and demanded by the people. This access should be irrespective of the capacity to pay.
We propose that conducive conditions for equitable access be created through: (i) Increased investment by the state in the
health sector, and more so for the underserved areas; (ii) redistribution and reallocation of resources away from the targetoriented and population control centred programmes towards those which reflect the real needs and concerns of the people,
especially of women, (iii) Understanding women's health concerns beyond the narrow confines of maternity, (iv) Halting the
alarming rate of privatisation of public health services, (v) Regulation of the private health sector and making it accountable in
terms of rational and affordable medical care.
In the final analysis we feel that only a conscious, articulate and sustained pressure from the people will ensure that the state
addresses these concerns, the role of all pro-people and secular movements in attaining this goal is crucial.
Maternity Benefits

We understand that there is new legislation before various state and central governments directed at withdrawing many
entitlements including the Maternity Benefits Act from the third child onwards. We see this as a retrogressive effort at
population control and also one among a series of such measures that are going to be heralded to withdraw whatever little
benefits that women and disadvantaged sections like the rural and urban poor, tribals dalits and minorities get from the state.

We strongly feel that maternity benefits must be made universally available to all women, irrespective of their parity. In fact
the scope of presently available maternity benefits must increase in quality and quantity to ensure the health of the mother
and for the survival of the child, most Indian women work in the ounorganised sector and have no access to basic human
rights at the workplace including maternity benefits. The need to provide these basic rights to all women workers is crucial.
We cannot allow maternity benefits to be withdrawn from the few women in the organised sector where trade unions have
fought hard to win access. We insist that it is the duty of the Indian state to provide improved maternity benefits including
child rearing facilities to all women.
Further we strongly oppose infringement on human rights in the name of disincentives in population control programme.
Maternal Care

Maternal care programmes in India are planned to cater to the needs of pregnancy, childbirth and peurperium through a
structure including various levels of health workers and dais. This is desirable though in reality it falls short of what is
planned. Apart from weak implementation, two other problems can be recognised with this approach: a) the focus of

7

maternal care tends to take for granted other aspects of women's health, b) the thinning out of efforts put into various 'tasks' of
maternal care has effectively prevented provisions of safe and effective obstetric services. This is because of an assumption
that antenatal care alone automatically ensures a normal pregnancy outcome, which is not true, especially as regards maternal
death.

In order to reduce maternal deaths, it is necessary toensure tha all women have access to affordable and effective obstetric
care which can cover emergency situations as well. This must be located in the context of good primary health care facilities.
Sex Education

The moulding of attitudes from childhood to adulthood relating to body and self requires an entirely new perspective which
could replace the existing perspective of the sex education curriculum. This perspective would address the aspects of male­
female sexuality and healthy man-woman relationship. This should find an important place in our schools and colleges and
other avenues of education, including media.

LI ST

QJZ-

THE

PARTICIPANTS

ANNUAL

MFC

AT_

MEET

WARDHA
JAN.1994)

< :13—15
Sr.No.

Name

1. Malini Karkal
2. Shiva Mani
3. Yogesh Jain
4. Sandhya Phadke
5. Prasadika Rathod

6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Smita Bajpal
Anuja Kak
Lele Madison
Ravi Duggal
Anita Borkar
Manisha Gupte
Vanaja Ramprasad
Mira Shiva
M.V.Warade
Anita Dasgupta

16.
17.
18.

Prabir
Mira Sadgopal
Darlendra David

19.

Sabala

20. Swatija
21. S.L.Pawar
22- Asmita M.J.

Address

4,Dhake colony,Andheri(W), Bombay-400 058.
15, Sarojini Street,Pollachi,Tamilnadu-642 002.
BB/49 C,Janakpuri,New Delhi - 110 058.
50,L.I.C Staff Quarters,G.K.Road,Pune-411 016.
CHETNA, Leelawati Lalbai's Bunglow, Civil Camp
Road, Shahi Bagh, Ahmedabad-380 004.
CHETNA, Ahmedabad.
CHETNA, Ahmedabad.
CHETNA, Ahmedabad.
4<jo
4/408,Vahtuk Nagar,Amboli,Andheri(W),Bombay-8®^
ABHIVYAKTHI,Susheela,Canada corner,Nasik-422005.
ll,Archana apts.,163,Solapur Rd.,Hadapsar,Pune-28 ■
839,23rd Main,J.P.Nagar,II Phase,Bangalore-560078
A-60,Hauz Khas,New Delhi 110 016.
A-10,Advihir,Ta-Motala,Dist. Buldhana.
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Puri New Delhi - 110 058.
FFWH,2,Vishwa deep,Bhandaji Road,
Matunga,Bombay-19.
FFWH, Bombay-19.
Ranebennur - 581 115, Dist Dharwad, Kanataka.
A-2,New Patkar's Block,Turner Road,Bandra(W),
Bombay -400 050.
8

23.
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25.
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33.
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Asha Kachru
Amita Godbole

STRAENTA,P.0.Ranjole,Medak,dist.,A.P.502 318.
Save the ChiIdren,207,Sita Park,17,Shivaji Nagar,
Pune-411 005.
Benjamin
CHC,Shrinivasa Nilaya,! Main,4th Block,
Koramangala,Bangalore-560 034.
Chander
CHC, Bangalore -560 034.
Ranjit Goswami
B.J.V.J.,Science & Technology Env.Council,
Panchavati, ShiIpukhuri,Gauhathi,Assam.
Khogendra Rajkumar (SOC)
B.J.V.J. Sagal Band Tera,Amndol,Imphal-1.
Prabhakar Pusatkar
12/3,Sarvapriya Vihar, New Delhi - 110 016.
Monju Kolita(SOC)
Panchavathi, Shilpukhuri,Gauhathi, Assam.
Ram Nath Rao (SOC) Bharat Gyan Vigyan,3/379,Biswas Klmad,
Gomatinagar, Lucknow (U.P.)
K.Lalita Damadoaran
ANVESHI,Osmania UNN Campus,OUB3, .
O.U.C,Hyderabad-7.
Veena Shatrugna
ANVESHI, Hyderabad - 500 007.
Usha Rani
C/o.Dr.Sheela Prasad,Centre for Area Studies,
O.U.Campus, Hyderabad - 500 007.

35.

K.Sajaya

36.

Vasudha

37.

Sheila James

38.

A.Umamaheshwari

39.

Madhavi Desai

40.
41.
42.

Usha Sethuraman
Sham Ashtekar
Amar Jesani

43. Anil Pigaokar
44. Annie George
45.
46.
47.
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C.Satyamala
Padma Prakash
Asha
Aditi Ayer

49.
50.

Marie D'souza
Sushma Jhaveri

51.

Chhaya Deshpande/
Kalplliwar
Mohan Deshpande
S. Srinivasan

52.
53.
54.
55.
56.
57.
58.
59.

BHUMIKA Women's Magazine,12-13-391,Tharnaka,
Secunderabad - 500 015.
Plot No . 13,Sripuri Colony,
Kakaguda.Secunderabad-15.
C/o.Indira Pakejanathan,A-l-l,546-1,Mushirabad,
Hyderabad- 500 020.
Deccan Devt.Society,A-6,Meera Apts.,Basheetabad,
Hyderabad - 500 0296.
Indian Inst.of Youth Welfare, 134,Shivajinagar,
Nagpur - 440 010.
B-ll,Shaukar Sarshan, 15th Road, Chembur, Bombay-7/.
Dindori, Nashik - 422 202.
310,Prabhu Darshan,Swatantra Sainik Nagar,Amboli,
Andheri (W), Bombay 400 058.
34-B,Noshir Bharucha Road,Bombay - 400 007.
5,Varsha Sangam,Chakala Road,Andheri(E),Bombay-99

B-7,88/1,Safdarjung Enclave, New Delhi - 110 029.
19,June Blossom Society,60 A,Pali Road,Bombay-50.
FRCH, 84 a,R.G.Thadani Marg,Worli,Bombay-400 018.
Gold Finch,514/C,R.P.Masani Road,
Matunga,Bombay - 400 019.
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Staff Nurses(Nurse Fedration) Wardha.

2,Surabhi, Old Gangapur, Nasik- 422 005.
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Baroda 390 015.
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2/20,Radhabai Buldings.lst floor,
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NL-5/9/14,Sector 3,Phase I,Nerul,
New Bombay-400 706.
Sadhana Shetty
37 A,Behind Maha Auto,Kalina KoliveryVillage Lane, Santa Cruz (E), Bombay-400 098.
Rajesh Mehta
23,Sharda Nagar,Ahmedabad - 380 007.
Madhukar Pai
23,Rajbdhar Street, Perambur - 600 011.
Padmini Swaminathan
Madras Inst.of Development Studies,79,11
Main Road
Gandhinagar, Adyar., Madras - 600 020.

. nillie Nihila
61. G.Suchitra
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63. Dhruv Mankad
64. S.Shridhar
65. Manjusha
66. Renu Khanna

67.
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70.
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Anant Phadke
Audrey Fernandes
Nagmani Rao
Shridhar Gavaskar
Mahesh Gavaskar

72.

Anupa Diwakar

73. Laxmi Kingam

74.

Madhukar Gumble

75.

Dilip Karale

76.

S.Opendra Singh

77.

Sunita

78. Thodsam Chandu
79.
80.
81.

Binayak Sen
Vidya Dehmukh
Padma Swadhi

82. Unni Krishnan
83. Sumith
84. Sushma

Madras Inst.Of Development Studies, Madras-20.
Madras Inst.of Development Studies, Madras-20.
Dept.of Humanities & Social Sciences,I.I.T . ,
Madras - 600 036.
VACHAN, Shivajinagar, Nasik-422 006.
SEWA RURAL, Jhagadia - 393 110.
SEWA RURAL, Jhagadia - 393 110.
l.Tejas Apts.,53,Haribhakti Colony,
Baroda-390 015.
50,L.I.C Quarters, University Road, Pune-16.
11, Ameya,Opp.Brahma Bagh,P.0.Mundhwa,Pune-3684/2,Moreshwar Society,Baner Road,Pune-411 007.
4091,Gondhali Galli,Belgaum,Karnataka-590 002.
12,Usha Kiran,44,Subway Road,Santacurz(W),
Bombay - 400 054.

Manas,52,Soubhagya Nagar, Gangapur Road,
Nasik - 422 005.
TISS (Woemn's Studies Unit) Deonar,
Bombay-400 088.
P . 0.Gurukumja Mozari,Tai.Teosa,
Dist.Amraoti-444 902.
P.0.Gurukumja Mozari,Tai.Teosa,
Dist.Amraoti-444 902.
Citizen Volunteers Training
Centre,
Palace
Compound (West), Imphal - 795 001.
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Palace Compound (West), Imphal - 795 001.
Gondwana Ci Inic,Indervelly,
Ad ilabad Dist.- 504 436.
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BJVJ, Shinde Camp, Akola 440 004.
Nagar,Gurukul
Gorakshan
Road,
BJVJ, Agase
Near Tukaram Hospital,Akola.
VHAI,Delhi.

I O

ICHD 1997-98

MH -

-

Rationalisation of Antenatal Care
Vincent De Brouwere

Background
The history of modem Antenatal Care began early twentieth century. Britons attribute
the initial conception of ANC to John William Ballantyne in 1901. Australians attribute it
to Wilson in 1910 (Oakley, 1984) and North-Americans to their Instructive District Nursing
Association of the Boston Lying-In Hospital, in 1901 (Kessel, 1987). The Ministry of Health
of the United Kingdom has set up the standard package of ANC in 1929. This package
will remain essentially the same up till now, even if sometimes a new technique has been
added or updated. The ‘principles’ of such ANC package have been described by the
MOH as follows (Memorandum on minimum standards in antenatal care: ‘Ante-natal
Clinics: their conduct and scope’, 1929):

1.
2.
3.
4.
5.

6.

to predict ‘difficult labour’ from examination in pregnancy;
to detect and treat toxaemia;
to diagnose/treat/prevent infection (e.g. dental, cervical);
to diagnose and treat vaginal discharges;
to ensure ‘the closest co-operation’ between the clinic and all persons in charge
of pregnancy care;
to recognise ‘the educational effect of a well-organised clinic’.

The ANC clinic schedule consisted in an average of twelve visits of which a medical
doctor should have attended three.
In the beginning of the 1930s, ANC is questionned because maternal mortality
showed no diminishing trend. Browne and Aberd (1932), then F. Neon Reynolds
highlighted (in a letter to The Lancet, on 29 December 1934) that “80 per cent of maternal
deaths were due to conditions (sepsis, haemorrhage, shock) not detectable antenatally”.
The answer was not a randomised controlled trial. The answer, from the promoters of
ANC, was to go ahead because one had not given a fair trial to ANC to prove its
effectiveness. The arguments for explaining such a poor impact on maternal mortality
were: (1) an insufficient proportion of the pregnant women attending for antenatal care;
(2) not enough antenatal visits, (3) an inadequate standard of care. At this time (1935) in
England, the ANC coverage (for at least one visit) was on average 50% (73% in towns
and 17% in rural areas).
In the 1960s, the individual assessment of risk factors in ANC became a routine
procedure. Confidential enquiries about maternal deaths carried out in the United
Kingdom showed and quantified, as soon as 1955-57, the maternal risk related to
maternal age and parity (Lawson and Stewart, 1967).
Extrapolation to developing countries was considered reasonable, although no
epidemiological study has been performed in such a context. Since the early 1950s,
antenatal care has been promoted in developing countries (OMS, 1952). It was
considered as one of the most effective strategies to decrease child and maternal
mortality together with, at the end of the 1960s, family planning, and then, in the 1970s,
the training of traditional birth attendants.

FLHS, Rationalisation of Antenatal Care

page 1

ICHD 1997-98

Modern justification: the risk approach
Rise and fall of the risk approach: the evidence-based filter
End of the 1970s, WHO published “An approach to maternal and child health care
based on the concept of risk” (OMS, 1978). And, in 1984, its methodological and
conceptual extension: “The risk approach in health care, with special reference to
maternal and child health, including family planning” (Backett et al., 1984). The 1980s
were the years of enthusiasm for this new paradigm called “risk approach”. Actually, it
was not exactly a “new” paradigm, but what made it new was the tuning of the method
to quantify the risk. The risk approach seeks to use information about risk to prevent a
variety of adverse outcomes (that is, illness, injury and death) through the application of a
strategy at many levels of care. It was assumed that once a risk was identified, women
were referred to the appropriate facility where one could take charge of the problem.
Developing countries would have thus a decision making tool available, a decision
making tool simple enough to be delegated to the poorly qualified health worker. Great!
The hope was that using this tool it could be possible to reduce the number of women to
be referred, thanks to this screening tool, and safely take charge of the others. And doing
so, it would be possible to reduce maternal and perinatal morbidity and mortality at low

cost.
In the beginning of the 1990s, about ten years later, WHO published the Rooney
report “Antenatal care and maternal health: how effective is it?” (Rooney, 1992). This
report observed quite officially that we know very little about the effectiveness of the
procedures promoted in antenatal care. She noted “performance of programmes based
on risk approach has been questioned, particularly where resources are rare []. It is
possible that the risk approach allows the health workers to recognise women who need
specific care during labour or delivery, but this needs to be carefully evaluated. We
currently don’t know exactly what is the performance of such a system in developing
countries and we urgently need to carry out careful studies on a large scale to assess the
results as well for women as for children”.

Bases of risk approach
A risk factor has been defined as any ascertainable characteristic or circumstance of a
person or group of persons that is known to be associated with an abnormal risk of
developing or being especially adversely affected by a morbid process (WHO, 1973). In
the field of MCH, one can observe that pregnancy and delivery present a risk of
morbidity and mortality for the mother and the child. The concept of high risk comes
from the observation that the risk of dying or to have adverse outcome (sequels) is
neither homogeneously nor randomly distributed in the population of pregnant women
and their babies. Most women deliver without any problem or sequel and their babies are
healthy. A small proportion of these women and of those children will experience
adverse outcome. The question is to know whether it is possible to identify those women
before the fatal event happens and whether it is possible to avoid the fatal event (and
how?). The assumption in the risk approach is that the answer is positive: some women
have indeed a higher risk to develop problems and that it is possible to identify the
characteristics or risk factors (related to a biological or environmental problem or both).
Of course, conceptually speaking, this makes sense only if one can prevent this risk to
become a problem. In other words, risks actually are identifiable before the predicted
event happens.

FLHS, Rationalisation of Antenatal Care

page 2

ICHD 1997-98

Two schools are in competition. One states that a pregnancy can only be labelled as
normal retrospectively, after the delivery, when one can prove that mother and child are
healthy (all pregnant women are at risk) (Papiemik, 1995). The other states that
pregnancy and delivery are natural events that can take place at home without any
intervention but under surveillance by a professional (midwife or general practitioner)
(Akrich and Pasveer, 1996; Enkin, 1993). In the first statement, all the women should
deliver in hospital under a more or less sophisticated technical surveillance. In the second
statement, women who are not identified at risk are encouraged to deliver at home under
the surveillance of a professional (to identify possible complications during labour or
after delivery, and refer the women in due time).

But is it really possible to separate, in an efficient and easy way, the true positives
(those women who will experience a problem during the pregnancy or delivery) from the
true negatives (those who won’t experience any problem)? I would add, in a context
where the referral hospital is poorly accessible (geographically or financially), that is in
most developing countries.

Figure 1. Screening for risk: cut-off points in a continuous variable

Figure 2. Screening for risk: " trade-offs” between false positives and false
negatives (hypothetical data from table)

POINT

FLHS, Rationalisation of Antenatal Care

page 3

ICHD 1997-98

In the example given above (Figure 2 from Backet et al., 1984), categories come from
hypothetical data (Table 1).

Table 1. The balance of false positives and false negatives in the use of risk

factors in preventive medicine_____ ______
Risk factor

Present +

Unwanted outcome
Present +
Absent 5 false
200 true
positives
positives

Absent -

25 false
negatives

725 true
negatives

Totals

225

775

Totals

250
750
1000

This means a prevalence of the problem of 22.5%, a sensitivity of 89%, a specificity of
94% and a positive predictive value of 80%. There exists no single maternal health
problem that gives an adverse outcome in 22.5% of the cases. All the possible problems
(not including iatrogenesis) together lead to a maximum of 1 to 2% of maternal deaths
(natural maternal mortality) and a maximum of about 10% of perinatal deaths. Every
single problem has a lower prevalence and consequently a lower positive predictive value.
Data from Kasongo (Kasongo Project Team, 1984) can offer a more realistic picture.
In the following example (Table 2), the best screening tool (bad obstetric history) for the

non-primiparous women was used.

Table 2. Prediction of obstructed labour with the risk factor "bad obstetric
history" in Kasongo

Bad obstetric history
No bad obstetric history
total

obstructed
labour
15
36
51

Labour not
obstructed
141
3422
3563

Total
156
3458
3614

Prevalence goes down to 1.4%, sensitivity to 29% and the positive predictive value to
around 10%. The relative risk however is high (9.2), meaning that a woman with a TDad
obstetric history’ has 9.2 more chance to experience a blocked labour. It is not possible
to graphically represent the data, as in Figure 2. There are indeed less ‘true positives’ than
‘false positives’ or ‘false negatives’ and far less cases from the three last categories than
the total number of‘true negatives’ for this criterion.

