i
Preface
This study entitled “Health Programmes and Empowerment of Rural
Women: An Evaluation” has been carried out in district Almora of Uttarakhand.As
per 2011 census report, 89.98% population of district Almora is rural. Rural women
of Uttarakhand are the backbone of the social, economic and cultural structure of the
State. They not only look after the young and the old in the household, but also carry
out a number of chores and are consistently put to arduous multi-tasking. Hence, of
late, concern for their health, has become one of the focal points in the policy arena. It
is also well known that there is an intrinsic relationship between women‘s health and
their empowerment. Consequently, a number of programmes have been mounted to
deal with the issues related to women‘s health and well being.
During the course of the present study, my endeavour has been to evaluate the
impact of health schemes on rural women in the study area. The study could be made
possible with the persistent support and constant guidance from my research guide. I
pay my sincerest gratitude to my supervisor Dr. Jyoti Joshi, Associate Professor,
Department of Sociology, D.S.B. campus, Kumaun University for constant inspiration
and guidance and for helping me in giving present shape to the thesis. I thank
Professor B.S. Bisht, Professor Indu Pathak and Professor D.S. Bisht, department of
sociology, D.S.B. Campus, Kumaun University for their encouragement and support
from time to time. I am also thankful to all the people whom I contacted directly or
indirectly for collecting data, gathering information, holding discussions and for the
valuable suggestions made by them to complete the study. I am also indebted to my
family members who always inspired and encouraged me during the entire course of
the study.
ii
DECLARATION
I declare that the thesis entitled ―Health Programmes and Empowerment of Rural
Women: An Evaluation‖ is my work completed under the supervision of Dr. Jyoti
Joshi, Department of Sociology,D.S.B. Campus, Kumaun University, Nainital.
Research Supervisor: Dr. Jyoti Joshi
Associate Professor,
Department of Sociology.
D.S.B.Campus,Kumaun University,
Nainital, Uttarakhand
I further declare that to the best of my knowledge, the thesis does not contain any part
of any work submitted for the award of any degree, either in this university or in any
other university without proper citation. All the sources, used or quoted, have been
indicated and acknowdged by complete reference.
iii
CONTENTS
Sl.
No. Contents Page No.
1 Preface i
2 Declaration ii
3 Contents iii-iv
3 Location map of study area v
4 Abbreviations vi-vii
5 List of Tables viii-ix
6 Chapter 1 : Introduction.
1.01: Review of literature and present state of
knowledge
1.02: Key concepts and conceptual analysis
1.03: Relevance of the study
1.04: Objectives
1-27
7 Chapter 2 : Research Design and Profile of
Respondents.
2.01: Profile of the area of the study
2.02:Socio-demographic profile of the district
2.03:Administrative setup in the district
2.04: Research Design
2.05: Sampling and sampling size
2.06: Sample size determination
2.07:Tools of data collection
2.08: Analysis of data and their presentation
28-43
8 Chapter 3 : Various Health schemes under National
Rural Health Mission (NRHM).
3.01: Maternal health
3.02: Janani Suraksha Yojana(JSY)
3.03: Janani Shishu Suraksha Krayakram (JSSK)
3.04: Village Health and Nutrition Day
3.05: Reproductive and Child Health (RCH)
3.06: Family Planning
44-58
iv
3.07:Total Fertility Rate
3.08: Adolescent Health
3.09: Adolescent Reproductive and Sexual
Health(ARSH)
3.10: School Health Programme
3.11: Rastriya Bal Swasthya Karyakram (RBSK)
3.12: Weekly Iron and Folic Acid Suppliment
Programme
3.12: Immunisation
9 Chapter 4: Impact of health programmes on mother and
child health (Women as mother).
4.01: Scenario in study area
4.02: Data analysis and findings
59-99
10 Chapter 5 : Family Planning and rural women (Women as
wife).
5.01: Scenario in study area
5.02: Data analysis and Discussions
5.03: Health Empowerment Index (HEI)
100-139
11 Chapter 6 : Health Programmes and status of rural girl child
(Women as Daughter).
6.01:Sex Ratio
6.02:PNDT Act
6.03:Number of children in family and their
genderwise details
6.04: Infant Mortality Rate
6.05: Under five Mortality rate
6.06: Children‘s nutritional status
6.07: Education and drop out rates
6.08: Mean age at marriage
6.09: Marriage before legal age for boys and
girls
6.10: Different govt. schemes for girl child
140-160
12 Chapter 7 : Conclusions and Suggestions.
161-187
13 Bibliography 188-199
14 Appendix :
Glimpses of Field Study
Interview Schedule
200-217
v
Map of the study area(District –Almora)
Map showing sample villages in selected Blocks
vi
ABBREVIATIONS
AFCCs Adolescent Friendly Counselling Centers
AHS Annual Health Survey
ANC Ante-natal check -up
ANM Auxillary Nurse Midwife
ARSH Adolscent Reproductive and Sexual Health
ASHA Accredited social Health Activist
AWC AaganWadi Centres
AWW Aagan Wadi Worker
BMI Body Mass Index
CHC Community Health Center
CMO Chief Medical Officer
DLHS District Level Health Survey
HDI Human Development Index
HDR Human Development Report
HEI Health Empowerment Index
HIV Human Immuno Virus
HV Health Visitor
ICDS Integrated and Child development scheme
ID Institution Delivery
IEC Informaton Education and Communication
IFA Iron Folic Acid
vii
IMR Infant Mortality Rate
JSSK Janani Shishu Suraksha Karyakaram
JSY Janani Suraksha Yojana
MDG Millennium Development Goals
MMR Maternal Mortality Rate
MoHFW Ministry of health and Family Welfare
NFHS National Family Health Survey
NRHM National Rural Health Mission
PHC Primary Health Center
PRA Participatory Rural Appraisal
RBSK Rastriya Bal Swasthya Karyakram
RCH Reproductive and Child Health
SC Scheduled Caste
SBA Skilled Birth attendant
TFR Total Fertility Rate
UIP Universal Immunization Programme
UKHFWS Uttarakhand Health And Family Welfare Society
UNDP United Nations Development Programme
VHND Village Health and Nutrition Day
WHO World Health Organization
WIFS Weekly Iron Folic acid Supplementation
viii
LIST OF TABLES
Sl.
No.
Table
Number
Table Title Page
no.
1 Table 2.1 Demographic profile of district Almora 30
2 Table 2.2 Blockwise demographic details of district 31
3 Table 2.3 Different schemes/programmes evaluated in the
present study for women in different roles
33
4 Table 2.4 Description of sample blocks and villages 34
5 Table 2.5 Villagewise sample profile 36
6 Table 2.6 Geographical Location of sample villages 39
7 Table 2.7 Education- profile of the sample 39
8 Table 2.8 Social profile of the sample 40
9 Table 2.9 Age gradation in the sample 40
10 Table 2.10 Family types for the respondents in sample 41
11 Table 2.11 Number of children and their gender profile(for
sample)
41
12 Table3.1 JSY Package for rural areas. 46
13 Table3.2 JSY Package for urban areas. 46
14 Table3.3 Implementation status of JSY in Uttarakhand and
Almora
46
15 Table3.4 Unmet need of Family Planning for Uttarakhand and
District Almora
50
16 Table3.5 Total Fertility Rate (TFR) in the country 50
17 Table 3.6 TFR for Uttarakhand and District Almora 52
18 Table 3.7 Current Family Planning Practices and Female
sterilization
52
19 Table 3.8 Current Family Planning Practices and Male
sterilization
52
20 Table 3.9 Current Family Planning Practices through
Temporary Methods
53
21 Table4.1 Castewise frequency of ANC done 65
22 Table4.2 ANC not done caste vs education 66
23 Table4.3 Status of institutional delivery 69
24 Table4.4 Education level and its effect on Institutional
Delivery
71
25 Table4.5 Remoteness of the sample blocks and status of
Delivery
72
26 Table4.6 Awareness about JSY across the castes 77
27 Table4.7 Availing incentive from JSY across Education levels 78
28 Table4.8 JSY benefits availed across the Blocks 79
29 Table4.9 Overall Awareness about VHND 80
30 Table4.10 Awareness about VHND across education level 81
31 Table4.11 Awareness about VHND across the blocks 82