The relative risk seems not to be a very effective tool. When considering the whole
population of pregnant women, because of the huge number of false positives (which
have a cost in terms of transport, stay in hospital and loss of confidence in the screening
by the population) and of false negatives (which decrease the effectiveness of the tool).
The positive predictive value could however become better for a more specific risk factor
at the expense of the global effectiveness of the screening. For instance, let’s assume that
among 1,000 nulliparous, 100 are smaller than 150 cm and that among these women the
proportion of blocked labour is 15 times more frequent than in the taller population (>
or = 150). In this case, it would be a pity not to counsel these small women to deliver in,
or near, the hospital, even if only 15% of them will actually experience a blocked labour.
We can also play a little bit more with the criterion, according to the trade-off we want

FLHS, Rationalisation of Antenatal Care

page 4

$

ICHD 1997-98

between false negatives (who are failures for the system’s effectiveness) and false

positives (who increase cost). One can increase the specificity of the sign and decrease
the cut-off point for the height to 147 cm. The positive predictive value would become
higher (i.e. 40%) at the expense of a loss in sensitivity. For smaller women, one can
wonder if it is still a risk or if it is already an obvious health problem (polio sequels, pelvis
fracture, rickets, etc.).

The definition of “risk” and of “risk factor” is not easy in practice. The criteria used
to identify women at high risk may be structured according to two types of classification
(Phuapradit et al., 1990):

1. relationships between risk factors and adverse outcomes; these are of three
kinds:
a.

causative, triggering of pathological process; for example, maternal malnutrition and
low birthweight, placenta praevia, and fetal death from anoxia, or first trimester
rubella infection and congenital malformations.
b.
Contributory, such as grand-multiparity predisposing transverse lie, and prolapse of
the umbilical cord.
c.
Predictive, or associative in the statistical sense; for example, a woman with
previous fetal loss is at geater risk of losing her next pregnancy.

2. biological, medical and social conditions; these include:
a.
b.
c.
d.
e.

biological risk factors (age, birth order, birth interval)
nutritional factors (height, weight, weight gain)
health care utilisation (antenatal care)
pregnancy complications (anaemia, hypertension, diabetes mellitus, antepartum
bleeding, twins, abnormal presentation)
social conditions (work load, birth attendance)

Such a classification of risks mixes “health problems’ with ‘risk factors’. Severe
anaemia, sexually transmitted diseases, bleeding or diabetes mellitus are health problems,
or possibly complications of the pregnancy or problems complicated by pregnancy. On
the other hand, age, height (except when it is the result of a disease), weight, obstetric
history or multiparity are risk factors. The sensitivity of risk factors is generally low, while
sensitivity of complications is high (Rohde, 1995). Some authors propose then to drop
risk factors and to invest only in two strategies. The first is complications case-finding
and the second education. The latter is supposed to help women to early identify
complications in order — and this is a condition — to make the decision to go to a well
equipped emergency obstetric care unit (Bhatia, 1993; Maine et al., 1991; Yuster, 1995).

All these considerations on predictive values, sensitivity, specificity of risk factors,
taken in isolation or regrouped in “scoring systems*12
”, have been explicitly formulated by
4
3
1 From Phuapradit (1990), a risk scoring system is a simple method for detecting and classifying pregnant women at
risk. Steps used to develop risk-scoring system are as follows.
1.
collect risk factors that influence health of mother and foetus during pregnancy from previous studies, journals
and theoretical papers.
2.
Categorise the risk factors according to the criteria based on biological, medical and social conditions.
3.
Scoring marks are given to each risk factor according to its severity and its effect on pregnancy and labour on the
basis of measurements of the actual risks in the same population. Those with the highest score are at greatest risk
for the defined adverse outcome. In case of multiple risk factors the score for each factor is added and the cut-off
point above which the mother is referred is arbitrarily given. However, this point must always be lower than the
score given to a single risk factor which is known to be associated with a major risk adverse outcome.
4.
Test for validity of the score and the scoring criteria.
Note: 1) due to different health problems and different levels of health personnel, the development of risk-scoring
system should be individually tailored in different communities, and simple to be used by the PHC workers. 2)
pregnancy is a dynamic process. Complications may occur anytime during pregnancy, labour and puerperium. Health
care providers should screen expectant mothers at proper time setting. 3) the cut-off point of the risk factors must be

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ICHD 1997-98

the creators of the risk approach and by the maternal health epidemiologists (Backettet

al., 1984; Golding and Peters, 1988). The study, more and more systematic, of the public
health interventions with the help of RCT (randomised controlled trials), made peop e
aware of the absence of validity studies or of the poor validity of the classical content o
ANO set up 70 years ago. This new awareness has had the effect of challenging
e
usefulness of ANC as a screening tool for maternal health programmes (Fortney, 1995,
Akalin and Maine, 1995; Maine et al., 1991). If the risk-scoring systems appear to be not
effective to identify needs in the maternal health field, what can developing countries
implement in order to rationalise the allocation of their scarce resources? Rooney (1992).
“Effectiveness of a risk-scoring system in its most restricted meaning should be
evaluated by its power to screen women at high risk from those at low risk, that is by its

sensitivity, its specificity and its positive predictive value. But, in order to set up an
effective public health strategy, there are still some other conditions to be met:

a)
b)
c)
d)
e)

primary screening should concern the whole population;
screening should include the main causes of morbidity and mortality;
if a high risk is identified, appropriate measures (i.e. referral to hospital) should be
taken;
appropriate care should be available at referral level;
women at risk should reach the referral level and have the motivation to do it”

All the authors seem to agree at least on one point, the necessity to have a wellequipped second level service able to take charge of emergency obstetric care. The
referral criteria would have to be decided according to the accessibility of the referral
level. If there is no access, it makes no or little sense to provide ANC at FLHS: it would
just make the women aware of risks that cannot be overcome (ethical issue). Listening to
the community and negotiating with women the place of delivery could be a second
recommendation.

Where are we now?
Assessing effectiveness of antenatal care that is provided in an ANC consultation is
something tricky. First, one has to clarify what ANC means and what is the content of
the package offered. It is in principle a standard package, but practically this is something
very different from one context to another (content and quality, reliability and
effectiveness). Moreover, studies that make a difference between the impact on mother
and the impact on child are rare (MacDonagh, 1996). Still rarer are studies that use RCT
designs on big enough sample size. That is why during many years people believed that
ANC was an independent variable influencing positively the outcome of pregnancy
(either for child or for mother in terms of perinatal mortality rates, Apgar scores and
maternal mortality and morbidity rates).

Current objectives of antenatal care
The goal of ANC generally consists in preventing morbidity and death of the mother
and her baby and in promoting maternal and child health. In practice, the current
literature proposes the following objectives (Llewellyn-Jones, 1994):
The aims of ANC are to ensure that:

appropriately chosen, taking into account the balance between die serious outcome of the false negative readings and
the inconvenience and waste of resources on false positives.

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The mother reaches the end of the pregnancy as healthy as, or even healthier than
she was before she became pregnant.



Any physical or psychological problems arising during the pregnancy are detected
and treated.



Any complication of pregnancy is either prevented or detected early and managed
adequately.



The mother gives birth to a healthy baby.



The mother has the opportunity to discuss her anxieties and fears about the
pregnancy.



The mother is informed about any proposed procedures, the reason for the
procedure and the probable outcome.



The couples are prepared for the birth and for child rearing, including receiving
information about diet, child care and family planning.

These aims are beautiful and comprehensive but difficult to implement in developing
countries. When resources are scarce, one should clearly define each of the procedures
he/she wants to choose, but also the rationale of the choice, the expected benefit, the
feasibility and the cost. In the evaluation of the procedures, one has to take into account
the series of tasks that leads to a health benefit. Identifying a risk has little sense if there
is no way to refer.

Content of ANC package
Again, setting up an ANC package is only justified if there is an effective referral
system, that is an accessible and effective obstetric care unit (able to perform C-section,
blood transfusion, a place where obstetric skills exist and where appropriate drugs and
equipment are available and affordable). So, the priority is to make such referral system
operational.

What then could be the content of ANC? Regarding the current state of the art, the
ANC package should be oriented towards two main axes:


Education of pregnant women



Identification and early treatment of vulnerable diseases and complications and, if
relevant, the assessment of individual risk.

Education of pregnant women
Diminishing anxieties and fears about pregnancy (hygiene, nutrition, sexual inter­
course during pregnancy, taboos, etc.) and promoting "good" attitudes that are
culturally acceptable.
This can be done only if the health personnel listen to the women. This listening
and simple answers (common sense) to anxiety help to create confidence. Such
relationship will be useful if a complication occurs, so that the health personnel will be
able to convince the woman to make the necessary effort to go to the referral level.

Educating pregnant women for early recognition of complications during pregnancy
and childbirth.
During education sessions (individual or in groups), the health worker will describe
and explain signs and symptoms of problems that may occur during pregnancy or
childbirth. This might be part of a programme aimed at helping women to rapidly get
treatment in case of complication. This programme can be enlarged to the whole

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community, including non-pregnant women and family decision mak

family,

mother-in-law,

traditional

birth

attendant,

healers,

'(h^

e J.

of

identification of signs, it is also important that women know w
j;n„
complication (where to go) and why. For instance, in case of bkedin^ the
information would be to rapidly go to the hospital with two people re y
blood (except if a blood bank is available in hospital). ANC consultation

gi
an

adequate place to deliver such messages.

Identification and early treatment of diseases and complications
Anaemia
Severe anaemia in pregnancy may be one cause of heart failure and may increase
the risk of dying from haemorrhage. In developing countries, it is estimated that twothirds of women are suffering from anaemia and that anaemia is often the underlying
cause of maternal mortality (Royston and Armstrong, 1989; WHO, 1993). The cause
of anaemia is multifactorial: nutrition deficiency of iron and folate, malaria, sickle cell
disease, intestinal parasites, infections, blood loss and poor economic conditions.

Routine administration of iron and folates to all pregnant women prophylactically
may prevent development of anaemia in large numbers of those with frank or
borderline iron deficiency, or correct mild anaemia in many. There is, however, a
paucity of well-conducted studies demonstrating this effect or an improvement in
outcome for mother or infant. The potential for benefit will depend on iron
deficiency prevalence. Haemoglobin levels can rise between 0.4 and 0.7 g/dl per week
on a dose of 120 mg ferrous salt with 5 mg folate, so that moderate iron deficiency
anaemia may theoretically be corrected by oral therapy in women attending for ANC
in the second trimester. Unfortunately, difficulties to implement an effective
programme are numerous. Causes of anaemia are multifactorial, drugs (in so high
quantity) are expensive, supply should regularly (without shortage) attain the
peripheral level, women should have attended ANC early in their pregnancy, they
should be compliant, etc. (Mongella, 1995; Sarin, 1995; Mac Donagh, 1996). That is
probably why there is very little evidence that supplements are effective in improving
the outcome of pregnancy for mother or baby.
Even if the iron and folate can be offered, screening for moderate or severe
anaemia is still indicated, since women with more titan mild anaemia need additional
investigation and treatment. At present, for many rural women this is only done by
inspection of conjunctivae and mucous membranes, if at all. The sensitivity and
specificity of clinical diagnosis with these methods have been shown to be poor.
Reliable tests exist to detect anaemia and investigate its cause including the
technology standard in industrialised countries, the Coulter counter, but it is difficult
to provide accurate diagnosis for the whole pregnant population.

Research has shown malaria to be responsible for severe anaemia especially in
pnmi^av'das, reducing the tolerance of haemorrhage and prolonged labour (Brabin
1991; Reuben 1993). In areas with a high prevalence it is recommended that malaria
prophylaxis be given in conjunction wij iron and folate as this has been found to be
a successful intervention (Brabin 1991; Greenwood et al., 1992).

Most of the content of this part comes from Acharya, MacDonagh and

Rooney (including large pieces of texts).

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Haemorrhage

The role of ANC in preventing or ameliorating the effects of this emergency is
limited since it depends on prompt treatment (medical and surgical at referral level) of
its cause to prevent further bleeding and replacement of blood loss to maintain the
circulation. Detection of those at risk of serious bleeding is theoretically feasible but is
not so in practice because it will only be beneficial if adequate delivery services are
available to and used by women. Even education of pregnant women has no clear
benefit: traditional interpretation of bleeding significance and traditional remedies may
delay women from seeking help. Moreover, Bhatia (1993) has shown that in India, for
22.2% of maternal deaths, the family was just not aware of the gravity of the problem.
However, it is easy to attribute to cultural barriers what are often failures to provide
adequate services or to make them accessible. Several risk factors for postpartum
haemorrhage are known3 (but poorly efficient) and no direct assessment of the
effectiveness of risk screening in preventing death from haemorrhage in developing
countries has been published (Acharya, 1995).

Hypertensive disorders of pregnancy (HDP)

HDP comprise hypertension during pregnancy, eclampsia and preeclampsia. There
is some evidence that HDPs are one of the main causes of maternal and perinatal
mortality in the world. The incidence is not precisely known but where it was
observed, it varied a lot from one setting to another (10 to 1.3 per 10.000 pregnancies
in Britain; in developing countries, Koblinsky, 1992, found 5.4 to 33.2% of women
presenting a diastolic blood pressure over 90 mm Hg during pregnancy). Very little is
known about the natural history of preeclampsia. Lethality goes from 7 to 25% in
Africa, where it was described, while it was only 1.4% in Sweden (Duley, 1990). This
shows that it would be possible to influence lethality.

The best means to detect preeclampsia is to measure the blood pressure. However,
the measurement of blood pressure, as a screening test for eclampsia, is flawed and
there is a problem of defining the limits. It means that some women with high blood
pressure will never experience a preeclampsia while others with a normal blood
pressure will suddenly present an eclampsia. The pre-clinical state of preeclampsia has
been defined as a blood pressure reading of 140/90 mm Hg but it has been suggested
that in developing countries, where women start pregnancy undernourished, the
diastolic limit should be reduced. As with routine weighing, there are intrinsic
systematic and random errors in recording blood pressure; but there are also errors
due to the transient nature of blood pressure that requires frequent readings. In
Aberdeen, results obtained a sensitivity of 71%, specificity of 95%, and a positive
predictive value of 40% for preeclampsia during pregnancy, labour and the
puerperium (Hall et al., 1980).
Nulliparous women are twice as likely to develop preeclampsia compared to
multiparous mothers, and the risk is particularly high at extremes of ages. History of
previous preeclampsia increases the risk, compared to those who have not. Risk is
also higher with a positive family history, obesity or excessive weight gain in
pregnane}’. However, none iof these factors alone or in combination confidently
predict development of HDP.

’ A biston- of previous PPH was found to be associated with a relative risk of 1.6 of recurrence, but only 6.3% of those
with a history suffered PPH in the index delivery (Chng et al., 1980).

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Dependent oedema is common in normal pregnancy (80% of oedema can be
found in normotensive women and oedema alone has no prognostic or diagnostic
value (Hussain, 1995)), but generalised oedema is a sign of preeclampsia. Women with
generalised oedema should be rapidly referred to a centre where blood pressure and
proteinuria can be measured and treatment arranged. The potential of this strategy is
not clear, but may be limited in view of the low screening sensitivity found in a WHO
collaborative study of proteinuria and oedema4 (Golding et al., 1988; Golding and
Shenton, 1990) and the problems of assuring referral and transport.
Once identified there is still no clearly defined treatment schedule or effective
intervention to prevent preeclampsia from becoming eclampsia. Rest in hospital
might have an indirect beneficial effect by putting women at risk of progression to a
more serious stage of HDP within the reach of medical care. The proportion who
might benefit in this way cannot be quantified at present, nor its inverse, the
proportion who would be admitted to hospital unnecessarily. Overviews of trials of
various hypertensive drugs, including diuretics, betablockers, hydralazine and
methyldopa, indicate that antihypertensive treatment does not prevent increase in
blood pressure when given to women with mild and moderate hypertension. Dietary
restrictions and diuretics have not been found to be effective. Sedation has been
successful to prevent eclampsia but it requires good technical expertise. However
neither the effects on the development of proteinuria nor the final outcome for
mother and infant are clear, and further trials are needed on a scale large enough to
determine them. In summary, even though there is no clear-cut documentation of
effectiveness, women with preeclampsia and eclampsia appear to experience better
outcomes when they have access to and use of professional care. This may be an
indication of effectiveness of ANC to prevent mortality from HDP.

Puerperal sepsis and urinary infections

In puerperal sepsis, ANC plays a limited role in the reduction of maternal
mortality. Health education to promote clean delivery in the home, distribution of
‘clean delivery kits’ directly to pregnant women and promotion of delivery by trained
attendants might prevent some infection. Education might also lead to better
recognition of the importance of symptoms and signs of infection after delivery and
earlier care seeking. However the crucial factors giving rise to unclean delivery are
probably more related to poverty and lack of any alternative facilities than to
ignorance, and thus the effect of health education alone is likely to be small. In
addition, the potential of referral for institutional delivery based on assessing likely
risk of infection at delivery is probably slight.

One of the most successful interventions in pregnancy in developing countries has
been the introduction of tetanus toxoid immunisation to pregnant women to prevent
maternal and neonatal tetanus resulting from infection at delivery. But it can be
performed outside the ANC clinics.

STDs during pregnancy may have serious consequences on maternal and child
health. Screening and treatment of syphilis has been found effective in the endemic
regions. Screening and presumptive diagnosis of gonorrhoea followed by treatment
seems to reduce foetal morbidity. Ophthalmic drops in the eyes of new-born is an

- This study using only oedema and proteinuria to screen for preeclampsia found a sensitivity of 43% for detecting
diastolic hypertension and 35% for eclampsia. Another study, testing for proteinuria, found 25% false positives and
6% false negatives using urine stixs (Enkin et al., 1989).

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ICHD 1997-98

effective

means

to

prevent gonorrhoea

conjunctivitis

(and

blindness

as

a

complication).
Treatment of symptomatic urinary infections should be included in the ANC
package since it has been proven effective (Rooney, 1992). Seeking bacteria in urine in

non-symptomatic women during pregnancy — if possible during the first trimester
followed by the treatment of positive cases (short course treatment) has also proven
its efficacy through RCT (less cystitis, pyelonephritis, premature delivery, low birth­
weight). The benefit of integrating such screening in the ANC package will depend on
tlie local prevalence of non- and symptomatic urinary infections in the pregnant
women population.

Obstructed labour

Obstructed labour is usually due to cephalo-pelvic disproportion (CPD) or
malpresentation. As a matter of fact, such a diagnosis is made when labour lasts more
than 24 hours (in primiparas). Solution is usually a major obstetrical intervention
(caesarean section, symphysiotomy, internal version, craniotomy and when too late a
laparotomy for breach repair or a hysterectomy).
Strategies for primary prevention of CPD are designed to improve nutrition of
girls so that they reach their full growth potential and behaviour modification of
women to delay their first birth until they are fully mature. These include
contraception and delayed marriage. Such factors combined with education and
improved economic opportunities for women, are obviously outside the scope of
ANC. However, there is some encouraging evidence that malaria prophylaxis and iron
and folate supplementation for very young primigravidae may increase their own
growth during pregnancy (Harrison et al., 1985).

All nulliparas might be regarded as high risk (no obstetric history). However, the
majority of these women will not experience a prolonged labour or obstruction, and a
more specific test, with higher predictive value is needed where specialist delivery
services are scarce. Hofmyer (1989) reviewed studies about risk factors all around the
world and concluded that, though short stature, small foot size and very young age are
undoubtedly correlated with risk of cephalo-pelvic disproportion and caesarean
section rates, they are poor discriminatory tools. A WHO collaborative study of
maternal anthropometry and pregnancy outcomes (Kelly et al., 1996) showed that
weights taken at pre- or early pregnancy and 5 or 7 lunar months were useful
indicators of low birth-weight and intra-uterine growth retardation (IUGR) risk and
provide warning of the need for intervention. However the ability of the study
indicators to predict pre-term births is very limited. Moreover, the identification of
IUGR at a so late stage of pregnancy does not let time enough to improve foetal
growth with food supplementation to the mother (if it could be supplied). Neither
maternal height or arm circumference emerges as effective indicators for any of the
foetal outcomes in this analysis. The ability of the study indicators (height, weight,
arm circumference, weight for gestational age, body mass index for the gestational
age, weight gain in the interval) to predict the three maternal outcomes (pre­
eclampsia, post-partum haemorrhage and assisted delivery) was much weaker.

There is, however, some evidence that experienced examiners can identify women
with severely contracted pelvis, but insufficient data are available to assess the
reliability of clinical examination in identifying women at high risk of obstructed
labour, or its effectiveness as part of an ANC. Even the reliability of roentgenography

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ICHD 1997-98

and ultrasound pelvimetry to predict CPD remain in doubt5, leaving little scope for
antenatal screening to improve outcome by arranging delivery appropriate to risk,
unless reliable screening tests that combine acceptable levels of sensitivity and
specificity can be established.
Transverse and oblique lie, with their various risks to mother or infant, should be
easier6 to detect than breech, even with very moderate skill or training, but insufficient
reliable data were found with which to evaluate this. In the current state of
knowledge, women with these presentations near term must be advised to give birth
in a fully equipped referral health facility. The problem is to set up such a referral
facility and to make the women use it.

Conclusion
Despite consensus from studies of different designs in favour of ANC, reservations
about the extent of its true effectiveness — as a screening tool — must remain for several
reasons. In places where it is lacking, delivery services are also likely to be poor and the
information system unreliable. In industrialised countries, comparison of outcomes
among women who did and did not receive ANC or who first attended late versus early
in pregnancy, have been shown to be confounded by socio-economic factors, education,
desire for pregnancy, maternal age and the factors influencing the outcome of pregnancy.
In developing countries there is likely to be further confounding with distance from,
access to and utilisation of other health services including those for delivery. No studies
have been identified which control adequately for these factors.

Even high quality ANC cannot be a substitute for adequate emergency access to
obstetric services. Antenatal surveillance can have little impact if services do not exist to
manage the clinical problems identified. Priority should definitely be oriented to improve
the referral level and its access and to ensure delivery surveillance with qualified
personnel who can refer women in time. Qualified personnel can do a lot in the
management of emergency obstetric at peripheral level (oxytocics, antibiotics, placenta
removal).
This does not mean that we have to stop ANC. ANC is indeed effective in the
following situations:



treatment of anaemia, prevention of malaria;
screening for hypertensive disorders of pregnancy;



first treatment (at FLHS) and referral of severe pre-ecclampsia;




active case-finding and treatment of STD’s (except AIDS) and urinary infections;

prevention of tetanus with immunisation.
ANC clinics may also be a privileged place where pregnant women have the
opportunity to express their anxieties and receive special attention (listening and
counselling) either from health professionals or from other pregnant women. ANC
might be an opportunity for the health professionals to create a relationship so that
women put trust in the personnel and will be compliant in case of emergency referral. In
the “Ten years after Safe Motherhood Conference” in Sri Lanka (annexe 1), ANC
objectives have been reoriented in this way.
5 A comparison of abdominal palpation and ultrasound found very little difference between the two methods both
produces over 50% false positives (Tew, 1990).
However, nurses in Kasongo over-diagnosed transverse lie since only 50% of the so-called transverse lies needed an
intervention (Dujardin et al., 1995).

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ICHD 1997-98

Lots of research questions on effective ANC interventions remain to be answered in
order to decrease maternal and perinatal morbidity and mortality. However, for the first
time since its creation about 90 years ago, an inventory of the evidence-based
interventions is now available and a list of questions to be answered is proposed.

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WHO/FHE/MSM/93.5.

Yuster, E.A. 1995. Rethinking the role of the risk approach and antenatal care in maternal mortality
reduction, int. J. Gynecol. Obstet. 50, S59-S61.

FLHS, Rationalisation of Antenatal Care

page 15

ICHD 1997-98

Annex 1. Specific function of ANC: the Colombo report
(October 1997)
Report of the working group “'Prenatal care and risk assessment’, Technical consultation on
Safe Motherhood, 18-23 October 1997

The aim:
Antenatal care aims to promote and facilitate entry into the health care system for all
women, to ensure a good continuum of high quality care.

The objectives:
To establish a true relationship between the woman and the health care provider
To offer the right information and initiate a dialogue which enables:

1.
2.



The provision of psychological and social support
Planning for pregnancy follow-up and birth (person, place, transport, etc.)



Women to maintain and improve their health (nutrition, etc.)

women, families and their community to identify and act on danger signs
To provide prophylactic treatment (tetanus, iron, etc.)
To detect and correctly manage existing pathologies (STD’s, etc.)
To identify women with special needs (nulliparous, adolescents, poor obstetric
history, etc.) and ensure appropriate action (specific follow-up, referral, etc.)



3.
4.
5.

The recommendations:
The working group recommends the adoption of the following principles for planning
ANC programmes:

1.
2.

3.
4.

5.
6.

existing policies must be reoriented to provide for a fundamental reordering of the
way in which current ANC services are provided and advocated
ANC services must be part of a total package of Reproductive Health Services, not a
“Stand alone” intervention.
The essential package of ANC must include ALL the elements listed in the
objectives, adapted to local circumstances and resources.
QUALITY rather than QUANTITY should guide ANC programme design: i.e.
content which has a known potential for real impact on women’s health, rather than
numerous routine visits.
Services should be provided as close to where the women live as possible (health
centres, home visits, outreach clinics, etc.)
Evaluation of ANC programmes must focus on quality and coverage, not on impact
on mortality.

FLHS, Rationalisation of Antenatal Care

page 16

ICHD 1997-98

Annex 2. Evidence-based effective interventions in ANC (from Rooney, 1992, WHO/MSM/92.4)
Troublc/stage
Prevention of anaemia

Screening and study of anaemia

Treatment of anaemia due to iron
deprivation

Screening and treatment of
hypertensive disorders of pregnancy

Test or treatment
Systematic supplementation with iron and folates

Effect
Decreases or prevents fall in haemoglobin concentration. Reduces percentage of anaemic
women

Malaria chemopropylaxis

Reduces percentage of women becoming anaemic. May diminish low birth-weight. May
improve growth in very young primiparae.

Test with copper sulphate

Screening of women below a defined cut-off point

Colorimetric tests

Estimate of Hb concentration

Red cells residue

Measure of haematocrit

Counting red cells

For diagnosis of type of anaemia

Microscopic blood film

Diagnosis of type of anaemia and type of malaria

Iron per os

May increase Hb from 0.4 to 0.7 g/dl per week

Iron IM and IV

Same increase of Hb. Avoid compliance problems, but necessitates trained personnel and
appropriate equipment for the injections IM and IV. Risk of anaphylaxis.

Transfusion of concentrated blood

Immediately increases Hb level, but has the risk of transfusion: infection, fluid ovedoad,
need of appropriate equipment and competence.

Measurement of blood pressure with a sphygomanometre

Screening of hypertension — most sensitive test for pre-eclampsia

Urine analysis (sample taken in “mid stream”)

Screening of proteinuria - indicator of pre-eclampsia if associated with hypertension.

Treatment of severe preeclampsia

Referral to specialised care at second level

Treatment of the disease. Reduces lethality.

Treatment of eclampsia

First primary care/support care - to let respiratory tract
free and to prevent injuries during crises

Reduces lethality

Identification and rapid referral to a well equipped second
level

Reduces lethality

Inducing delivery

The only final treatment

FLHS, Rationalisation of Antenatal Care

page 17

1

ICHD 1997-98

Screening for infection

Serological screening for syphilis

Microbiological screening for gonorrhoea

Identifies non-symptomatic cases. If associated with effective treatment, follow-up and
active case-finding in contacts, it reduces foetal deaths and maternal and infant morbidity.
Identifies non-symptomatic cases. If associated with effective treatment, follow-up and
active case-finding in contacts, it reduces foetal deaths and maternal and infant morbidity.
Identifies non-symptomatic cases. An appropriate antibiotic treatment prevents
pyelonephritis, prematurity and low birth-weight.

Looking for bacteriuria

Primary prevention ofinfcction

Immunisation against tetanus of pregnant women or of
women in reproductive age

Tetanus prevention for mother and new-bom.

The other interventions have not been proven to be effective.
Rooney proposes a list of possibly effective interventions (about 10 pages), needing further research, in the same book.

FLHS, Rationalisation of Antenatal Cate

page 18

Standard answer

Exercise 1.
New attendants for IUD is 4% (deemed too low).

Hypotheses
1. Figure is under-estimated
1.1.1.
bias in the recording: some of the IUD are inserted in another public health service,
outside the area of your HC (and thus are not counted for your population)
1.1.2.
bias in the recording: some of the IUD are inserted in non-govemmental facilities or
by private practitioners (and thus not counted for your population)
1.1.3.
the figure of the New Attendants, during the trimester, is low but the prevalence is
high. You are supposed to have achieve an optimal proportion of IUD new attendants
1.1.4.
the figure is low because you had a shortage in you IUD supply
2. Figure is actually low
2.1. women think that IUD is not a safe method (acceptability): it can fall during hard work in
the fields. Or they don’t like it for many reasons to be investigated.
2.2. the nurse does not like to insert IUD and women do not accept to go elsewhere.

Looking for the cause
Hvpo±esis 1.1: seek information in the other facilities that insert IUD:

Is the origin of the women precisely recorded?

If yes, how many come from your area?

If not, is the proportion of IUD inserted in this health facility significantly more
important than in the others? In other words, may the higher number of IUD’s
observed be explained by catching women from other areas?
Hypothesis 1.2: seek the information in private practices, drugstores and in NGO driven
health services. This way is rather tricky and often figures are not reliable. That is why you
have to carry out such a data collection once you have rejected all the other hypotheses.
Hypothesis 1.3: measure prevalence of women with an IUD with the information from the FP
registers (cumulated number of women to whom an IUD has been inserted and who did not
abandon).
Hypothesis 1.4: direct information: used resources (stock=0) and direct information from the
health worker in charge of the drugs supply.

Hypothesis 2.1: the only source of information is the dialogue with the community (asking the
question to women when they come at the health centre) and the personnel. If the health
workers don’t believe in IUD (just check how many health workers - wives or members have an IUD among those who are under FP methods), they won’t be able to convince women
to have an IUD inserted.
Hypothesis 2.2: direct information from the health worker in charge. Additional information:
where is the nearest health facility that inserts IUD?

Now, let’s imagine that the following hypotheses have been confirmed: lack of confidence in
the IUD and no means to presently insert IUD in the health facility under study.

Possible solutions
One way may be for the health worker in charge of the health centre to re-discuss with the
personnel the technical effectiveness of IUD, in order to diminish the fear of IUD in the
personnel’s minds. It would be helping if it were possible to present “good” figures from
other health centres with population of similar characteristics (proof that actually it is possible
to achieve better results). A dialogue with the community will be longer and more difficult
since people are less sensitive to “scientific” arguments. Basis for confidence is a good
relationship between community and health workers on one hand, and on the other hand, a
clear and correct infonnation.
Making IUD insertion more accessible will depend on resources availability and on the
potential efficiency of decentralising IUD insertion. It will thus depend on the average
possible number of IUD insertions per month. This in turn will depend on the target
population size and on IUD acceptability. If the health worker in charge of the health centre is
interested to increase the number of IUD insertions, he/she can leam the method and see
whether the supply will induce some demand in the population... Results should be assessed
6
months later for instance.

Exercise 2: Too many diarrhoea cases referred

Hypotheses
1. the need is not actual:
1.1: the strategy is too sensitive (many false positives due to referral criteria too sensitive).
1.2: the health worker in charge does not comply with the instructions because he/she is just
unable to screen children who should be referred from the others.
1.3: the health worker in charge did not respect the instructions because there was a shortage
of rehydratation salts.
2. The need is real

Looking for the cause
Hypothesis 1.1: direct infonnation from the one in charge of the HC. If the mothers went to
the referral level, analyse the referral letters and the counter-referral letters. What type of
treatment did the children receive at referral level?
Hypothesis 1.2: supervision
Hypothesis 1.3: direct information from the health worker in charge.
Hypothesis 2: analysis of the referral and counter-referral letters percentage of children who
needed hospital (for whom a more sophisticated technique has been necessary)?

Possible solutions
If hypothesis 1.1 has been confirmed, re-write more specific instructions on referral criteria.
If hypothesis 1.2 has been confirmed, the problem may be at the level of the instructions: re­
write them with more specific criteria of referral. Or the problem is at the level of the health
worker in charge: if yes, supervision and training to make him/her able to screen symptoms
and apply correctly the referral criteria.
If hypothesis 1.3 has been confirmed, one should solve supply shortage, analysing at what
level it occurred. In any way, alternative solutions for rehydration salts should be proposed.
If hypothesis 2 has been confirmed, the problem becomes a problem of health coverage. First
thing to check is to know whether this situation is exceptional or not (re-read former reports).
Then, one should measure the proportion of children who arrive at the referral hospital. And
for those who attained it, defining the percentage of those who needed hospital care or who
died during the transfer or in the health facility. It becomes necessary to envisage the
decentralisation of a more sophisticated technique in order to reduce the number of referrals.

Exercise 3.

Problem:
ANC coverage is too low

Hypotheses
Hypothesis 1: Figures are under-estimates.
Hypothesis 2: Accessibility is low
Hypothesis 3: Acceptability is insufficient
3.1. because the consultation is carried out by a man (or awful
personnel)
3.2. because the quality of care is perceived as weak.
3.3. Because criteria for referral are too sensitive (inefficiency).

Looking for a possible cause
Hypothesis 1: re-calculate coverage with another denominator: the number of children
immunised with BCG. But even if the coverage increases a little, it would not be
significant in most of the cases (except if denominators given by MOH are very bad).
Hypothesis 2: make a comparison of coverage according to the area. Near (where
women are supposed to attend ANC in HC) versus far (where women are supposed to
be covered by mobile clinics). Or make a comparison between Urban and Rural. It
would be interesting to desegregate according to the villages and calculate recruitment
rates by village (distance bias). But it will cost and you should have a denominator
large enough.
Hypothesis 3.1: comparison of coverage according to the gender (most often, mobile
clinics are carried out by a male nurse). But you have to take into account the distance
bias and the quality of care delivered by such nurse. Dialogue with mothers will help
to identify what is precisely the problem.
Hypothesis 3.2: information on the way women are welcome can be get through
supervisions and through dialogue with mothers and the staff (schedule for
consultations, room where the consultation takes place in mobile clinics, relationship
with the health worker). Information on the perception of the usefulness of ANC by
women could be collected through dialogue with mothers and with TBA’s.
Information about quality of care would be collected through supervisions and
analysis of ANC cards (effectiveness of criteria for risk identification and referrals;
number of problems solved at ANC consultations; false negatives; what happened for
the referred cases?). If the referral level has no means to deal with severe
complications, women would be aware of that and their decision to not attend ANC
may be appropriate.
Hypothesis 3.3: information about the inefficiency of the strategy would be collected
through analysis of ANC cards: number of women who needed a sophisticated
technique for delivery (caesarean section, vacuum extraction, forceps) among those
who were referred. It would be interesting to measure the positive predictive value of
each of the risks proposed as criterion for referral.
It is probably a set of multiple factors that explains a so low coverage and not only a
single factor. We shall assume, however, in this simulation that the acceptability is the
only one: women refuse to attend ANC provided by a man.

Possible solution
In this case, the theoretical solution is obvious, but not necessarily its implementation.
Female nurses are often reluctant to carry out outreach clinics. You should mobilise
additional resources (car or appropriate transport) and re-organise the tasks between
the health workers.
The way to monitor the progress after your intervention is obvious: coverage of ANC
in outreach clinics.
A (very) few recommendations

First, check if data are reliable. Then, reject “external” hypotheses (shortage of
supply, absence of health personnel, under or over estimates).
Analysis of rates is important but you also need “absolute” figures in order to interpret
your rates. 25% of diarrhoea referred is a high proportion but has no meaning if you
have only 1 referred out of 4 children.
Comparison between health facilities is interesting and important since it gives you a
picture of the best possible. But you have also to compare a single HC according to
time in order to understand trends.

Exercise 3.

Problem:
At the end of the year, you receive reports from your HC. You observe that very few
women have attended ANC.
What could be your hypotheses?
Look for the most probable hypothesis: what will be the data you need to confirm
your hypotheses?
What could be the necessary information to monitor progress, once you have
implemented a solution?

Report from your HC’s: see table below. “Near” means less than 5 km. Population
living in this radius are supposed to attend ANC in the HC. “Fa/’ means more than 5
km and women living far are supposed to attend ANC through outreach activities.

Table. ANC programme: number of women and coverage, district X, year 1990
Distance
between HC
and hospital

HCl
HC2
HC3
HC4
HC5
HC6
Total

1
2
20
30
40
80

Inhabitants
Urban
30,000
70,000
0
0
0
0
100,000

Rural
near
5,000
10,000
5,000
6,000
4,000
4,000
34,000

far
0
0
15,000
10,000
21,000
36,000
82,000

To make a comparison:

HCl
HC2
HC3
HC4
HC5
HC6
Total

Number of expected
pregnancies
Rural
near
far
1,050
175
0
2,450
350
0
0
75
525
210
0
350
0
140
735
0
140
1,260
3,500
1,190
2,870

Urban

Number of women attending at least 1
ANC (coverage)
Urban
Rural
near
far
420 (40%)
42 (24%)
0
735 (30%)
49(14%)
0
0
18(10%)
21 (4%)
0
20(10%)
14 (4%)
0
7(5%)
8 (1%)
0
21(15%)
0
1,155 (33%)
157(13%)
43 (1.5%)

for children less than 1 year

Children immunised with BCG in post­
partum consultations
Urban
Rural
near
far
1,100
150
0
2,100
290
0
0
160
420
0
200
310
0
120
590
0
150
850
3,200
1,070
2,170

NB: a Unicef survey showed that coverage rate for BCG was 98% in urban area and
95% in rural area.

b'

Contraceptive Use and Annual Acceptors
Required for Fertility Transition:
Results of a Projection Model
John Bongaarts
Major fertility declines in developing countries are invariably accompanied by large increases in
contraceptive prevalence and in the annual number of new acceptors. This article applies a target­
setting model to make hypothetical projections of trends in prevalence and number of acceptors
over the course of a full fertility transition. The sensitivity of these trends to imriations in
proximate determinants such as the marriage pattern and the duration of lactational amenorrhea,
as wdl as in the discontinuation rate and the method mix, are examined. It is concluded that a
contraceptive prevalence of around 75 percent is needed to achieve replacement-level fertility and
that variations in proximate determinants other than contraceptive prevalence have only a modest
effect on this result. On the other hand, trends in new acceptors are demonstrated to be very
sensitive to discontinuation rate changes. As a consequence, it is generally difficult to draw
conclusions about trends in fertility from trends in acceptors.