32 Table4.12 Various services availed during VHND castewise 83
33 Table 4.13 Overall awareness about RCH Camps andCaste-wise 86
ix
34 Table 4.14 Awareness about RCH Camps across Education
levels
88
35 Table 4.15 Awareness about RCH Camps across Blocks 89
36 Table 4.16 Overall status of breast feeding practices 90
37 Table 4.17 Blockwise status of breast feeding practices 91
38 Table 4.18 Status of breast feeding practices by educational
Qualification
91
39 Table 4.19 Overall status of immunization among Pregnant
mothers and their children
94
40 Table 4.20 Block wise Immunization Coverage of Pregnant
mothers and their children
95
41 Table4.21 Immunisation Coverage of Pregnant mothers and
their children across Education levels
96
42 Table 5.1 Overall Perception about Health among respondents
Knowledge about various Family Planning methods
among respondents
105
43 Table 5.2 Treatment of ailments at various stage of illness by
responents across castes
107
44 Table 5.3 Education level of respondents andtreatment of
ailments at various stage of illness by them
107
45 Table5.4 Perception of respondents about their need for
different Health Services Provider for treatment of
gynecological problems
112
46 Table5.5 Usual Sources of Information about healthrelated
issuesand services
113
47 Table5.6 Health Facility Usually Accessed by Respondents for
Primary Health Care
115
48 Table5.7 Block-wise number of Health facilities in District 117
49 Table 5.8 Distance of nearest govt. health facility for the
respondents
118
50 Table 5.9 Perception of respondents regarding affordability of
primary healthcare facilities caste wise
119
51 Table 5.10 Perception of respondents regarding affordability of
primary healthcare facilities across blocks
121
52 Table 5.11 Body mass index (BMI) of respondents 123
53 Table 5.12 Knowledge about various Family Planning methods
among respondent
128
54 Table 6.1 Number of children and their Gender-wise details 144
55 Table 6.2 Genderwise details of children examined and found
anemic by school health teams under during year
2012-13
147
56 Table
No.6.3
Perception of respondents about nutritional
requirements of children
147
57 Table
No.6.4
The Target Adolescent Boys and Girls
157
1
Chapter1
Introduction
Discrimination against women on the basis of their gender has been prevalent
globally since the very advent of social systems and the history is replete with such
examples where women have been discriminated against through the conventions,
societal dictats, cultural marginalisation, economic dependence and the like. Global
literature also reflects this fact in its various manifestations.
Even the right to vote in the otherwise liberal and democratic systems of
governance also did not come naturally even in countries like the US, the UK and
France. The modern movement for women's suffrage originated in France as late as in
1780s and 1790s and women's suffrage has generally been recognized only after
continuous political campaigns to obtain it were waged. In 1893, the British colony of
New Zealand became the first self-governing nation to extend the right to vote to all
adult women. Voting rights for women were introduced into international law by the
United Nations' Human Rights Commission, whose elected chair was Eleanor
Roosevelt. In 1948Violence against women, inequalities in social structure, exclusion
of women in decision making processes, preference for male child, prenatal tests for
sex determination of the foetus, neglect in education, nutrition and health concerns
etc. are some examples of gender bias present in the society. This bias also often
results in inequalities in the sharing of power, say in decision-making at different
levels; lack of respect inadequate promotion and protection of the human rights of
women.