Many governments of developing countries consider
fertility reduction to be an important component of their
overall strategy for improving standards of living. Family
planning programs aimed at increasing contraceptive
prevalence are the most widely used approach to bring­
ing about fertility reductions. Due to the keen national
and international interest in the progress that is being
made toward reducing fertility, extensive monitoring of
trends in fertility and contraceptive use and acceptance
has been and is being undertaken. The most widely
^^ailable sources of such data are: (T) family planning
program statistics, which typically include estimates of
the annual numbers of acceptors of different contracep­
tive methods, and ^2) singfe round surveys such as the
World Fertility Survey (WFS) and Contraceptive Prev­
alence Survey (CPS), which measure, among other
things, the current level of fertility and contraceptive
prevalence By method and source.
In addition to the important role these data play in
the monitoring and management of family planning
programs, they have been used for evaluating the de­
mographic impact of family planning programs and for
target-setting (United Nations, 1979, 1982; Bogue, 1973;
Nortman et al., 1978; Laing, 1982; Chandrasekaran and
Hermalin, 1976; Ross and Forrest, 1978; Bongaarts,
1984a). However, these applications have, in general,
/ohn Bongaarts, Ph.D. is Senior Associate, Center for Policy
Studies. The Population Council, One Dag Uammarskjold
Plaza. New York. NY WM7. USA.

been concerned with the short term—for example, a de­
cade or less. Relatively few studies have examined the
long-range dynamics of the interrelation between fertility
and contraceptive use and acceptance over the full course
of a fertility transition. It is the objective of this paper to
analyze trends in family planning behavior from this
broader perspective. Since empirical data covering com­
plete transitions are not available, a recently developed
target-setting model is used to project trends in preva­
lence and acceptance. To simplify the presentation, the
transition in contraceptive use associated with a fertility
transition is analyzed first; the second part of this paper
discusses related trends in the number of acceptors.

Contraceptive Prevalence Trends
During the Fertility Transition
Major fertility declines in contemporary developing
countries are invariably accompanied by large increases
in contraceptive use. The fact that increased contracep­
tive use is indeed the principal cause of fertility declines
is indicated by the high degree of correlation between
population measures of fertility, such as the crude birth
rate (CBR) or the total fertility rate (TFR), and contra­
ceptive prevalence (Nortman, 1985; Bongaarts, 1984b).
(Contraceptive prevalence equals the percent.currently
practicing contraception among married women of re­
productive age, MWRA.) However, the prevalence of
contraception is not the only proximate determinant of

Studies in Family Planning

Volume 17

Number 5 SeptemberiOctober I9S6

209

fertility. The effectiveness of contraception varies among
populations, in part due to differences in method mix
and in part due to differences in method-specific effec­
tiveness. Other factors being equal, the more effective
contraception is, the less prevalence will be required to
achieve a given reduction in fertility. Furthermore, other
proximate determinants such as the marriage pattern.
breastfeeding, and induced abortion also affect fertility.
Although this has not occurred in reality, a population
could in theory achieve replacement fertility without any
practice of contraception by delaying marriage to a suf­
ficiently late age or by aborting all but about two preg­
nancies. The overall relationships between the variables
of interest for the present analysis are summarized in
Figure 1.
Mathematical examples can help illuminate the ef­
fects of other proximate variables on the relationship be­
tween prevalence and fertility. For this purpose, a set of
projections of contraceptive prevalence trends associated
with prescribed declines in fertility are made for a hy­
pothetical but not atypical developing country as it moves
through the transition from high to low fertility. A 30year period, 1980 to 2010, is assumed for the transition,
and over its course the total fertility rate is assumed to
drop from 7.0 to the replacement level of 2.1 births per
woman. Even though a 30-year transition period is rel­
atively short by historical standards, it was chosen be­
cause several contemporary developing countries (for
example, Taiwan, Hong Kong, Singapore, Korea) have
completed the fertility transition in about three decades,
between the 1950s and 1980s. The methodology for pro­
jecting the contraceptive prevalence trend that accom­
panies this decline in fertility is described in Bongaarts
(1984a) and Bongaarts and Stover (forthcoming).1
To facilitate comparisons of the different contracep­
tive prevalence projections that are made here, one
"standard" projection is used as a reference. Table 1
presents the assumed trends in the other proximate de­
terminants for this standard. The pre-transitional pop-

Figure 1 Overall relationships between contraceptive
prevalence, fertility, and other proximate
determinants

210

Studies in I amity Planning

Table 1 Assumed values of fertility and proximate
determinants at beginning and end of fertility
transition, for standard projection of associated
contraceptive prevalence
Assumed values

Year

1TR*

1980

7.0

2010

2.1

Age
pattern of
marriage and
fertility

Duration of
lactational
amenorrhea
(months)

Contra­
ceptive
effective­
ness

. Pakistan,
1973"
Hong Kong,
1978"

12

0.9

()

3

0.9

0

Total
induced
abortion
rate

Total fertility rate.
'’See J. Bongaarts and S. Kirmeyer, "Estimating the impact of contra­
ceptive prevalence on fertility: Aggregate and age-specific versions ot
a model," in The Role of Surveys in the Analysis of Family Planning Programs.
edited by A. Hermalin and B. Entwisle (Liige: Ordina Editions. 1982).

">■—'"■"-t'

ulation is modeled after Pakistan (1973)_and the post^
transitional variables are similar to those of Hong Kon||
(1978). The choice of these two populations is to some
extent arbitrary, but the use of data from actual popu­
lations was judged preferable to the use of entirely hy­
pothetical data. In any case, the general findings given
below are not affected significantly by these choices.
As is typical of many developing countries with high
fertility, Pakistan in 1973 had early and universal ma.rriage and a long duration of lactational amenorrhea. In
contrast, age at marriage in Hong Kong was high and
duration of breastfeeding short, as is characteristicof de­
veloped countries. For simplicity, method effectiveness
in this paper is kept constant at 0.9, and induced abortion
is assumed absent throughout the standard projection.
For the years between 1980 and 2010, linear interpolation
is used to estimate all proximate variables except the total
fertility rate, which is assumed to decline fastest in the
middle of the transition. After the year 2010 all proximate
variables are held constant.
Figure 2 plots trends in the total fertility rate fron4
1980 to 2030 and the contraceptive prevalence required
in the standard projection to achieve the fertility decline
from 7.0 to 2.1 births per woman over a 30-year period.
As expected, contraceptive prevalence rises rapidly dur­
ing the transition from a level of ^percent in 1980 to 76
percent in 2010, when replacement fertility' is achieved.
This prevalence estimate is within the normal range of
65-80 percent typically found in developed countries
with near-replacement fertility, short breastfeeding du­
ration, relatively late marriage, and low abortion rates
(United Nations, 1984). After 2010, prevalence remains
virtually constant as fertility is assumed constant.
As already noted, the contraceptive prevalence
needed to achieve a given reduction in fertility depends
in part on contraceptive effectiveness and on other prox­
imate determinants. To examine this dependency, a

Figure 2 Level of contraceptive prevalence required
to achieve a prescribed decline in the total fertility rate
for standard projection, 1980-2030

Note: For details, see text. MWRA = married women ot reproductive age.

Figure 3 Contraceptive prevalence levels, 1980-2030,
required to achieve a prescribed fertility decline
under alternative assumptions about trends in the
marriage pattern and in the duration of lactional
amenorrhea

number of prevalence projections were made incorpo­
rating different assumptions about the other proximate
determinants. Figure 3 plots the results of two alternative
projections. The first one (a) is the same as the standard
projection except that the marriage pattern is held con­
stant at its pre-transitional level. In this case the preva­
lence level required to maintain replacement fertility is
84 percent, which is higher than the 76 percent in the
standard projection because the constant marriage pat­
tern adds no fertility-inhibiting effect. The second pro­
jection (b) in Figure 3 differs from the standard by holding
the duration of lactational amenorrhea constant at 12
months throughout the projection period. As expected,
the absence of a trend in the fertility-inhibiting effect of
lactational amenorrhea results in a lower prevalence re­
quirement for the prescribed fertility decline. At replace­
ment fertility, the latter projection requires 68 percent
prevalence compared with the 76 percent standard. A
third projection with constant marriage pattern and lac­
tational amenorrhea is not included in Figure 3 because
it is virtually identical to the standard.
Alternative projections are also made to estimate the
impact of variation in trends in induced abortion and
contraceptive effectiveness. The effect of a rise in the in­
duced abortion rate (from zero in 1980) on the required
prevalence is summarized in the following:
Total induced
abortion rate in
2010 (abortions
per woman)

Contraceptive
prevalence in 2010
(percent)

76 (standard)
72
bS

0.0
0.5
1.0

Increasing or decreasing contraceptive effectiveness from
its initial level of 0.9 affects required prevalence after the
transition:
Contraceptive
effectiveness
in 2010

Required contra­
ceptive preva­
lence in 2010
85
76 (standard)
69

Key

--------- Standard except lor constant marriage pattern
--------- Standard

— • — Standard except lor constant duration of
postpartum amenorrhea

These projections indicate that trends in the mar­
riage pattern, duration of breastfeeding, induced abor­
tion, and contraceptive effectiveness can have substantial
effects on the contraceptive prevalence associated with
fertility change as a population moves through the de­
mographic transition. I lowever, in none of the alter­
native projections does the prevalence level after .the
transition deviate more than 9 percent from the standard
value of 76 percent. Clearly, al the end of the fertility
transition different levels of the proximate determinants
other than contraception affect fertility far less than con-

Volume 17

Number 5

September.'October 1W6

211

traceptive prevalence; achieving replacement level of
fertility in the presence of changes in other proximate
determinants still requires large increases in prevalence.
These model findings are therefore consistent with em­
pirical evidence that no populatiorThas achieved a fertility
transition without a large rise in contraceptive use.
The results presented here focus on factors affecting
prevalence levels at the end of the transition. No attempt
is made to present a similar analysis of trends in the early
phases of the transition, because a wide variety of pat­
terns is possible. It should be emphasized that trends in
prevalence and fertility in the first phase of the transition
can deviate substantially from the standard plotted in
Figure 2. It is even possible for a population to have a
rising level of prevalence with temporarily constant fer­
tility if, for example, lactational amenorrhea is declining
simultaneously (see Bongaarts, 1986, for a discussion).
Whatever the trends in fertility and proximate deter­
minants are early in the transition, the above conclusions
about prevalence requirements at the end of the tran­
sition are still valid.
Trends in Number of Users
Up to this point the discussion has focused on contra­
ceptive prevalence, that is, the proportion practicing
contraception among MWRA. For many purposes it is
useful to know not just the proportions but also the actual
number of (current) users. The number of users in each
year is easily calculated by multiplying prevalence by
the number of MWRA. To obtain the latter a standard
population projection is needed; the projection used here
assumes a total population size of one million in 198O.;
The resulting trend in numbers of users can be sum­
marized as follows. Between 1980 and 2010 the number
of users grows from 7,700 to 234,400. This increase is
substantially more rapid than the accompanying rise in
prevalence (from 5 to 76 percent) because the number of
MWRA more than doubles from 148,000 to 308,000 be­
tween 1980 and 2010. Furthermore, the number of users
continues to grow after the year 2010 (reaching 300,000
in 2030) despite a constant prevalence, because the num­
ber of MWRA keeps growing. In general, therefore, the
number of users increases more rapidly and for a longer
period than contraceptive prevalence.

Trends in Contraceptive Acceptance
During the Fertility Transition
Contraceptive use is initiated by contraceptive accep­
tance. A new acceptor is defined as a woman (or her
husband) who starts using a contraceptive method. (Al­
though seemingly straightforward, acceptor definitions
do vary; see Laing, 1982, for a discussion of this problem.
As is often done in existing writings on the subject, the
terms "acceptor” and “new acceptor" are used inter­

212

Studies in Family Planning

changeably in the present paper.) The term (new) ac­
ceptor is clear-cut in the case of a sterilization or an IUD
insertion, but it can also be applied to individuals who
start using other methods such as the pill or the condom.
An individual who discontinues a method, for example,
to begin a planned pregnancy, and starts practicing con­
traception again at a later date is counted as a new ac­
ceptor. As a consequence, an individual can be an ac­
ceptor more than once during his or her lifetime.
In this section, the annual number of new acceptors
needed to achieve a given trend in prevalence is exam­
ined. The link between numbers of users and acceptors
depends directly on the rate of discontinuation of use
following acceptance: the higher the discontinuation rate
is, the more acceptors are needed. In the present exercise,
the proportion of acceptors, pff), who are still using the
method t years after acceptance, is assumed to be rep­
resented by a simple exponential decay curve:
p(t) = e~"

where r is the annual discontinuation rate.1 According
to this curve, the mean duration of use per acceptor ia
the inverse of the discontinuation rate r. For example™
an annual discontinuation rate of 0.333 yields a mean
duration of use of three years per acceptance. (Observed
discontinuation patterns are slightly better represented
by a modified exponential curve such as the one proposed
by Mauldin., 1967, but the gain in accuracy in estimates
of numbers of acceptors is too small to be of practical
importance here.)4
To examine the impact of variations in discontin­
uation rates on the trends in acceptance, three projections
are made of the annual number of acceptors needed to
yield the contraceptive prevalence levels for the standard
projection discussed in the previous section. The three
projections differ as follows in their assumption of the
annual discontinuation rate:
1
2
3

Low discontinuation: r = 0.01.
Medium discontinuation: r = 0.333.
High discontinuation: r = 0.667.

The low discontinuation rate corresponds roughly
to what might be expected for sterilization acceptors,
among whom discontinuation would result only from
death and marital disruption. The medium discontin­
uation rate implies a mean use interval of three years
that is not atypical for the IUD, and the high discontin­
uation rate, with an average use interval of J.5 years, is
compatible with the use experience of the pill or tradi­
tional methods in some populations.
The results of the three standard acceptor projections
are plotted in Figures 4 and 5, Figure 4 presenting the
data in absolute number of acceptors, and Figure 5 in
terms of a rate, that is, acceptors per 1,000 MWRA.' As
expected, the level of the discontinuation rate has a large
effect on the required number (or rate) of acceptance.

Figure 4 Annual number of acceptors needed under
high, medium, or low discontinuation rates to achieve
required contraceptive prevalence levels for standard
projection

similar differences between the projections as in Figure
4, except that acceptor rates are virtually stable after the
year 2010 when both prevalence and fertility are con­
stant.6
An intriguing feature of the low discontinualion
projection is that the number of acceptors reaches a pla­
teau around 2000 and the acceptor rate actually declines
after that time even though prevalence is still rising. To
study this finding in greater detail, it is necessary to de­
compose the acceptor trend into its three components.

Decomposition of Trends in Annual
Numbers of Acceptors
Three factors determine the need for annual recruitments
of acceptors—discontinuation, aging, and growth in
users.

1

Figure 5 Annual acceptor rates per 1,000 married
women of reproductive age (MWRA) needed under
high, medium, or low discontinuation rates to achieve

|-'or example, as shown in Figure 4, alter the year 2010
more than ten times as many acceptors are needed in
the high as in the low discontinuation case. The corre­
sponding acceptor rates (that is, number of acceptors per
1,1)00 MWRA) plotted in Figure 5 show proportionately

Discontinuation Since users can discontinue prac­
ticing contraception (either temporarily or perma­
nently), additional acceptors are needed annually
to make up for each year's loss of users.
2
Aging To maintain a given level of contraceptive
use among MWRA, users who age past the end of
the reproductive years (exactly age45 in the present
case) also have to be replaced by new acceptors.
3
Growth in users If an increasing number of users is
required over time, then even in the absence of dis­
continuation or aging, additional acceptors will be
needed to achieve this growth in contraceptive use.
These components and their sum, the total number
of acceptors, are presented in Table 2 for the high, me­
dium, and low discontinuation projections in the stan­
dard case. Three features of these results are noteworthy.
First, the level of the discontinuation rate does not affect
the acceptor requirement attributable to growth in users
or their aging. The only source of the substantial variation
in total number of acceptors among the high, medium,
and low projections is therefore the discontinuation
component. Second, the trends in the aging and discon­
tinuation components are proportional to the trend in
the number of users, while the remaining component
varies with the annual growth in the number of users. As
a consequence, the latter reaches a maximum during the
transition and declines to zero after the year 2030 as the
number of users reaches a plateau. Third, the proportion
of all acceptors that is attributable to each component
varies greatly between the projections. With a high dis­
continuation rate, the discontinuation component dwarfs
the other two, while with low discontinuation, the re­
quirement due to growth in users predominates, al least
before the year 2(110 when fertility is declining. This ex­
plains why the total number of acceptors in the low dis­
continuation projection levels off much earlier than in
the other projections (see also Figure 6).
This last phenomenon is of interest to family plan­
ning program administrators who may view with alarm

Volume I"

Numbers September-October l‘)Sh

213

Table 2 Composition of required number of annual
acceptors (thousands) with high, medium, and low
discontinuation rates to achieve prevalence increases
in standard projection, 1980-2030

the number of sterilizations and a decline in the steril­
ization rate are consistent with an increase in prevalence
of .sterilization in populations that are approaching the
end of the fertility transition.

Components of acceptor totals

Effects of Changing Method Mix

Aging

Discontinuation
rate and year

1 ligh
1980
1990
2(XW
2010
2020
2030
Medium
1980
1990
2000
2010
2020
2030
Low
1980
1990
201X)
2010
2020
2030

Acceptor
total

Growth
in users

6.0
47.8
116.3
171.0
208.7
214.2

2.D
/ .6
9.9
6.5
3.5
-0.8

5.0
28.6
65.0
92.9
112.1
113.9

2.5
7.6
9.9

3.0
9.9
15.5
17.1
18.6
16.9

3.5
- 0.8

2.5
t .6

3.5
-0.8

44

Discontinuation

0.4
1
4.0

14.8

3.1
38.5
102.3
156.1
193.0
200.2

0.4
1 /
4.0
8.4
12.2
14.8

2.1
19.2
51.1
78.0
96.3
100.0

0.4
1.7
4.0
8.4
1? 2
14.8

0.1
0.6
2.3
2.9
3.0

Figure 6 Components of annual number of acceptors
for low discontinuation rates, standard projection,
1980-2030

a lack of growth in the numbers of sterilizations before
the end of the fertility transition. The preceding analysis
indicates that this can be expected to occur before either
the prevalence level or the number of users has reached
a maximum. In other words, an absence of growth in

214

Studio in Family Planning

The foregoing analysis examined acceptor patterns
predicated on given discontinuation rates for all accep­
tors. While this simplified the analysis, actual popula­
tions use a varietyof methods with different discontin­
uation rates. One consequence of this heterogeneity in
methods is that the distribution of users by method is
typically quite different from the distribution of acceptors
by method, A simple mathematical example demon­
strates this. Suppose that a population following the
“standard" pattern of change in fertility and prevalence
relies on three contraceptive methods with low (r = 0.01).
medium (r = 0.333), and high (r = 0.667) discontinuation
rates, respectively. Assume further that one-third of
current users practice each of these methods. In that case,
only 6.1 percent of all acceptors in the year 2010 will be
initiating use of the low discontinuation method, while
62 percent will be accepting the high discontinuation
method, despite the fact that prevalence levels of these
methods are the same. The cause of this difference in
method distribution between acceptors and current users
is simply that many more acceptors of high than of low
discontinuation methods are needed to maintain a given
level of prevalence.
Not only do populations typically use more than one
method, but the method mix tends to change over time.
(Method mix refers here to the method distribution
among users.) An important consequence of this change
in mix is that it can have a drastic impact on the trend in
the total number of acceptors of all methods combined.
If there is a trend toward proportionately more use of
low discontinuation methods, then the total number of
acceptors will rise less rapidly over time than would be
the case with a constant method mix. In fact, it is possible
for the total number of acceptors to decline over time
while the number of users rises. For example, assume
that a population uses two methods, one with a low (r
= 0.07) and one with a high (r = 0.667) discontinuation
rate. Assume further that, over the course of the "stan­
dard" transition, the proportion with the high discon­
tinuation method declines from 100 percent tot) percent
of all users and the proportion with the low discontin­
uation method rises from 0 to 100 percent between 1980
and 2030. In this admittedly extreme example, the num­
ber of acceptors of both methods combined would rise
to a maximum in the year 1995 and decline thereafter,
while the number of users rises throughout the 19802030 period. If, instead, the method mix had remained
constant, then the number of acceptors would of course
also have risen throughout the projection interval.
Another somewhat unexpected result of a change
in method mix is that it can have a large impact on the

Figure 7 Annual number of sterilizations, 1980-2005,
with percentage of sterilized users rising from 10
percent before 1995 to 20 percent after 1999

75 percent of married women of reproductive age to re­
duce fertility to replacement level. Variations in trends
in the other proximate determinants such as marriage,
breastfeeding, induced abortion, and contraceptive ef­
fectiveness have, in general, only a modest impact on
the prevalence trend needed to move fertility through
the transition.
While there is a relatively close correspondence betwggrideclines in fertility and increases in contraceptive
prevalenee^this is not the case for the acceptor rates. Of
course the number of acceptors has to rise to accomplish
an increase in contraceptive prevalence, but in the later
phase of the transition there is only a loose connection
between acceptor and prevalence rates. Rising preva­
lence can be associated with declining acceptor rates. Two
factors are responsible for this. First, the total number
of acceptors required to achieve given increments in
prevalence depends heavily on the average discontin­
uation rate, which in turn is a function of the method
mix. A changing method mix can yield acceptor trends
that change much faster or slower than the correspond­
ing numbers of users. Second, the required number of
acceptors in a given year depends both on the level and
on the growth rate in the number of users. A declining
rate of growth in users toward the end of the transition
trend in thenumber of acceptorsofa particular method.
puts downward pressure on the numbers of acceptors.
To illustrate this effect, we take again the standard pro­
As a consequence of these fairly complex relationships
jection and assume that by 1995,10 percent of users have
between acceptance and use, it is rather difficult to draw
been sterilized. Suppose further that between the years
simple conclusions about prevalence and fertility trends
1995 and 2000 a special campaign is undertaken to raise
from trends in total numbers of acceptors. Since, fur­
the sterilization proportion among all users from 10 to
thermore, acceptor statistics are usually available only
20 percent (for simplicity, this change is taken to be linear
from official government program statistics that do not
from 1995 to 200(1). The annual number of sterilizations
include private sector acceptance, these acceptor data
needed to raise prevalence in this way is plotted in Figure
do not generally give the total picture on acceptance. It
7.
Clearly, the number of sterilizations in the 1995-2000 is therefore often necessary to rely on survey-based
period has to be much larger than an interpolation be­
prevalence measures to assess trends in overall contra­
tween the pre-1995 and post-2000 trends would suggest.
ceptive use.
Rhe cause of this finding is that the rate of growth in the
number of users between 1995 and 2000 is more than
double the level that would prevail in the absence of the
References and Notes
sterilization campaign. Since the growth component is
1
The prevalence projections are made with the age-specific
the most important acceptor requirement factor for low
version of the target-setting model described in J. Bongaarts
discontinuation methods such as sterilization, it also
and J. Stover, "The Population Council Target-Setting
more than doubles, yielding the elevated levels of acModel: A User's Manual," Center for Policy Studies Working
ceptors during the campaign. Italso is worth notingthat
Paper (New York: The Population Council, forthcoming).
the decline in acceptors in 2000 is not associated with a
2
The population projection was carried out with the com­
decline in prevalence. Only the rate of growth in users
putermodel developed by Shorter and Pasta; see F. Shorter
is slower after 2000 than before. In general, then, modest
and D. Pasta, Computational Methods for Population Projections:
changes in method mix can be associated with rather
With Particular Reference to Development Planning (New York:
The Population Council, 1974). Three inputs were required:
volatile patterns of contraceptive acceptance.

Conclusion
The objective of this analysis was to examine general
contraceptive use and acceptance trends that are required
to bring about a transition in fertility in developing coun­
tries. The model projections of these variables indicated
that contraceptive prevalence has to rise to approximately

(1) age structure in 1980, which was set equal to the one
estimated lor Pakistan (1970); see United Nations, "World
population prospects as assessed in 1980," Population Stud­
ies. No. 78 (New York: Department of International Eco­
nomic and Social Affairs, United Nations, 1981), (2) fertility
trend and pattern, which was taken from Table I. and (3)
female mortality trend, expressed in life expectancy at birth.
was assumed to rise from 50 years in 1980 to 75 years in
2010 and held constant thereafter.

Volume I"

Numbers

September October l*>86

3

4

It s' ould be emphasized that r is not the same as the prob­
ability of discontinuing in a year after acceptance. This
probability (d) equals d = 1 - e'.sothatr = -ln(l-d).
To estimate the impact of using different discontinuation
schedules, two sets of acceptor projections (corresponding
to the standard user pattern in Figure 2) were made: the
first set with the simple exponential exp (- rt) and the second
set with the modified exponential rte.rpl - r'l). Each set con­
sisted of three projections with low, medium, and high dis­
continuation rates, respectively. The values forrandu used
in this exercise were:

— low discontinuation: r = 0.01. a = 0.99;

— medium discontinuation: r = 0.333, a = 0.90;
— high discontinuation: r = 0.667, a = 0.90.
Corresponding values for r' were obtained from r' = r x
n. which yields the same mean duration of use per acceptor
for both sets of projections at each level of discontinuation.
The projection results for selected years are summarized as
follows:

Discontin­
Simple
■Modified
uation rate Year exponential exponential
Low

1990
2010

9.9

10.0
17.4

Medium

1990
2010

28.6
92.9

29.5
94.6

High

1990
2010

47.8
171.0

48.8
172.6

Bibliography
Bogue, D., S. Edwards, and E. Bogue. 1973. "An empirical
model for demographic evaluation of the impact of contra­
ception on marital status and birth rates." Manual ,V<>. 6.
Chicago: Community and Family Study Center, University
of Chicago.
Bongaarts, J. 1984a. "A simple method for estimating the con­
traceptive prevalence required to reach a fertility target."
Studies in Family Planning 15, no. 4 (July/August): 184-190.

Bongaarts, J. 1984b. "Implications of future fertility trends for
contraceptive practice." Population and Development Review
10, no. 2 (June): 341-352.

Bongaarts, J. 1986. "The transition in reproductive behavior in
the Third World." In The New Population Dilemma: Issues and
Choices for the United Strifes, edited by Jane Menken. New
York: W.W. Norton & Company
Bongaarts, J. and J. Stover. Forthcoming. "The Population
Council Target-Setting Model: A user's manual." Center for
Policy Studies Working Paper. New York: The Population
Council.

Chandrasekaran, C. and A. Hermalin. 1976. Measuring the Effect
of Family Planning Programs on Fertility. Liege: Ordina Edi­
tions.
Laing, J. 1982. "Demographic evaluation of family planning
programs." Demographic Teaching Notes 4. Canberra: Devel­
opment Studies Centre, The Australian National University.

Mauldin, W.P. 1967. "Retention of IUDs: An international
comparison." Studies in Family Planning, No. 18 (April): 1The total number of acceptors in year I is calculated as the
12.
sum of its three components: (1) growth in users—this
Nortman, D., R. Potter, S. Kirmeyer, and J. Bongaarts. 1978.
component is estimated asU'(t + l) - Ll'(t), the difference
Birth Rates and Birth Control Practice: Relations Based i»i the
between the total number of users at the beginning of years
Computer Models TABRAP and CONVERSE. New York: The
t + 1 and I, (2) discontinuation—the number of acceptors
Population Council.
needed to replace users who discontinue in year t is esti­
mated as r x U(l). where Utt) is the total number of users
Nortman, D. 1985. Population and Family Planning Programs: A
in mid-year and r the average annual discontinuation rate,
Compendium of Data Through 1983. A Population Council Fact
(3) aging past 44—this component is assumed to equal 0.2
Book, 12th edition. New York: The Population Council.
x U'tl. 40—14). i.e., one fifth of the users in age groups 40Ross,
J. and). Forrest. 1978. "The demographic assessment of
44 at the beginning of each year.
family planning programs: A bibliographic essay/8 Popu­
6
A finding of Figure 4 that is at first, perhaps, puzzling is
lation Index 44, no. 1 (January).
that the acceptor rate exceeds 500 per 1,000 MWRA for the
high discontinuation rate after the year 2010. This level
United Nations. 1979. Tire Methodology of Measuring the Impact
would appear to be inconsistent with a prevalence level of
of Family Planning Programmes on Fertility. Manual IX. Pop­
76 percent. That these results are, in fact, consistent is easily
ulation Studies, No. 66. New York: Department of Inter­
demonstrated with a hypothetical example. Suppose in a
national and Economic and Social Affairs, United Nations.
hypothetical population the duration of contraceptive use
United Nations. 1982. Evaluation of the Impact of Family Planning
before discontinuation is one year for all acceptors. In that
Programmes on Fertility: Sources of Variance. Population Stud­
case, the prevalence level would be equal to the acceptor
ies, No. 76. New York: Department of International Eco­
rate if one ignores the "aging" and "growth in users" com­
nomic and Social Affairs, United Nations.
ponents of acceptor requirements. In the case in which r 0.667 and prevalence is 76 percent, the acceptor rate needed
United Nations. 1984. Recent Let-els and Trends of Contraceptive
to replace users who discontinue would be 1.000 x 0.667
Use as Assessed in 1983. New York: Department of Inter­
x 0.76 = 507.
national Economic and Social Affairs, United Nations.
5

2 lb

Studies in 1-ainily Planning

he Fertility-Inhibiting Effects of the
htermediate Fertility Variables
John Bongaarts

11 he term intermediate fertility variable was first inEroJBced in the mid-1950s bv Davis and Blake.1 Thev
gprc^Wsed a set of 11 intermediate fertility variables de­
fined as tne factors through which, and only through
fivhich. social, economic, and cultural conditions can
feffect fertility. Although the Davis and Blake frameRvork for analyzing the determinants of fertility has
Sound wide acceptance, it has proven difficult to in­
corporate into quantitative reproductive models.
Since the pioneering work of Henry in the early
1950s, a variety of models that incorporate so-ciobiological proximate determinants of fertility have
teen constructed? Model builders now use a set of
intermediate fertility variables that is different from,
but closely related to, the Davis and Blake set. It is
this new set that will be discussed here.
I
The objective of this paper is to demonstrate that
differences in fertility- among populations are largely
due to variations in only four intermediate variables.
In addition, estimates of the fertility- effect of these
factc^^nd of the levels of general fertility, marital
fertilffr and natural fertility will be made for popula­
tions at various stages in the fertility transition.

Selecting the Important Intermediate
fertility Variables
Jhe following is a complete set of intermediate fertilfy variables often encountered in reproductive
nod els:
fl proportions married among females
|2 contraceptive use and effectiveness
>3 prevalence of induced abortion
?
ihn Bongaarts. Ph.D., is Senior Associate. Center for Poi-

y..Studies, the Population Council.

4
5
6
7

duration of postpartum infecundability
fecundability (or frequency of intercourse!
spontaneous intrauterine mortality
prevalence of permanent sterilitv

Each of these seven intermediate variables di­
rectly influences fertility, and together they deter­
mine the level of fertility. The first factor measures
the extent to which women are exposed to regular
intercourse (marriage is defined broadly to include
consensual unions). The second and third factors
measure the prevalence of deliberate marital fertility
control, and the last four are the determinants of nat­
ural marital fertility.3
It is generally not necessarv to devote the same
effort to analyzing and measuring each of these inter­
mediate variables because they are not of equal inter­
est in studies of fertilitv levels and differentials. Two
criteria can be applied to select the intermediate vari­
ables that deserve most attention. The first is the sen­
sitivity- of fertility to variations in the different
intermediate variables. A variable is relatively unin­
teresting if large variations in it produce only minor
changes in fertility. The second criterion is the extent
of a factor's variability among populations or over
time. A relatively stable intermediate variable can
contribute little to explaining fertility differentials and
is hence less important.
In Table 1 the seven intermediate variables are
given an approximate rating for these two criteria,
based on other studies of the relationship between
these intermediate variables and fertility.4 Fertility- is
least sensitive to variations in the level of intrauterine
mortality and most sensitive to changes in the pro­
portions married and the prevalence of contracep­
tion. Variability is lowest for the prevalence of
sterility and the risk of intrauterine mortality. The
overall rating, based on both criteria, indicates that
four intermediate fertility variables—proportion mar-

Studies in Family Planning

Volume 13

Number 6."

June'Julv 19S2 .

179

TABLE 1 Rating of intermediate fertility variables
with respect to sensitivity of fertility and variability
among populations___________________________
Sensitivity* of
Variability
fertility to
Overall
among
intermediate
population:> rating
variables

Intermediate
fertility variables

Proportions married
Contraceptive use
Prevalence of induced
abortion
Postpartum infecundability
Fecundabilitv
Spontaneous intrauterine
mortality
Permanent sterility
-------- = High


_ _ _


_ _ _


- - -

— —
- —
- -

— — _ _ _

- - —
_ _ _



-





-

-

- - = Medium

- -

- = Low or absent

ried. postpartum infecundability, contraception, and
induced abortion—are the most important ones in the
analysis of fertility' levels and trends. This conclusion,
which will be confirmed quantitatively later in this
paper, does not of course mean that the other factors
are never important. For example, a population's fer­
tility' mav be lower than expected if widespread vene­
real disease causes a high prevalence of sterility, or if
fecundabilitv is reduced substantially bv prolonged
spousal separations. Although less important than
postpartum infecundability, fecundabilitv also ex­
plains some of the variance in the natural marital fer­
tility’ of historical populations.5

A Model Relating the Intermediate
Variables and Fertility
A model relating fertility to the intermediate fertility­
variables is described in detail elsewhere6 (a sum­
mary of the equations and an example of an applica­
tion are provided in the Appendix). Only the model's
basic concepts and variables will be outlined here.
In this model the four principal intermediate
variables are considered inhibitors of fertility, be­
cause fertility’ is lower than its maximum value as a
result of delayed marriage (and marital disruption),
the use of contraception and induced abortion, and
postpartum infecundability' induced by breastfeeding
(or abstinence). As is illustrated in Figure 1, four dif­
ferent types of fertility levels are identified from
which the impact of the intermediate variables can be
derived. With the inhibiting effects of all intermediate
variables present, a population's actual level of fertil­
ity is observed, measured by the total fertility' rate,
TFR (the total fertility rate and other fertility rates in
this paper include only legitimate births). If the fertil­

180

Studies in Family Planning

ity-inhibiting effect of celibacy is removed, fertil
will increase to a level TM. the total marital fertil
rate. If all practice of contraception and induced abt
tion is also eliminated, fertility will rise farther to
level TN, the total natural marital fertility rate. R
moving, in addition, the practice of lactation ar
postpartum abstinence further increases fertility t
the total fecundity rate, TF. The total fecundity rat
measures the combined effect of the remaining inter
mediate variables: fecundabilitv, spontaneous intra
uterine mortality, and permanent sterility. While th
fertility' rates TFR, TM, and TN vary- widely’ amon
populations, the total fecundity rate is rather stable
The TF values of most populations fall within the
range of 13 to 17 births per woman, w'ith an average of
about 15.3." Lower values are found only in special
circumstances—for example, if there is a high prevalence of diseases causing sterility or if prolonged
spousal separations are common.’
...
The fertility effects of the four most important in-;
termediate variables are measured in the model by
FIGURE 1 Relationships between the fertility’-in- i
hibiting effects of the intermediate variables and i
various measures of fertility
3

Total fecundity

Fertility-inhibiting
effect of:

Postpartum
intecundability

Total natural
marital fertility

Total fertility

four indexes. The indexes can only take values be­
tween 0 and 1. When there is no fertility-inhibiting
effect of a given intermediate variable, the corre­
sponding index equals one: if the fertility inhibition is
complete, the index equals zero.
The four indexes are defined as follows:

C,n = index of marriage (equals 1 if all women of
reproductive age are married and 0 in the
absence of marriage)
C(. = index of contraception (equals 1 in the ab­
sence of contraception and 0 if all fecund
women use 100 percent effective con­
traception)
C„ = index of induced abortion (equals 1 in the
absence of induced abortion and 0 if all
pregnancies are aborted)

C,- = index of postpartum infecu nd ability
(equals 1 in the absence of lactation and
postpartum abstinence and 0 if the dura­
tion of infecundability is infinite)
Each index (or set of indexes) by definition equals the
ratio of the fertility' levels in the presence and in the
absence of the inhibition caused by the correspond­
ing intermediate fertility variablets):

- _ HE

Lm

Cr x C„

TM

TN

C,. rn

(1)
(2)

®

It follows from these equations that:
TFR = C„ x C, x C„ x C, x TF

(4)

This simple equation summarizes the relationship be­
tween the total fertility rate and the intermediate fer­
tility’ variables.
The indexes C,„, Cr, C„, and C, can be calculated
with equations (1), (2), and (3) if measures of the fer­
tility rates TFR, TM, TN, and TF are available (which
is rarely the case). In most applications, the indexes
are estimated directly from the following measures of
the intermediate fertility variables:
m(a) = age-specific proportions of women cur­
rently married
u = proportion of married women currently
using contraception
e = average use-effectiveness of contracep­
tion’
TA = total induced abortion rate (abortions per
woman)

: = mean duration of postpartum infecundabilitv (in months)

The equations for calculating the indexes from
these variables are given in Appendix 1 (note the
minor change in the equation for C,. compared with
the earlier version of the model).

Testing the Validity
of the Model
It was concluded earlier that variations in fertility are
usually due to variations in only four factors: the pro­
portions married, contraceptive prevalence and effec­
tiveness, the incidence of induced abortion, and the
duration of postpartum infecundability. The remain­
ing intermediate variables, generally much less im­
portant, were represented in the model bv the total
fecundity rate, which has values around 15.3 births
per woman. The validity of these findings will now
be tested by comparing the observed total fertility
rates of different populations with the model esti­
mates of total fertility rates obtained from the follow­
ing equation (from equation (4), assuming TF = 15.3):
TFR = C„, x C,. >. C„ x C, 115.3
(5)

The testing procedure will be applied in 41 develop­
ing, developed, and historical populations, and in­
volves four successive steps: estimation of the
intermediate fertility variables; calculation of the in­
dexes; estimation of the total fertility rates using
equation (5): and a comparison of the model esti­
mates of TFR with the observed TFRs to determine
how well the four principal intermediate variables
predict the fertility level of a population. “
Table 2 presents the estimates of the intermedi­
ate variables; rather than including the entire ni(o)
distribution, the values for TTR and TM are given,
from w’hich Cm is calculated with equation (1). The
data are obtained from a variety’ of sources, including
WFS surveys.Estimates of the duration of postpar­
tum infecundability were the most difficult to obtain,
and indirect estimation procedures had to be applied
in nearly all populations. For WFS countries, infor­
mation about the average duration of breastfeeding
was available” from w’hich the infecundable interval
was obtained with an equation presented else­
where.12 For the historical populations the infecun­
dable interval was derived from the average differ­
ence between the interval from marriage to first birth
and subsequent birth intervals.
From the data in Table 2, one can calculate the
indexes Cm. Cc, C„, and C( w'ith equations summa­
rized in Appendix 1. The results are presented in
Table 3. The total fertility rates can now be estimated

Volume 13

Number 6/7

June/July 1982

183

TABLE 2 Estimates of total fertility rate, total marital fertility rate, and intermediate fertility variables for
selected populations
Total
fertility
rate

Populations
Developing countries
Bangladesh, 1975
Colombia, 1976
Costa Rica, 1976
Dominican Republic, 1975
Guatemala, 1972
Hong Kong, 197S
Indonesia, 1976
Jamaica, 1976
Jordan, 1976
Kenya, 1976
Korea. 1970
Lebanon, 1976
Malaysia, 1974
Mexico, 1976
Nepal. 1976
Pakistan, 1975
Panama. 1976
Peru. 1977
Philippines. 1976
Sri Lanka. 1975
Syria. 1973
Thailand. 1975
Turkey, 1968

Developed countries
Denmark, 1970
Finland, 1971
France, 1972
Hungary, 1966
Poland, 1972
United Kingdom. 1967
United States, 1967
Yugoslavia, 1970

Historical populations
Bavarian villages
1700-1850
C ru lai
.Mar.4 1674-1742
Grafenhausen
1700-1850
Hutterites
.Mar. 1921-1930
lie de France
.Mar. 1740-1779
Oschelbron
1700-1850
QuebecMar. 1700-1730
Tourouvre au Perche
Mar. 1665-1714
Waldeck villages
I700-I850
Werdum
1700-1850
Alar. = marriage*.