Though biological sex differences are very few and would not lead to gender
inequality, more often than not, gender inequalities are socially determined and can be
changed with change in attitudes and social practices Gender discrimination affects
both male and female adversely, but women are the worse victim. Last few decades
have seen a greater awareness in this regard and issues like gender sensitization,
gender equality, gender budgeting, gender justice etc have figured as central theme at
national and international level. The 1995 Beijing Platform for Action remains a
relevant guideline for development programming. It provides ―an agenda for women‘s
2
empowerment‖and signed by all governments that is seen as ―a necessary and
fundamental pre-requisite for equality, development and peace.‖As articulated by the
UN Economic and Social Council (ECOSOC) in 1997, the goal of gender
mainstreaming is gender equality, for which women‘s empowerment is usually
required.
The Millennium Development Goals (MDGs) consolidated previous
agreements, including those on women‘s rights, women‘s empowerment and gender
equality, into a single set of core goals, targets and benchmarks for the development
community.
―The formal global calls for the inclusion of women in national and
international development began in the early 1960s, but the women were integrated as
a special concern in the Indian development and planning process even before the
formulation of India‘s first development plan (1951-1956). The Indian Constitution,
guarantees justice, liberty, and equality to all citizens. Article 14 provides that the
state shall not deny to any person equality before, or equal protection of, the law
Article 15 prohibits any discrimination. Article 16(1) guarantees equality of
opportunity for all citizens in matters relating to employment and clause (2) of this
article prohibits discrimination in employment of the basis of religion, race, caste and
sex.‖ 1
―The health of Indian women is intrinsically linked to their status in
society,especially for those living in a rural area. Research into women‘s status in
society has found that the contributions Indian women make to families are often
overlooked. Instead they are often regarded as economic burdens and this view is
common in rural areas of the northern belt. There is a strong preference for sons in
India because they are expected to care for ageing parents. Indian women have low
levels of both education and formal labor-force participation. The average Indian
woman bears her first child before she is 22 years old, and has littlecontrol over her
own fertility and reproductive health.‖ 2
―Many of the health problems of Indian women are related to high levels of
fertility Overall, fertility has been declining in India; the total fertility rate was 3.4,2.9
and 2.7 in NFHS-1, NFHS-2 and NFHS-3, respectively. However, there are large
differences in fertility levels by state, education, religion, caste and place of residence;
for instance, the interstate total fertility rate was more than 5 children/woman in Utter
Pradesh and less than 2 in Kerala.”3.
―The average female life expectancy today in
3
India is low compared to many countries, but it has shown gradual improvement over
the years. In many families, esp. rural ones, the girls and women face nutritional
discrimination within the family, and are anemic and malnourished. The maternal
mortality in India is the second highest in the world. Only 42% of births in the
country are supervised by health professionals. Most women deliver with help from
women in the family who often lack the skills and resources to save the mother's life
if it is in danger. According to UNDP Human Development Report (1997), the
proportion of pregnant women (age 15-49 aged) with anemia was found to be as high
as 88%. The average nutritional intake of women is 1400 calories daily. The
necessary requirement is approximately 2200 calories. 38% of all HIV positive people
in India are women yet only 25% of beds in AIDS care centers in India are occupied
by them. 92% of women in India suffer from gynecological problems. 300 women die
every day due to childbirth and pregnancy related causes.Female literacy is gradually
rising, the female literacy rate in India is lower compared to the male literacy rate.
According to the National Sample Survey Data of 1997, only the states of Kerala and
Mizoram have approached universal female literacy rates. According to majority of
the scholars, the major factor behind the improved social and economic status of
women in Kerala is literacy.According to a 1998 report by U.S. Department of
Commerce, the chief barrier to female education in India are inadequate school
facilities (such as sanitary facilities), shortage of female teachers and gender bias in
curriculum (majority of the female characters being depicted as weak and helpless)
Girls are often taken out of school to help with family responsibilities such as caring
for younger siblings. Girls are also likely to be taken out of school when they reach
puberty as a way of protecting their honor. The data on school attendance by age
show the proportion of girls attending school decreases with age while for boys it
remains stable. In 1992-93, only 55 percent of girls aged 11 to 14 were attending
school compared with 61 percent of the younger age group. The difference between
male and female literacy rates is much higher in rural areas compared to urban areas.