182

Total
marital
fertility
rate

Prevalence of
contraceptive use

Use-effec­
tiveness

0.08
0.39
0.64
0.32
0.03
0.72
0.26
0.40
0.24
0.03
0.24
0.35
0.33
0.29
0.02
0.05
0.54
0.31
0.35
0.32
0.22
8.33

0.82
0.84
0.86
0.89
0.87
0.86
0.87
084
0.84
0.75
0.89
0.83
0.85
0.86
0.94
0.83
0.90
0.7S

Duration of
postpartum
infecundability
(in months)
18.61
5.28
3.60
4.76
14.18
3.01
16.16
4.25
6.50
11.22
11.90

14.39
5.90
11.80
8.90

■3.0)
■3.0)
'3.0)
(3.0)
.3.0)
■3.0)
■3.0)
■3.0)

0.35

0.91
0.80











1.5













2.11

4.78
3.91
3.71
3.69

(0.701
(0.80)
<0.o7)
<0.67)
(0.60)
<0.72)
0.72
(0.62)

0.96
0.96
0.94
0.93
0.91
0.95
0.96
0.95

0. '.69
0.2S4
0.093
2.086
0.427
0.039
0.004
1.980

14.45)

1T.S9

•—





4.9

5 60

9.S9







■ 1.2

6.a4
4.57
3.69
5.85
7.05
2.26
4.69
4.32
8.02
3.97

4.76
a./ 3
6.37
7.02

5.01
3. ->3
7.00
4.70
5.o0
1.78
I.bl
2.21
1.80
2.09
2.38

7.91
6.46
9.74
4.?o
6.b4
7.99
9.95
10.44
6.85
3.28

9.40
7 48
8.94
8.92
8.17
6.88
".48
/ a/

3.21
j. u
4 26
-> Q-)

3.80
5.28
17 86
12.65

7.85

(4.74)

10.73







11.3

9.50

12,96







6.0

6.10

12.08







U.O

(5.06)

10.60







9.0

8.00

12.72







O.2

6.00

10.15





<4,41:

u uy

(3.78)

9 37

NOTE: Figures -n parentheses are approximate.

Studies in Family Planning

Total
induced
abortion
rate

—■





:1. .





(_..

_______
SOURCES: See note 10.

? TABLE 3 Estimates of the indexes of the intermediate fertility variables and model estimate of total fertilitv
f rates for selected populations

Populations
Developing countries
Bangladesh, 1975
Colombia, 1976
Costa Rica. 197b
Dominican Republic, 1975
Guatemala. 1972
Hong Kone, 1978
Indonesia, 197o
Jamaica, 1976
Iordan, 1976
Kenva. 197b
Korea. 1970
Lebanon. 197b
Malaysia. 1974
^Mexico. 1976
J Nepal. 1976

Pakistan, 1975
Panama, 197o
Peru. 1977
Philippines, 1976
Sri Lanka. 1975
Syria, 1973
Thailand, 1975
Turkey. 19bS

Developed countries
Denmark, 1970
Finland. 1971
France. 1972
Hungary, 1966
Poland. 1972
United Kingdom, 1967
United States, 1967
Yugoslavia, 1970
Historical populations
Bavarian villages
1700-1850
^Crulai
W Mar.a 1674-1742
Grafenhausen
1700-1850
Hutterites
Mar. 1921-1930
He de France
Mar. 1740-1778
Oschelbron
1700-1850
Quebec
Mar. 1700-1730
Tourouvre au Perche
Mar. 1664-1714
Waldeck villages
1700-1850
Werdum
1700-1850

*Mar.=marriages.

Model
estimate
of total
fertility’ rate

Index
of
marriage

Index
of
contraception

of
abortion

Index
of postpartum
infecundability

0.853
0.578
0.571
0.601
0.724
0.496
0.706
0.541
0.745
0.768
0.580
0.576
0.607
0.O10
0.S52
0.785
0.640
0.573
0.613
0.515
0.730
0.628
0.760

0.929
0.646
0.406
0.692
0.972
0.331
0.756
0,637
0.782
0.976
0.769
0.68b
0.697
0.731
0.980
0.955
0.475
0.739
0.705
0.710
0.793
0 676
0.698

(1.0)
(1.0)
(1.0)
(1.0)
(1.0)
(1.0)
(1.0)
(1.0)
(1.0)
(1.0)
0.82
(1.0)
(1.0)
(1.01
(1.0)
(1.0!
(1.01
(1.0)
(1.0)
(1.0*
(1.01
(1.0*
(1.0*

0.539
0.841
0.905
0.860
0.612
0.930
0.577
0.879
0.800
0.673
0.658
0.780
0.897
0.841
0.550
0.642
0.879
0.759
0.759
0.608
0.730
0.660
0.730

0.555
0.514
0.519
0.617
0.437
0.60°
0.631
0.572

(0.274)
(0.171)
(0.3201
(0.3271
(0.4101
(0.261)
0.254
(0.364)

0.939
0.887
<1 073
0.564
0.884
0.989
0.999
0.751

(0.930)
(0.930)
(0.930)
(0.930)
(0.930)
(0.930)
(0.930)
(0.930)

2.27
2.2-

(0.374'■

(1.0)

(1.0)

0.856

4.89

0.566

(1.01

(1.0)

0.673

5.83

(0.442*

(1.01

(1.01

0.671

4.54

6.?4
4.80

6.59
2 3d
4.71
4.63
7 13
-

3.81
5.81
5 73
7.02
, 3
4.09
4.92
5.02
3.39
o 4.*
2 OQ
5.92
2.03
1.11
2.30
1 .o2
2.2b
-» 74

0.733

(1.0)

(1.03

0.816

Qi;

0.505

(1.0)

(1.01

0.712

5.50

(0.4771

(1.01

(1.0)

0.727

5.31

0.629

(1.0)

(1.0)

0.810

7.80

0.591

(1.0)

(1.0)

0.749

6.77

(0.4421

(1.0)

(1.0)

0.676

4.57

0.403

(1.0)

(1.0)

0.640

3.95

NOTE: Figures in parentheses are approximate.

SOURCE: Equations in Appendix.

Volume 13

Number 6/7

June/July 1982

1S3

FIGURE 2 Observed and model estimates of the
total fertility rates (TFR) of 41 populations

made. These assumptions make the model less
than fully accurate.
Deviations from the total fecundity value of 15.3'
The total fecundity rate is a function of the three
intermediate variables not explicitly included in
the model (i.e., natural fecundability, intra­
uterine mortality, and the prevalence of perma­
nent sterility). As a consequence, the assumption
that TF = 15.3 is only an approximation. As al­
ready noted, the normal range of TF is from 13 to
17 births per woman.
4
Errors in the observed total fertility rates. Since
existing methods for measuring fertility are not
perfect, it follows that the best available fertility
estimates differ somewhat from the true rates.
5
Induced abortion is assumed absent except in the
developed countries and in Korea (a low level of
induced abortion common to all populations is
allowed for in the estimate of TF = 15.3). If incor­
rect, this assumption results in an upward bias in
the model estimates of TFR.
6
All births are assumed to be legitimate except in
the developed countries, where the total fertility
rates given in Table 2 are corrected to exclude il­
legitimate births. In the developing countries in
which this assumption is incorrect, the observed
TFRs are overestimated.
3

from the indexes using equation 15). These model es­
timates of TFR are given in the last column of Table 3.
A comparison of the model estimates with the
observed TFRs reveals that there is good agreement
between these two fertility levels (see Figure 2). In
fact, the model estimates of TFR, and therefore the
four principal intermediate fertility variables. explain
96 percent of the variation in the observed fertility
rate. The standard error of the model estimate is 0.36,
and in only two populations (Tourouvre au Perche
and Malaysia) are the differences more than twice
this standard error. Clearly, the earlier conclusion
that proportions married, contraception, induced
abortion, and postpartum infecundability are the
most important intermediate fertility variables is sup­
ported by this finding. These results also confirm the
general validity of the model.
The variance in fertility that is not explained bv
the four principal intermediate variables is due to
several factors, including:
1

2

Errors in the measurement of the intermediate
variables in Table 2.
Errors in the specification of the model. To arrive
at a simple analytic model for the relationship be­
tween fertility and the intermediate variables, a
number of simplifying assumptions had to be

Although the overall fit of the model is quite
good, the combined effect of these error components
is sufficiently large to make equation (5) unsuitable
for the accurate estimation of fertility levels. Errors
exceeding 0.5 births per woman in the total fertility
rate are not unusual, and other existing methods for
estimating fertility are therefore preferable. The pur­
pose of this equation is not to provide a new estima­
tion method: instead, it gives an approximate
breakdown of the contributions made by different in­
termediate variables to levels and trends in fertility.

The Transition in the Intermediate
Fertility Variables
As a population moves through the transition from
natural to controlled fertility there is, by definition,
an increase in deliberate marital fertility control. This
control is exerted primarily through a rise in con­
traceptive use, but in a number of populations the
practice of induced abortion olavs a major role. Ac­
companying the transition in the deliberate control of
marital fertility are transitions in the other principal
intermediate variables—marriage and postpartum in-

tfecundabiiity. As a consequence of these trends in the
intermediate variables, important changes take place
in the levels of natural marital fertility, marital fertil­
ity', and overall fertility.
In examining changes in these fertility measures
over the course of the transition, it is unfortunately
not possible to rely on time trends in individual pop­
ulations because the necessary data are Jacking. In­
stead a comparative analysis will be made here of
contemporary populations at different points in the
transition. The result will be an outline of a typical
"synthetic" transition from the fertility behavior
found in contemporary developing countries to that
currently observed in developed countries. To pro­
vide a clearer picture of the trends in the intermediate
variables, populations are divided into four transition
phases according to the level of fertility:

FIGURE 3 Estimated average total natural marital
fertility rates, total marital fertility rates, and total
fertility rates of countries in different phases of the
fertility transition
Fertility-inhibiting
effect of:

1 TFR over 6.0
11 TFR 4.5-6.0
fell TFR 3.0-4.5
IV TFR less than 3.0

The fertility of most populations in phase 1 is
close to natural, while populations in phase IV have
completed most or all of the fertility transition.
Estimates of the intermediate variables—the in­
dexes C„. Cr. C„, and C,—and of the total natural
marital fertility rate, the total marital fertility rate, and
the total fertility rate of groups of populations in each
of the four transition phases are obtained by averag­
ing the data of 31 developing and developed coun­
tries in Tables 2 and 3. The results are presented in
Table 4 and Figure 3. (All estimates in Table 4 are sub-

TABLE 4 Averages of measures of the intermediate fertility variables, the indexes, and the total, marital,
and natural marital fertility rates for groups of populations in different phases of a synthetic transition
Phase of fertility transition

I

II

III

IV

Prevalence of contraceptive use
Use-effectiveness of contraception
Total induced abortion rate
Postpartum infecundability

0.10
0.85
0.0
12.9

0.35
0.85
0.0
/ .6

0.40
0.86
0.38
8.5

0.69
0.94
0.46
3.0

Index of marriage
Index of contraception
index of induced abortion
index of postpartum infecundability

0.780

1.000
0.649

0.627
0.682
1.000
0.780

0.551
0.630
0.961
0.763

0.550
0.301
0.887
0.930

Total fertility rate
Total marital fertility rate
Total natural marital fertility rate3

7.03
9.08
9 9^

5.03
8.08
11.93

3.88
7.05
11.67

2.06
3.80
14.23

11

4

?

Number of countries included
“Estimated as 15.3 times index of postpartum infecundability.

SOURCE: Tables 2 and 3.

Volume 13

Number 67

lune/lulv 1982

185

ject to large sampling errors because of small num­
bers of populations included in each transition
phase.) The total natural marital fertility rate (TN)
rises from 9.93 to 14.23 births per woman between the
first and last phase of the transition. This is the conse­
quence of a shortening of the mean duration of
postpartum infecundability from 12.9 to 3.0 months,
which yields a rise in C( from 0.649 to 0.930. Despite
the large increase in TN, the total marital fertility rate
declines from 9.08 to 3.80 during the transition. The
reason is clearly a large rise in the contraceptive prev­
alence from 0.10 to 0.69, accompanied by an increase
in contraceptive use-effectiveness from 0.85 to 0.94.
The combined effect of the changes in prevalence and
use-effectiveness is expressed in the index of con­
traception, which declined from 0.912 to 0.301 over
the course of the transition. Induced abortion plays,
on average, a minor or negligible role except in the
last two phases of the transition when its effect be­
comes significant. Interestingly, the decline in marital
fertility during the first three phases is quite modest,
as the increase in the practice of contraception barely
manages to compensate for the fertility-enhancing
impact of a shortening of the duration of postpartum
infecundability. Finally, the total fertility rate changes
from 7.03 to 2.06 during the transition, due to the re­
duction in marital fertility as well as to the decline in
the index of marriage from 0.78 to 0.55. This decline
in the proportion of women married is largely the re­
sult of a rise in the mean age at marriage.
In sum, this outline of the transition in the vari­
ous fertility measures indicates that a typical transi­
tion from natural to controlled fertility is accom­
panied bv a shortening of postpartum infecun­
dability, a large increase in contraceptive use, and a
decline in the proportion married. It should be em­
phasized that this pattern is based on a comparison of
contemporarv populations at different stages in the
transition. Actual transitions over time in developing
countries probably resemble this pattern quite
closely, but the transitions in historical European
populations are different in one respect. Instead of a
reduction in the proportion married, these historical
populations typically experienced a decline in the
mean age at marriage and a rise in the proportion of
women married.

Conclusion
The principal finding of this study is that a small
number of intermediate fertility variables are respon­
sible for most of the variation in fertility levels of pop­
ulations. Four intermediate factors—proportion mar­

Saidies in ramih

ried, contraception, induced abortion, and postpar-.'
turn infecundability—are the most important deter-i
minants of fertility. These four factors explain 96'i
percent of the variance in the total fertility rate in a'
sample of 41 populations that included developing-:
and developed countries as well as historical popula­
tions. The remaining intermediate variables—natural
fecundability (or frequency of intercourse), spon­
taneous intrauterine mortality, and permanent steril­
ity—are generally much less important although they
may substantially affect fertility in some populations.
In the last section of the paper the average fertil­
ity effect of the intermediate fertility variables, as
measured by the corresponding indexes, was esti­
mated for groups of contemporary populations with
different total fertility rates. Postpartum infecun­
dability resulting from breastfeeding has a strong fer­
tility-inhibiting effect in countries with high total
fertility rates. As a result, natural marital fertility in
these countries is much lower than in the developed
countries. Although natural marital fertility is very
high in the developed world, marital fertility is rela­
tively low because of high contraceptive prevalence:
around 1970 about two-thirds of married women of
reproductive age were using contraception (this level
increased further during the 1970s). This high prev­
alence of contraceptive use is the primary reason for
the low total fertility rates in the developed countries,
but late marriage and a high rate of marital disrup­
tion. as well as significant use of induced abortion,
also contribute to lowering the total fertility rate.

Appendix: A Summary of the Model
Several equations relate the fertility rates TFR, TM,
TN, and TF to the indexes C,„, C.., C,„ and C, (see text
or reference in note 6 for a definition of these vari­
ables):

TFR = C,„ x C, < C„ x C,- «. TF
= C,„ < C.. < C„ < TN
= C,„ ■< TM
TM = TFR C.„
= Cr ■< c.; < Cf x TF
= C,. < C„ x TN
TN = TFR (C„, x C„ x C„)
= TM (C,. x C„)
= C, < TF
TF = TFR (C,„ x C.. x C„ x C,-)
= TM (C.. x C„ < C,)
= TN C,

Each of the indexes can be calculated from meas­
urements of the intermediate fertility variables, as is
illustrated below for Sri Lanka, 1975.

Effectiveness levels for the developed countries
are based on L'S data1-5:

’index of Marriage

TFR
TM

L-

- f<‘i>
~ f(a):m(ai

' where mta) equals the proportion currently married
■ among females, by age. and flat is a schedule of age. specific fertility rates Lw(<?) should include consensual
unions, but visiting unions are given a weight of 0.5].
. Onlv births to married women should be included in
f(ai.
For Sri Lanka, 1975, the estimated values for f(a)
and m(a> are:
Age group

/(fl)

frt(n)

15-19
20-24

‘JX G

0.065
0.380
0.650
0.822
0.856
0.814
0.817

148.7
1C'' |
170.0
117.2
36.2
5.6

JO-34

40-44
4=L-1&

=
(293.5)

20o-S

44.5
TM ~ 6.877

TFR = 3.528

3.52S
and therefore: C,„ = & g„ = 0.513

The value of the age-specific marital fertility rate
giai for the age group 15-19 is estimated asg(15-19) =
0.75 X g(20-24i, because the direct estimate f(15-19)/m
(15-19) tends to be unreliable, especially in popula­
tions with low values for m(15-19).

Estimated
use-effectiveness

Method
Sterilization
Pill
IUD
Condom
Diaphragm
Foam cream jelly
Rhvthm
Other

1.00
0.99
0 97
0.94
0.92
0.91
0.87
0.93

The sterility correction factor is estimated to be
1.08. In the version of the model published earlier
(see note 6), this coefficient was estimated to equal
1.18 on the not quite accurate assumption that all con­
traceptive users are nonsterile. The new coefficient is
calculated from the reported age-specific prevalence
of sterility’ from a number of WFS survevs.1*’
For Sri Lanka, 1975, u — 0.32 and e = 0.84, so that
Cr = 1 - 1.08 x 0.32 x 0.84 = 0.710.
Average use-effectiveness, c, is estimated as the
weighted average of the method-specific use-effec­
tiveness levels, elnii, with the weights equal to the
proportion of women using a given method,
■ ■:
= - e(m' utmhii. For Sri Lanka. 1975:
Method

ftnri

0.019
0.048
0.09°
0.154

Pill
IUD
Sterilization
Other

0.90
0.95
1.00
(0.70»

0.32

Index of Contraception
Cr = 1 - 1.08 x c x u
^fcpere i< is the prevalence of current contraceptive use
including male methods and sterilizing operations)
i among married women of reproductive age (15-49), c
; is the average use-effectiveness of contraception, and
11.08 is a sterilitv correction factor. Since estimates of
r. contraceptive effectiveness are difficult to obtain and
Etherefore rarely available, the following standard
fcmethod-specific values (adapted from data from the
Philippines'4) are used in the calculation of average
Eeffectiveness levels in developing countries.

Method
Sterilization
IUD
Pill
Other

so thatc = (0.019 x 0.9 -r 0.048 x 0.95 - 0.099 * 1.0 0.154 x 0.7)10.32 = 0.84.
Index of Induced Abortion

TFR
TFR - 0.4 x (1+u) x TA

where TA equals the total abortion rate (including
only abortions among married women).
Reliable statistics for induced abortions are not
available in Sri Lanka. If induced abortion is assumed
to be absent, C„ = 1.0.

Estimated
use-effectiveness

Index of Postpartum Infecundability

1.0
0.95
0.90
0.70

c'

20

where i is the mean duration of postpartum infecun­
dability.

Volume 13

Number 6.7 June:)uly 1982

187

If a direct estimate of i is not available, it is possi­
ble to obtain an approximate value from the duration
of breastfeeding, B, with the following equation17:

8

i = 1.753 exp (0.1396 x B - 0.001872 x 8:)

In Sri Lanka the mean duration of breastfeeding
was 21 months, yielding i = 14.4 months and

20

c‘ = IZJTIZ = °-608

References and Notes
This is a revised version of a paper originally prepared for
the IL’SSP and WFS Seminar on the Analysis of Maternity
Histories, London, April 1980 (Proceedings forthcoming).

1 K. Davis and J. Blake. "Social structure and fertility: An
analytic framework." Economic Development and Cultural
Change 4, no. 4 <1956): 211.
2 On the Measurement of Human Fertility: Selected Writings of
Louis Henn, translated bv M. C. Sheps and E. LapierreAdamcyk lAmsterdam: Elsevier Publishing Company,
1972); M. C. Sheps and J. A. Menken. Mathematical
Models of Conception and Birth rChicago: University of
Chicago Press. 1973); M. C. Sheps. "A review of modeis
for population change." Review of the International Statis­
tical institute 39 11971): 185; ,1. A. Menken. 'Biometric
models of fertility," Social Forces 54 (1975): 52; J.
Bongaarts. "Intermediate fertility variables and marital
fertility." Population Studies 30. no. 2 (1976): 227; J.
Bongaarts. "A dynamic model of the reproductive proc­
ess." Population Studies 31, no. 1 '1977): 59.
3

The term natural fertility is defined as fertility in the ab­
sence of deliberate parity-dependent birth control; see
Louis Henry. "Some data on natural fertility," Eugenics
Quarterly 3, no. 1(19611:81.

4

Bongaarts (1976). cited in note 2 I. Bongaarts and J. A.
Menken, "The supply of children. ' in Determinants of
Fertility in Developing Countries: .4 Summary ot Knowledge
'Washington. D.C.: National Academy of Sciences,
forthcoming, 1982); j. Bongaarts. "Dues malnutrition af­
fect fecundity? A summary of evidence." Science 208 i9
May 1980): 564-569.

5

C. Wilson. "The components of natural fertility in his­
torical Europe." paper prepared for the IL’SSP and WFS
Seminar on the Analysis of Maternity Histories,
London. April 1980.

b J. Bongaarts. "A framework for analyzing the proximate
determinants of fertility." Population and Development Re­
view 4. no. I < 1978): 105-132. See also J. Bongaarts and
R. G. Potter. Behavior. Bioiogu .ma Fertility Behavior: An
Analysis of the Proximate Determinants (New York; Aca­
demic Press, forthcoming).
7

See note o.

188

Studies in Family Planning

9

An index of spousal separation has been proposed to
quantify the effect of separation; see A. Hill and F.
Shorter. "Intermediate variables in fertility analysis: A
practical guide." Regional Paper of the Population
Council in West Asia and North Africa, 1979.
This variable measures the reduction in the monthly
probability of conception due to the use of contracep­

tion.
10

Sources of data for Table 2 are as follows.

For developing countries: estimates are taken from
J. Bongaarts and S. Kirmeyer. "Estimating the impact of
contraceptive prevalence on fertility: Aggregate and age
specific versions of a model," in The Role of Surveys in the
Analysis of Familu Planning Programs, ed. A. Hermalin
and B. Entwisle (Liege: Ordina, 1981), except Korea,
which is based on Bongaarts, cited in noteb. with fertil­
ity estimates updated from L. Cho, "The demographic
situation in the Republic of Korea." Papers of the EastWest Population Institute, no. 29.
For developed countries: Demographic Yearbook 1969
and 1975 (New York: United Nations’. Department of

Economic and Social Affairs. 1970and 1976); Fertility and
Family Planning in Europe around 1970. Population Stud­
ies no. 58 (New York: United Nations. Department of
Economic and Social Affairs. 1976) (total fertility rates
do not include illegitimate births); C. Tietze. Induced
Abortion: 1979 (New York: The Population Council.
1979). Contraceptive prevalence data were inflated to
include sterilizing operations for noncontraceptive rea­
sons 'in the European countries 3 percent was added for
lack of direct esnmates of the incidence of such opera­
tions).
For historical populations: German populations—).
Knodei. 'Natural fertility in pre-industrial Germany,"
Population Studies 32. no. 3 (19781; 481: "Demographic
transitions in German villages." paper prepared for the
Summary Conference on European Fertility. Pnnceton.
N. J.. July 1979; ' From natural fertility to family limita­
tion: The onset of fertility transition in a sample of Ger­
man villages. ' Demography 16. no. 4 (1979): 493: C.
Wiison. cited m note 5. Mean duration of postpartum
infecundabiiity was estimated by subtracting the mean
interval between marriage and first birth from the aver­
age birth interval among married women with two or
more legitimate births: total fertility rates were esti­
mated by multiplying the average number of children
ever born per married woman in completed unions by
0.88, the approximate value of the proportion ever mar­
rying among women. Other populations —H. Leridon,
Human Fertility: The Basic Components (Chicago: Univer­
sity of Chicago Press. 1977). Mean duration of postpar­
tum infecundabiiity was estimated by subtracting the
mean interval between marriage and first birth from the
interval between the first and second birth, adding one
month to correct tor increasing durations of birth inter­
vals with age. The estimate of postpartum infecun­
dabiiity among the Hutterites was taken from M. Sheps.
"An analysis of reproductive patterns in an American
isolate,” Population Studies 19. no. 1 (1965): o5.

developing countries indicates that the use-etlectiveness of the pill is lower than in the Philippines. A possi­
ble explanation for this finding is that literacy levels in
the Philippines are among the highest in the developing
world. The average effectiveness levels in the develop­
ing world used in Appendix 1 are therefore estimated to
be slightly lower than in the Philippines

U B. Fern-, "Breastfeeding.' WFS Comparative Studies.
r no. 13.'.May 1980.

2 J. Bongaarts. "The proximate determinants of natural
marital fertility." in Determinant? o’ Fertility in Dct’clopuig
Countries, cited in note 4.

.13 S Watkins. "Regional patterns of nuptiality in Europe
1870-1960." Population Studies 35 no. 2 (1981): 199-216.
'■,14 J. Laing. "Estimating the effects of contraceptive use on
f.
fertility." Studies in Family Planning 9. no 6 (1978): 150
i
Laing gives the following effectiveness estimates for
;
four methods in the Philippines: the pill. 0.949: the IUD,
0.963: rhythm. O.~9S: and the condom. 0.616. Prelimi­
nary evidence from as vet unpublished studies in other

15

16

17

Bongaarts and Potter, cited in note 6.

D. Xortman. "Voluntary sterilization: Its demographic
impact in relation to other contraceptive methods." Pa­
pers of the East-West Population Institute, no. 65.1980.
See note 12.

Volume 13

Number 67

Junelulvl9S2

189

child-spacing in
tropical Africa:
traditions and change

edited by

Hilary J. Page
Ron Lesthaeghe
Interuniversity Programme in Demography
Vrije Universiteit Brussel, Belgium

This is a volume in

STUDIES IN POPULATION
ACADEMIC PRESS

Under the Editorship of: H. H. Winsuorough
A complete list of titles in this series appears al the end of this volume

A Subsidiary ofHarcourt Brace Jovanovich, Publishers

London

New York Toronto Sydney San Francisco

15
the policy implications of
changes in child-spacing practices
in tropical Africa
A. L. MABOGUNJE

The demographic situation in most tropical African countries is usually
characterised as one of rapidly declining mortality in circumstances of high
and fairly stable (or even slightly rising) fertility levels, leading to what are
perhaps some of the highest rates of population increase in the world
today.' For many of these countries, birth rates lie between 40 and 55 per
thousand whilst death rates continue to drop below 25 per thousand. Given
this situation, it is natural to assume that little is happening among the
generality of the population with regard to the management of their fertility
behaviour. Policy prescriptions for coping with the developmental
consequences of such growth rates have varied from an out-and-out
advocacy of vigorous family planning campaigns and programmes to a
more laissez-faire approach based on a form of the post-Bucharest position
of “development being the best contraceptive” (Funkle and Crane,
1975). Either way, it was becoming somewhat depressingly apparent that
policies addressed to population problems in many developing countries
have had rather ambiguous or sometimes even contradictory results.2
In these circumstances, it is natural to expect a re-appraisal not only of
these policies but also of the body of knowledge on which they are based.
Two elements have been crucial in this re-appraisal. The first has been the
need for a better understanding of the causal relations among the variables
that impinge on fertility behaviour; the second is the greater application of
what Lasswell (1975) calls their contextuality — the context within which
these relations are situated and policy guidance proffered. The significance
of the former is that it gives special emphasis to identification of the
sequential relations between variables: an attempt is made, as it were,
303

304

POLIC^MPLICATIONS

to peep into the “black box” of causation and to identify ^ntabies that are
"intermediate” or “intervening” between the input and the output of
particular social processes. This enables a distinction to be made between
those behavioural or biological factors that affect fertility directly (the
intermediate variables) and socioeconomic, cultural and environmental
factors which do not influence it directly but only through their effect on
the intermediate variables (Davis and Blake, 1956).
This distinction has special significance in the design of policy measures
to cope with problems arising from the particular fertility patterns of
African societies since it helps in particular to establish their cultural
contextuality. Contextuality defines an approach to policy formulation
that considers a given problem in relation to the larger context of the
social process in which it is embedded and with which it interacts.
With regard to fertility behaviour this approach requires a conceptual
map that depicts the interplay between population factors and policy and
locates this interplay in the social processes of the particular community. Such
a map permits a clearer perception of those critical points in the relationship
that provide specific and effective opportunities for policy interventions.
The preceding chapters in this volume have been concerned with
reporting the results of research activities and identifying changes in
traditional child-spacing practices among different communities in tropical
Africa. The basic hypothesis is that child-spacing practices represent one of
the crucial intermediate variables affecting fertility levels. The demographic
models discussed in the introductory chapter (chapter 1, Section 3) and by
Bongaarts (chapter 5) show that lactation-related amenorrhoea and
postpartum abstinence are indeed major determinants of fertility, having
the potential of roughly doubling average birth intervals, thereby halving
fertility, while the case studies have documented the extent to which this
potential check on fertility is actually realised in selected populations. Also
implicit throughout the book is the notion that child-spacing practices must
be situated correctly within the larger context surrounding the social
processes of child-bearing and child-rearing. We may now be in a much
better position to appreciate their implications for policy and to identify
strategic areas where policy intervention may be more effective and
productive of desired results.
The purpose of this concluding chapter is, therefore, four-fold. First, it
summarizes the salient features of traditional child-spacing practices among
various communities in tropical Africa; second, it examines the factors that
arc inducing wide-ranging changes in these practices; third, it considers the
context of these factors and their potential for policy intervention; and
finally, it assesses the constraints that are likely to facilitate or inhibit the
formulation and implementation of appropriate policy measures.

1

TRADITIONAL CHILD-SPACING PRACTICES

1

Salient featufll of traditional child-spacing practices

305

Although the evidence is far from complete, the various studies reported in
this volume emphasize that among various communities in tropical Africa,
traditional child-spacing practice has involved an interval of about three
years between successive births (except when early infant mortality
intervenes). This practice is hallowed in many communities because it
protects the health of the newborn babe and increases the child’s chances of
survival by ensuring a longer period of lactation: the medical evidence of
the advantages of lactation and also of adequate birth intervals in general is
clear from chapter 4. Postpartum abstinence is also seen in some
communities as a means of protecting the health of the new mother (see
chapter 3, (Sections 3 and 4), for example), although this particular concern
would seem in most cases to be of more recent origin. Even more recent is
the idea that a long interval between child-bearing is desirable because it
guarantees the rights of women to live a normal life of social and economic
involvement and not be regarded or treated simply as “baby machines”. In
many traditional African societies, although these last two reasons for
fairly lengthy child-spacing were not always as clearly articulated,
they were nonetheless recognised because of the high level of participation
of women in the economic life of the communities. Some exceptions
may be found among those Islamised communities where the institution
of keeping women in purdah is prevalent, but elsewhere it is generally
recognised that the roles played by African women as agricultural
producers and/or traders are facilitated by child-spacing practices,
since these ensure that their labour input is less restricted by frequent
pregnancies or by the difficulty of caring for a small child and a baby
at the same time.
Clearly, the overall effect of lengthy child-spacing is to restrain
considerably the fertility of women in traditional society, although this does
not imply a preference for small family size. This culturally accepted
restraint is often ignored in conventional descriptions of fertility in
underdeveloped societies where high levels of fertility were assumed to have
been always characteristic. Moreover, and of far greater significance, the
social context within which the restraint was practised and the institutional
support developed around it were hardly ever investigated. For example,
little research has been carried out on the role of older women (not
necessarily mothers) in advising younger ones as to the essential facts of
child-rearing and on the societal evaluation of various practices related to it.
Anthropologists who have been placed in a unique position to examine
these areas of social relations in depth have usually shown little interest in
matters of demography. Yet, it is obvious that the daily routines of
households in traditional societies tend to maximize opportunities for this

306

POLICY IMPLICATIONS

form of social education of younger by older women Veh routines include
the long trek to fetch water, the concourse at the periodic markets, the
numerous annual festivities and family celebrations and other occasions of
a more private nature.
The mothers or older siblings of the married couple also play a
very special role in the maintenance of this practice. In many communities,
one or the other of these close relations is expected to take up residence
with the new mother both to assist her in the very demanding task
of child-rearing and to offer advice and guidance whenever necessary.
The physical presence of such third persons encourages abstinence on
the part of the couple and thus ensures the achievement of a desirable
birth-spacing.
Not all communities seek to achieve their spacing objectives through
absolute abstinence. The anthropological material surveyed in chapter 2
shows broad areas (notably in eastern Africa and, to a lesser extent, in
Islamised areas of western Africa) where child-spacing relies more on
prolonged lactational amenorrhoea and/or on coitus interruptus or low
coital frequency. The anthropological evidence also indicates that, within
this broad pattern, child-spacing practices can show considerable local
variation between ethnic groups and between sub-groups, a fact which is
emphasized by some of the case studies, most notably the chapters from
Zaire but also those from Ghana, Togo and Senegal. Nonetheless, whether
through abstinence or other means, a woman is not expected to conceive
another child until after a socially acceptable interval has elapsed.
In many communities, infringement of this social norm attracts formal
sanctions. Such sanctions are imposed within the extended family or by the
peer group of either husband or wife. But perhaps more important are the
informal sanctions ranging from public ridicule to social ostracization. All
these sanctions are induced by a certain feeling of outrage at the callousness
implied in imperilling the life of the young infant (see the discussion of
sanctions given in section 6 of chapter 3, for example). Indeed although
without real medical foundation, it is generally believed among many
communities that sexual intercourse during the critical years of lactation
actually poisons the mother's milk.
Lactation closely ties child-spacing practices with issues of nutrition.
Research into traditional food practices among various communities in so
far as it affects pregnancy and child-rearing still has a long way to go.
Among some groups, however, there are food taboos on the basis of sex
and age. Women, and in some cases pregnant women, are not expected to
cat certain types of food. Generally, it is assumed that the choicest food is
reserved for the male head of the household. What we know less about is
whether among certain groups special items of food are regarded as having

2

CHANGES IN CHILD-SPACING PRACI ICtb



significance foi^femen at different stages in the child-bearing and childrearing cycle. Nonetheless, in the wet tropics in particular, among
communities whose diet is heavily dependent on root crops, the relatively
low protein content makes weaning rather strenuous on the infant', who has
to ingest considerable quantities of this material to secure adequate
quantities of body-building substances.

2

Factors inducing wide-ranging changes in
child-spacing practices

The perspective on fertility behaviour that is provided by looking at the
intermediate variables of child-spacing practices enables us to appreciate
better the directions from which some of the most significant changes
affecting fertility are coming. In many tropical African countries, these
directions are closely related to the current process of modernisation.
Everywhere one is aware of a decrease in the length of the breast-feeding
period and also of less regard for postpartum sexual abstinence, particularly
among younger women, with or without a compensatory adoption of
contraceptive practices. These changes are accompanied by a new
perception of women’s sexuality in marital relations, changes in the
relationship of parents to children, the possibility of excess fertility and the
emergence of the phenomenon of “unwanted” children. For the modern
woman, sexual relations are no longer simply a means of child-bearing but
more a lubricating element to ensure the smooth running and success of
marriage. But such natural enjoyment of sex increases exposure to
pregnancy and places greater importance on the need for artificial means of
contraception. The urgency is further emphasized by the growing reversal in
the direction and magnitude of intergenerational flows of wealth and
services between parents and children.3 Increasingly, parents regard their
children less as useful farm labour and eventual security in their old age but
as an additional burden on their meagre resources. All of this is creating
a new situation in which the desirable number- of children is being re­
evaluated less in terms of their economic value and more in terms of the vital
psychic satisfactions of parenthood. Beyond the preferred number, a new
pregnancy is regarded as unwanted, an excess and a mistake.
One of the most significant results of the various researches reported in
this volume (analysed in most detail in chapters 6 and, particularly, chapter
7 on Lagos and Ibadan respectively) is the indication that certain categories
of women have been responding positively to this new situation through
deliberate contraceptive practice. The most important element in the
characteristic profile of these women is that most of them have reached
at least a secondary level of education. Other elements shown to have

POLICY IMPLICATIONS

3

been of some importance though not as critical include urban,residence
(particularly the neighbourhood location of residence), income levels
and employment within the modern, white-collar sector of the urban
economy. Significantly, elements such as ethnicity and religion are of less
importance even though these have an influence on more traditional
child-spacing practices.
Clearly, the role of education in this transitional process is not only
paramount, but also very complex. The significance of attaining a
secondary level of education, for example, may or may not indicate the
existence of a critical threshold above which education begins to have a real
impact on fertility. The controversy about the relevance of threshold values
for changes in fertility behaviour need not concern us here. What is
important is to note that the education of women up to the secondary level
has two important effects on the contextual framework of their fertility
behaviour. First, by keeping girls in-school up to the age of puberty, it has
made it difficult for the oiagf'women to continue to play their customary
role in sex education and has thus removed to the public domain activities
which were in the past exclusively in the private domain. It is of
considerable interest that in virtually all the researches conducted, the
women practising contraception claimed to have learned about it first from
their ^class-mates, peer group or even boyfriends. Hardly any of them
mentioned their mothers, older women or"alder siblings. Second, for most
women educated to this level not only are they more assertive of new social
norms, including changes in practices related to child-bearing and childrearing, but society itself shows a greater willingness or tolerance towards
this assertiveness. It is now commonplace to see young educated mothers in
cities insisting, especially with their mothers or relations, on how they
would want babies to be reared.
From this perspective, it is easy to appreciate that the problem oLhigh
fertility in most tropical African countries occurs largely among women
who have received some education but usually no more than the primary
level and who have been removed from situations in which traditional
norms and sanctions continue to have their erstwhile strength or validity.
These women have escaped the socially imposed restraints of traditional
society but have not been able to attain positions where they can self­
regulate their fertility. The fertility problem of most countries in tropical
Africa thus arises not only from the fluidity in the child-spacing practices of
a category of women caught as it were, “between two stools” but also from
the fact that the number of such women has been increasing rapidly with the
recent, and sometimes dramatic, expansion of primary educational
opportunities for girls.