Although substantial progress has been achieved since India won its independence in
1947, when less than 8 percent of females were literate, the gains have not been rapid
enough to keep pace with population growth”4.
4
1.01 Review of literature and Present status of knowledge:
Comprehensive review of related literature was done to know how earlier
work relates to the present study and the directions taken by other researchers. This
section contains the majority of the analysis of what other researchers and authors
have said about the subject. Care has been taken to cite the sources and to give
appropriate credit to the concerned persons or institutions.
The principle of gender equality is enshrined in the Indian Constitution in its
Preamble, Fundamental Rights, Fundamental Duties and Directive Principles. The
Constitution not only grants equality to women, but also empowers the State to adopt
measures of positive discrimination in favors of women. Within the framework of a
democratic polity, our laws, development policies, Plans and programmes have aimed
at women‘s advancement in different spheres. From the Fifth Five Year Plan (1974-
78) onwards has been a marked shift in the approach to women‘s issues from welfare
to development. In recent years, the empowerment of women has been recognized as
the central issue in determining the status of women.
One of the most important and vital indicator/parameter of the Human
Development Index (HDI) is the status of the women in the society. Our first Prime
Minister Pt. Jawaharlal Nehru said ―you can tell the condition of a nation by looking
at the status of its women.‖ It is also a well experienced fact that the socio-cultural,
educational and economic progress of any family is greatly influenced by and
dependant on the status of the women in the family. Education, health and decision
making ability and freedom to have her own choice in the matters related to her have
direct bearing on the empowerment status of the women. However much a mother
may love her children, it is all but impossible for her to provide high-quality child
care if she herself is poor and oppressed, illiterate and uninformed, anemic and
unhealthy, has five or six other children, lives in a slum or shanty, has neither clean
water nor safe sanitation, and if she is without the necessary support either from
health services, or from her society, or from the father of her children.‖5 ―The low
status of women in large segments of Indian society cannot be raised without opening
up of opportunities of independent employment and income for them. But the process
of change to raise the status of women under various spheres of socio-economic
activities would require sustained effort over a period of time."6
5
―The health problem of women in society at large is another crucial area not
given the required attention. Due to the predominantly patriarchal order, women are
confined within an oppressive environment. Differences are frequently noted between
health and nutritional status of men and women. Nutritional surveys have indicated
high rates of inadequacies among females compared to males. Female infants and
children are subject to neglect in respect of nutrition and health care. Statistics from
primary health centres show that adult women do not generally take treatment from
them. Maternal mortality continues to be very high. A number of studies have
indicated that a large number of children suffer from malnutrition, to which the
mother's poor health contributes to a great extent. Anemia among rural women is
estimated to be as high as 60—80 per cent, leading to low birth weight among babies.
According to the 1981 Census, only 14 per cent of the total female population
in the country falls in the category of "workers". The unpaid economic activities of
women and their contribution through work in the domestic sectors remain unreported
in the census. An ILO study has estimated that the value of unpaid household work
constitutes 25-39 per cent of the total gross national product in developing countries."
7
"Severe malnutrition amongst the child population as a reason for restricting
their learning capacity as well as high sickness and mortality. High maternal and
infant mortality rates and unacceptable levels of anemia among women and children
and lack of access to affordable health care to people, especially in rural areas has also
been highlighted in the document. It has been pointed out that in addition to curative
health care, a wide range of other interventions, such as dietary improvement,
nutrition supplementation for children, better child care practices, and access to safe
drinking water, improved sanitation, and immunization are required along with a
superior and affordable system of curative health care. Importance of the National
Rural Health Mission, the Rashtriya Swasthya Bima Yojana etc in this regard has
been mentioned."8
"On Human Development Index (HDI) India currently ranks 119 in Human
development Index (HDI), unacceptable in a country that‘s among top ten in GDP
growth. Last year UN applauded 59% fall in our maternal mortality rate (MMR)
between 1990 and 2008, but cautioned that it remains the highest in the world: 230
per 100000 live births, that is 63,000 of our women still die from pregnancy related
6
causes every year. Only 37% of Indian mothers get to see any health worker at all.
She concludes her article saying that preventing women‘s death and disability spreads
large concentric circle of health and happiness, make all other development
investment pay large dividends, and restore precious women‘s hour otherwise lost to
exchequer. It‘s a simple enough maths, but yet to be grasped by those who make the
political decisions and allocations."9
The Asian Enigma, a study conducted by the UNICEF stated that "The
exceptionally high rates of malnutrition are rooted deeply in the soil of inequality
between men and women. These gender disparities are present at ages as young as
five years and less. They manifest mainly as neglect of the girl child during illness
and partiality in the rationing of food for girls in the family. It leads to anemia and ill-
health both of which are risk factors in pregnancy. Health care is another sector that
has failed to establish inroads and make a substantial difference in the condition of
rural women."10
"A number of studies have shown that women may be empowered in
one area of life while not in others."11
"Empowerment of women should be a key
aspect of all social development programs."12
"The frequently used Gender Empowerment Measure (GEM) is a composite
measure of gender inequality in three key areas: Political participation and decision-
making(measured by the percentage of seats in parliament held by women), economic
participation and decision-making (measured by the percentage of female
administrators and managers, and professional and technical employees) and power
over economic resources (HDR: 2003). It is an aggregate index for a population and
does not measure Empowerment on an individual basis. It also does not capture the
multidimensional view of women‘s empowerment. It cannot be assumed that if a
development intervention promotes women‘s empowerment along a particular
dimension that empowerment in other areas will necessarily follow."13
"Some significant beginnings towards women and child welfare such as the
establishment of the Central Social Welfare Board in 1953, promotion of Mahila
Mandals, legislative measures to protect the interests of women Suppression of
Immoral Traffic in Women and Girls Act, 1956, the Hindu Succession Act, 1956, the
Dowry Prohibition Act, 1961 and the Maternity Benefit Act, employment and training
for women as the principal focus ―The main approach in these Plans was generally to
view women as the beneficiaries of social services rather than as contributors to
7
development.‖14
"The focus of the Ninth Plan was on ―Growth with Social Justice and
Equity.‖15
"Creating an environment for full development of women to enable them to
realize their full potential; freedom on equal basis with men in all spheres – political,
economic, social, cultural and civil; equal access to participation and decision making
in social, political and economic spheres; equal access to health care, quality
education at all levels, career and vocational guidance, employment, remuneration,
occupational health and safety, social security and public office etc.; elimination of all
forms of discrimination; changing societal attitudes and community practices by
active participation and involvement of both men and women; mainstreaming a
gender perspective in the development process viii) Elimination of discrimination and
all forms of violence against women and the girl child; and building and strengthening
partnerships with civil society, particularly women‘s organizations. A scheme on
Gender Budgeting was introduced in 2007 with a view to building capacity so that a
gender perspective was retained at all levels of the planning, budget formulation and
implementation processes.
A more responsive and gender sensitive legal-judicial system to women‘s
needs, especially in cases of domestic violence and personal assault, need for
enactments to ensure that justice is quick and the punishment meted out to the culprits
is commensurate with the severity of the offence; mainstreaming a Gender
Perspective in the Development Process vision for economic and social empowerment
including issues like poverty eradication, micro credit, women and economy,
globalization, women and agriculture, women and industry and support services
education, health, nutrition, drinking water and sanitation, housing and shelter,
environment and science and technology.‖16
A study by SEWA of 14 trades found that 85 per cent of women earned only
50 per cent of the official poverty level income. The sociological research on the
status of women has generally suggested that the Indian women enjoy a low status in
their households because family decisions relating to finances, kinship relations,
selection of life partner are made by the male members and women are rarely
consulted.
WHO estimates show that out of the 529,000 maternal deaths globally each
year, 136,000 (25.7%) are contributed by India. A factor that contributes to India's
high maternal mortality rate is the reluctance to seek medical care for pregnancy.