3

308

CONTEXTUALITY OF POLICY Ibbuco

Contextuality of policy issues

Phrased in this way, the problem of high fertility levels in many African
communities poses a different set of challenges for policy intervention. It
facilitates a contextual approach to the identification of an appropriate
policy strategy for dealing with the problem. The conceptual map needed to
locate both the fertility variable and policy measures within on-going social
processes can only be accurately drawn by re-affirming the centrality of
certain social goals. In traditional society, these goals revolve around the
concern for safeguarding the health and survival chances of infants and also
the well-being of the mother. It was primarily for this reason that these
societies were prepared to create appropriate institutions, to devise means
of inculcating supportive value systems and to apply sanctions, both formal
and informal, to discourage infringement.
These goals of maternal and child health-care remain critical in all
African countries today as they were in the past. But added to them are new
societal objectives entailing not simply healthy survival but also a
progressively enhanced living standard resulting from a fuller exploitation
of national resources. Raising living standards, however, is predicated on
much improved knowledge of the complex relations between resources and
the size and composition of the population of a country. The possibilities of
resource depletion and of irreversible negative ecological change as a result
of too high a pressure of population on the land impose special obligations
on governments to"keep a vigilant interest in all those factors that determine
the rate at which population is growing (Tinbergen, 1975). The preceding
chapters, have shown that changes in child-spacing practices are one of the
most dynamic elements influencing the rapid rate of population growth in
much of tropical Africa.
In locating policy measures within a contextual framework appropriate to
this particular problem, it is important to stress that two types of measures
are available to government, namely those designed to have a direct impact
and those whose effects’are bound to be indirect. Policies with direct impact
depend in general on the use of monetary or fiscal measures, administrative
or regulatory procedures, physical activities such as the provision of
infrastructure and service facilities, or the creation of special agencies to
deal specifically with the problem in hand. Those withTiirect impact on the
other hand, operate in such a way that although not initiated explicitly to
deal with the particular problem, their effects spill over and exert some
influence on its incidence or intensity. Indeed, in terms of what has been
said so far, it is easy to appreciate that changes in child-spacing practices are
themselves the unintended by-product of policies applied in other areas of
national life notably in education.

’OLICY IMPLICATIONS

Clearly, the problems arising from these changes are themselves
amenable to policy intervention of both a direct and indirect nature. Of
direct policy measures, four are relatively obvious and specific. First, there
is the expansion of educational opportunities for girls, especially at the
secondary, school level. This policy can be defended not simply on the
grounds that it would keep girls in school to the age where they can better
appreciate the importance of sex education and the value of contraception
but particularly because it will enhance their capacity for a more
economically useful life. Second, there is a need to provide more maternal
and child health-care facilities and to pursue ante-natal education in them
more vigorously. The latter is particularly vital as a means of creating a
substitute for traditional institutional arrangements based on the guidance
and counselling role of older women. Antenatal education should stress the
importance of a longer period of lactation (and thus amenorrhoea) as a
means of improving the survival chances of babies. It should also pay
attention to improving the knowledge of the women as to the critical role of
appropriate nutrition. Maternal and Child Health-Care Units, especially in
the context of tropical African countries, also have a responsibility in
trying to cope with the special problems of sterility in a segment of the
population and the varied demands of minority and cultural groups, such as
the demand for abortion for pregnant unmarried girls. Third, family
planning facilities should be considerably expanded and contraceptive
devices made more easily available. Finally, the present permissible age at
marriage should be re-examined with a view to legislating a minimum age
that is more in consonance with present aspirations for improved living
standards. For many African countries, a minimum age of 21 years for girls
would appear to have much in its favour. Other direct measures could
include tax reductions for keeping the number of children below a certain
figure such as three. Fiscal advantages and subsidies can also be provided as
incentives for keeping the size of families close to an acceptable national
norm.
Nonetheless, in the longer run, it is the indirect policy measures that
may have the greatesfimpacT on the ability of women in countries of
tropical Africa to cope more effectively with their fertility and the issue of
their desired family size. Some of these may lead in the short run to an
increase in fertility as traditional child-spacing practices decline, but in the
longer term they are likely to lead to fertility decline through greater use of
contraception and development of preferences for smaller families.
Of such indirect policies, five are likely to be of real importance. The [first)
relates to policies concerned with the whole question of income re­
distribution. In many tropical African countries, there is growing concern
with the sharp income inequalities between social classes, sub-national

3

CONTEXTUALITY OF POLICY ISSUES

311

regional units, and urban and rural areas. This concern finds expression in
development programmes directed specifically at target groups such as the
urban poor and the landless peasants. In its most comprehensive form, the
concern has led to a growing emphasis being placed on the development
of the rural areas as a whole. Such policies, to the extent that they seek to
raise the income of the rural population in general, have the potential of \ 1
also affecting their perception of their role in society and their better
appreciation of new opportunities for upward social and economic
mobility.
The effect of such development on the reproductive and child-spacing
behaviour of women cannot be under-estimated. If the results of researches
reported in this volume are anything to go by, this is likely to change
dramatically. The potential for change from traditional to modern patterns
of child-bearing can be enhanced, and the potential problems of unwanted
high fertility avoided, if from the very beginning maternal and child health­
care facilities and antenatal and family planning counselling are built into
the rural development programmes. Experience from other parts of the
world shows that such'facilities need not involve expensive investment in
costly buildings and equipment. Instead, they can be largely community­
based with, for instance, a systematic re-involvement and re-education of
older women to play their customary role in this field. For such community­
based programmes to succeed, McNicoll (1975) has emphasized that they
must be part of a coherent development policy which must have three
concurrent aims:
first, 'to establish or strengthen community solidarity in economic and
'-social affairs, accentuating the felt xeed fo£ cooperative effort in
addressing mutual problems; ^second,-lo eliminate serious external
diseconomies at the community level”— in other words, to ensure that any
adverse consequences of individual behaviour within the community are
not seriously felt by groups outside it; ancfjhird, to encourage economic
growth and demographic restraint through an array of incentives and
sanctions that are presented to^the community as a whole and that invoice
community accountability.

A ^second] set of indirect policies are those concerning employment
promotion and increased urbanisation. For most tropical African
countries, problems of urban unemployment and under-employment figure
among the most visible and pressing challenges facing their governments.
Proposals for their solution emphasize the importance of labour-intensive
programmes to counterbalance the capital-intensive processes of modern
urban-industrial development. Such solutions, if effectively implemented,
are bound to involve the employment of an increasingly large number of

312

POLICY IMPLICATIONS

women with relatively low educational qualifications, at least for the
unskilled and female-related activities. Apart from the fact that this
development will lead to a further rise in female out-migration from rural
areas to urban centres, the consequential erosion of traditional social
restraint in matters of fertility may contribute to a rapid increase in
population. This eventuality needs to be planned for and greatly
underscores the importance of expanding maternal and child health-care
centres in urban areas and emphasizing their role in antenatal education and
family planning counselling.
t’>j 'I An equally important attention needs to be paid to policies concerned
■-with raising the status of women. In many tropical African countries,
various initiatives are being taken at national and international levels to
improve and enhance the direct participation of women in development
programmes and community decision-making. 4 Apart from improving
access to educational opportunities for females, many countries are also
engaged in removing various discriminatory provisions in the field of wages
and salaries, superannuation, social security and legal protection. The
impact of these policies on fertility behaviour is currently somewhat
uncertain. What is, however, indubitable is that positive changes in the
status of women are bound to enhance their capacity to articulate and
achieve their preferred family size and to self-regulate their fertility.
^_/The general health programmes of governments also tend to have an
indirect impact on fertility behaviour, particularly through their more direct
effects on infant mortality. Improvements in social and preventive medicine
in so far as these increase the survival chances of infants are bound to enter
into the calculation of preferred family size. The same significance attaches
to improvements in the food productive capacity of a country and its effect
on raising general nutrition status. Not only the amount but the mix
between carbohydrate and protein food material is crucial in this respect.
The mix factor is particularly important in terms of resistance to ill-health
among adults and may also greatly influence levels of infant mortality in a
given population.

4

Constraints on policy formulation and
implementation

The likelihood that realistic policy measures of a type that impinge directly
or indirectly on reproductive behaviour and child-spacing practices will be
formulated and implemented is greatly dependent on the strength of various
constraints that are part of the decision-making environment in tropical
African countries today. This environment has been largely determined by
the strategy of development currently operative in these countries. This

4

CONSTRAINTS ON POLICY

313

strategy has been based essentially on a neo-classical Keynesian-type
approach to the management of national economic systems and places great
emphasis on the use of monetary and fiscal policies to stimulate the
economy. However, in tropical Africa, a large part of the economy still
belongs to the so-called subsistence sector and the efficacy of such policies
in this situation is very much in doubt. Similarly, the strategy also
concentrates on import-substitution industrialisation as a means of
stimulating economic growth/usually on ‘the-grounds (somewhat incon­
clusive in tropical African countries) that such activities facilitate the
achievement of a very high capital-output ratio. A final element in this
strategy is the emphasis on export production of agricultural or mineral raw
materials to earn the foreign exchange needed to pay for the growing
volume of imports.
This development strategy has important implications with regard to
dealing with population-related problems. In general, it has a strong
tendency to be commodity-oriented rather than people-oriented. A country
is adjudged developing if it can show real growth in its gross national
product irrespggljye of how this affects the life chances of various social
classes in the population. Moreover, this strategy has tended to encourage
“enclave” development with concentration on one or a few choice urban
centres and on specific rural areas where export commodities can be
produced. Even when, as in recent years, the strategy is directed at
increasing food production, its project-oriented style of operation still
limits the scope of its effectiveness. More seriously, this strategy has led in
many tropical African countries to an increasing preoccupation with the
problem of escalating foreign-debts and the resultant high cost of debt­
servicing.
Clearly, the policy environment resulting from this development strategy
has not been very pre-disposing to people-oriented policies. Indeed, in many
countries it has not been too concerned with the health of the population at
large beyond the level of rhetoric nor has it encouraged the articulation of a
population policy beyond, in a few cases, responding to international or
United Nations demands for written documents on this issue. The non­
viability of this strategy in the long run is, however, becoming increasingly
apparent in the strong trend towards economic stagnation noticeable in
most tropical African countries as a result of the widespread neglect of rural
areas where the majority of the population are still to be found.
The fragility or impending collapse of economic systems based on this
strategy in country after country in tropical Africa is creating conditions
more favourable to the adoption of an alternative and more self-reliant
development strategy. This hew strategy, whose major features are only
gradually being articulated, differs from the preceding one in the emphasis

^.ICY IMPLICATIONS

314

5

it places on the full mobilisation of population and natural resources in the
development process and on the importance it attaches to ensuring the
cultural authentication of the modes of societal modernisation adopted
(Seers, 1977, p. 3). Such a strategy is more sensitive to the need for policies
aimed at enhancing the capacity of individual households to articulate and
achieve their preferred family size. At present, few countries in tropical
Africa have been engaged in such fundamental changes in their
development strategy. The most outstanding example is Tanzania where
efforts at a complete restructuring of the rural areas have been pursued
vigorously since 1976. The impact of this strategy on the responsiveness of
the Tanzanian government to population-related issues is now generally
recognised, as is shown by the more comprehensive structure of decision­
making from village^ community or district level to the central government
(Rweycmamu, 1976). It will be a matter of considerable interest to
investigate the effects of this new orientation on fertility behaviour and
population dynamics in the country as a whole.

enhanced when demographic research investigates and emphasizes the
social and cultural context in which the patterns are embedded rather than
simply extrapolating from other cultures or historical experience, however
similar these may appear.
The second conclusion is even more important because of its practical
implications. This is that fertility regulation is not a recent discovery of
American organisations. Traditional African societies have always been
preoccupied with this matter although their.capacity to maintain vigilance
has been eroded with recent development.
By'providing the necessary historical perspective to this set of social
changes, the various studies in this volume make it possible for decision­
makers to adopt a more realistic contextual approach to policy formulation.
The social norms whose breaching is the cause of the problem are more
clearly indicated, as are the profiles of those institutions, practices and
value system whose obsolescence is making their breach possible. In such a
situation, the need for countervailing action is easier to appreciate. The
nature and scope of the required policies when designed against this
perception can be expected not only to be more consistent with prevailing
social and economic conditions but also to reflect familiar aspects of
cultural life such that their apparent authenticity will evoke more positive
and appropriate responses from the masses of the people.

5

Conclusion

This investigation of the factors impinging on the intermediate variables of
child-spacing has necessitated a close consideration of the social context in
which a wide variety of decisions concerning family formation,
reproductive behaviour, child-bearing and child-rearing practices take place
among different communities in various countries of tropical Africa. It has
revealed the wide variation in these practices in traditional society,
particularly the variation between communities practising long abstinence
and those recognising little or no need for abstinence. In either case, as
many of the studies have shown, child-spacing was embedded in and
interacted with other aspects of social life and institutions. This
appreciation underscores the fact that in the modern period, these issues
cannot be successfully dealt with outside the context of broad social
policies and institutions.
This fact points to two major conclusions with implications of both a
theoretical and a practical value. The first conclusion is that in dealing with
population problems we need to know more about the people concerned.
The chapters in this volume, for instance, underscore the importance for
population studies of making intensive use of the research methodology of
the different social sciences. It is perhaps commonplace to assert that
population studies are largely concerned with individual and aggregate
behaviour patterns and that few behaviour patterns are understandable
outside the context of a given social and cultural milieu. As such, the
capacity to understand, interpret and influence these patterns will be greatly

CONCLUSION

315

Endnotes
'See the excellent discussions as to the resource for the persistence of high levels of
fertility in Caldwell (1977)
2For an excellent review of this situation, see McGreevey and Birdsall (1974).
3For a fuller discussion of the implications of this issue for changes in fertility
behaviour, see Caldwell (1976).
4See United Nations Economic Bulletin for Africa (1975).

References
Caldwell, J. C. (1976). "Towards a restatement of demographic transition theory”.
Population and Development Review Vol. 2(3/4), pp. 321-366
Caldwell, J. C. (ed.). (1977). The Persistence of High Fertility. Department of
Demography, Australian National University, Canberra
Davis, K. and Blake, J. (1956). "Social structure and fertility: an analytic
framework”. Economic Development and Cultural Change Vol. 4 (3),
pp.211-235
Funkle, J. L. and Crane, B. B. (1975). "The politics of Bucharest: Population,
Development and the New International Economic Order". Population and
Development Review Vol. 1(1), pp. 87-114
Lasswell, H. D. (1975). “Population change and policy sources: proposed
workshops on reciprocal impact analysis”. In Policy Sciences and Population
(F. 1. Warren etal., eds) pp. 117-135. Toronto

316

POLICY IMPLICATIONS

McGreevey, W. P. and Birdsall, N. (1974). The Policy Relevance of Recent Social
Research on Fertility. Smithsonian Institute, Washington
McNicoll, G. (1975). “Community-level population policy: an exploration”.
Population and Development Review VcA. 1 (1), pp. 1-21
Rweyemamu, J. (1976). "Development planning in the United Republic of
Tanzania”. United Nations Economic Bulletin for Africa Vol. 12(1), pp. 45-65
Seers, D. (1977). "The new meaning of development ”, international Development
Review No. 3
Tinbergen, J. (1975). “Demographic development and the exhaustion of natural
resources”. Population and Development Review Vol. 1(1), pp. 23-32
United Nations. (1975). “The role of women in African development ”. Economic
Bulletin for Africa Vol. 11 (1), pp. 57-78

author index

Abraham, R. C., 57, 65
Addo, N. 0., 97, 107
Addy, D. P., 103, 104,
107
Adegbola, O., 74,91,
111, 124, 129,168,179
Adelstein, P.,93,96,99,
108
Aguirre, A. L., 93,99,
109
Ahmed, S., 107
Ahsan, M.,32
Alexandre, P., 54,65
Antoine, Ph., 268,273
Arowolo, O. O., 91 n
Ashton, H.E., 47, 65
Ayeni, O., 147, 179
Azar, J. E., 108
Baldwin, D. S., 235
Barton, J., 51,65
Becker, S. R., 144n, 145
Beidelman, T. O.,
50-52,65
Bertan, M., 108
Bierman, J. M., 109
Binet, J., 54, 65
Binns, C.T., 32, 58,65
Birdsall, N.,315n, 316
Blake, J., 112, 129, 304,
315
Blount, B.G., 52, 65
Bongaarts, J., 10,22,
113, 114, 118n, 129,
177n, 179, 249, 250,
253, 262n, 262, 278,
285
Bonnar, J., 102, 107
Bonte, M., 29n, 37, 46,
65
Bourgeois, R., 29n, 45,
65
Bradbury, R„ 57, 65
Brineman, E., 108

Brass, W.,3,21n,22,
108
Brokensha, D. W., 29n,
53,65
Bruel, G.,48, 54, 65
Buchanan, R., 100, 103,
107

Caldwell, J. C., 14, 22,
74,76,90n,91,118n,
129, 181, 184, 186n,
190, 198n,199,218n,
219, 222, 223,315n,
315
Caldwell, P., 14,22,74,
76, 90n,91, 118n, 129,
141, 145, 181,186n,
190, 199
Cantrelle, P., 94, 100,
104, 105-106, 107,
123, 129,267n, 267,
268, 269n, 271,272n,
273n, 273
Carael, M„ 29n, 37,46,
65,286
Chakraburty, J., 108,
285
Chang, M. C., 108
Chen, L. C„ 100, 101,
107
Chitkara, I. D„ 108
Chowdhury, A. K., 108,
285
Coale, A. J., I2,21n,
22, 157, 169, 177n,
179, 196n, 199n, 199,
228,235,236,251,
253,260, 263
Cohen, R., 66
Cole, J., 66
Colle, R. P., 45, 66, 277,
285
Conant, F. P., 67
Connor, A., 109
317

Cory, A., 56, 66
Coulibaly, S. P.,48,66
Courel, A., 66
Crane, B.B., 303, 315
Crook, N„ 17,22
Curley, R.T.,29n, 37,
52, 66
Cuypers, J. B„ 55, 66
Czechanowski, J., 276,
285
Danakpali, H., 22
Davis, K., 112, 129, 304,
315
De Jong, F. H„ 109
Delaine, G.,269n, 273
Delgado, H„ 101, 108,
278, 285
Delhaize-Arnould, C.,
46,66
Delobsom, A.,32,53,66
Delogne-Desnoeck, J.,
108
Delvoye, P„ 102, 108
Demaegd, M., 108
Denreny, P., 2ln
Deng, F. M.,32,48, 66
De Ryck, F., 52,66
D’Hertefelt, M., 45, 66
Dikonda wa Lumanyisha,
277,285
Dina, I. O., 235
Doke, C. M„ 52,66
Dorjahn, V. R.,29n,56,
66
Dow.T. E., 121, 129
Doyle, P., 5, 66
Dugast, I., 54, 66

Eastman, N. J., 95, 108
Eaton, J., 118n, 129
Edel, M. M., 48, 66
Edwards. W„ 58,66
Ellison, R. E.,51,66

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