8
According to Indian writer and activist Devaki Jain, "the positive
discrimination of PRI has initiated a momentum of change. Women's entry into local
government and their success in campaigning, including the defeat of male
candidates, has shattered the myth that women are not interested in politics, and has
no time to go to meetings or to undertake all the other work that is required in
political party processes.17
Women leaders in the Panchayati Raj are tackling issues that had previously
gone virtually unacknowledged, including water, alcohol abuse, education, health and
domestic violence. According to Sudha Murali, UNICEF Communications Officer in
Andhra Pradesh, women are seeing this power as a chance for a real change for them
and for their children and are using it to demand basic facilities like primary schools
and health care centres.
Significant transformations in the lives of women have resulted due to it and
their empowerment is reflected in self-confidence, political awareness and affirmation
of their own identity. Sudha Pillaisuccinctly sums it up as follows: "It has given
something to people who were absolute nobodies and had no way of making it on
their own. Power has become the source of their growth.18
" In the words of UN
Secretary General Kofi Annan "Gender equality is more than a goal in itself. It is a
precondition for meeting the challenge of reducing poverty, promoting sustainable
development and building good governance."19
"One of the important factors which affect the health and productivity and
consequently the empowerment is the nutrition availability to the women.
Government of India adopted the National Nutrition Policy in 1993. A number of
initiatives such as Nutrition Advocacy and Awareness Generation on National
Nutrition Policy, Micronutrient Malnutrition Control, Disaggregated Data in the form
of District Nutrition Profiles and Establishing Nutrition Monitoring, Mapping and
Surveillance based on Triple AAA Approach, Promoting a Comprehensive Approach
for Micronutrient Malnutrition Control and Intensifying IEC Activities on Nutrition,
have been undertaken by Food and Nutrition Board (FNB), Department of Women
and Child Development (DWCD) on different instruments of the National Nutrition
Policy."20
"A number of literatures have highlighted the utilization of maternal health
care services varies with the socio-economic characteristics of the population
(Kanitkar and Sinha1989; Govindaswamy 1994; Kavita and Audinarayana1997;
9
Bloom 2001; Navaneetham and Dharmalingam 2002; Gymiah et al. 2006; Dey2009)
have mentioned that education of the mother is an important social variable thathas a
positive effect on the utilization of maternaland child health services.
Theothersocioeconomicfactorsusually found to be importantare place of residence,
religion and standard offliving of the household. The economic status of the
household also determines the utilization of antenatal care and delivery care services
(Pandey et al. 2002). Kavita and Audinarayana (1997) documented a strong
association of the caste system with the utilization of maternal care services. "21
According to Sen and Kumar, 2001"women are under-represented in
governance and decision making positions. At present, less than 8% of Parliamentary
seats, less than 6% of Cabinet positions, less than 4% of seats in High Courts and the
Supreme Court, are occupied by women. Lessthan 3% of administrators and managers
are women. Women are legally discriminated against in land and property rights.
Most women do not own any property in their own names, and do not get a share of
parental property."22
"Maternal mortality reflects one of the shamefulfailures of human
development. According to WHO (2005)approximately80 percent of the
maternaldeaths globally occur due to hemorrhage,sepsis, unsafe inducedabortion,
hypertensivedisorder of pregnancy, and obstructed labor. These deaths are unjust and
can be avoided with key health interventions, like provision of antenatal care and
medically assisted delivery."23
"One of the disturbing trend in terms of women‘s health is the increase in
HIV/AIDS rates. Women and girls account for 50% of HIV/AIDS cases worldwide,
or 15.5 million. Yet there is a persistent gap in treatment for women and it is now a
leading cause of women‘s ill health and death"24
. "While dealing with the third world
context and Gandhian view on human rights writes that though the 21st century began
with the uncertainty over future of human rights. Yet it holds lot of promise for the
future. Great advances have been made since 1945, not only is standard setting the
institution building, but also in freedom and well being for many people in many
countries. Donnelly has dwelt upon the issues related to human rights with reference
to national state and its institutions, especially, it's legal and law enforcement agencies
and its institutional mechanism to respond to the growing needs of human rights."25
10
"Afully functioning, mother-baby package interventionhas been estimated to
have the potentialcumulativeeffect of averting 75–85% of maternaldeaths and
disability in developing countries .Factorinfluencing maternal health
servicesutilization operate at various levels-individual, household,
community.Depending on the indicatorof maternal health services, the
relevantdeterminants vary. Although, in general, womenin higher socio-economic
groups tend to exhibitpatterns of more frequent use of maternal healthservices than
women in the lower socio-economic groups."26
"The emphasis on two out of eight criticalUnited Nations Millennium
Development Goals,that is, reducing under five mortality by twothirdsbetween 1990
and 2015; and reducingmaternal mortality ratio by three quarters between1990 and
2015 epitomize the relevance of theseindicators in globalefforts towards human
development."27
"Under-nutrition is also a problem even in middle and high income group
adolescent children, both boys and girls and is not confined to lower income group.
She further mentions that according to World Bank, improving health care for
women offers the biggest return on health care spending for any demographic group
of adults along with other multiple pay offs such as well being and productivity of
women, significant benefits for families, communities and national economies."28
"Health and nutrition education can be recommended as an extremely valuable
tool in alleviating the malnutrition in infants, which may occur as a result of
inappropriate infant feeding practices followed by the mothers."29
"Bearing and rearing children serves critical cultural functions and hierarchical
societies and confers power on women, which is otherwise not available to her. She
further elaborates that a child holds importance everywhere, irrespective of the culture
or society. In India, through the child a women gets her identity and her sense of
completeness, confirming the belief that a woman is incomplete without the child and
that she does not have an identity of her own. The power, respect and position that she
gets in the family and also in the society depend upon her reproductive capacity."30
"Health education is one of the best means to empower people to adopt
healthy behaviour and lead a satisfying, socially useful and productive life. People
need to be aware of their potential for improving their own health through their own
efforts."31
"Women, particularly rural women from low socio-economic status have
little say on issues of family size, when to bear a child, spacing between children."32
11
"Dwelling upon the invisibility of women‘s work mentions that a major index
of neglect is that many women‘s economic contributions are grossly undervalued or
not valued at all. Many tasks of the housewife have alternate market prices and hence
every housewife is performingwork in the economic sense of the term irrespective of
the fact of direct payment. "33
"Only 24.53% mothers gave birth to infant who weighed more than 2.5 kg
while majority (47.17%) of them gave birth to infants who weighed between 2.01 to
2.5 kg and 28.3% infants were below 2 kg weight. The main cause of low birth weight
was poor calorie and protein intake by mothers during the pregnancy in one hand and
hard work in difficult terrain on the other. Health facilities available in the village or
region were poorly availed by the samples."34
"Weekly hours spent by men and women on Systems of National Account
(SNA) work and unpaid care work in 6 countries in the developing world Men in
India spent the least amount of time in unpaid care work while men in South Africa
spent the most. When the unpaid care. Work is further measured in terms of the kinds
of unpaid work, , most of men‘s unpaid work is in community service rather than
house work or person care."35
"More women have access to HIV testing and counseling than men (WHO
2009). The report goes on to add that there is a direct correlation between women‘s
health and economic empowerment. Access to education, household wealth, and place
of residence are important factors in women‘s and girls‘ health outcomes in
developing and developed countries. Women and girls in wealthier households have
lower mortality and higher use of health care services than those living in poorer
households. "36
"In most cases, lack of health education and access to affordable health care
continue to prevent women from enjoying good health. Lack of infrastructure,
capacity building, and financing continue to be issues as does societal
discrimination.Women in many countries such as Kenya, Rwanda, India have had
difficulties in gaining inheritance rights. Policies such as joint ownership and spousal
consent on issues relating to property have been passed in several countries. In
Maharashtra, India, a social movement developed a program called “Laxmi Mukti” or
freeing the goddess of wealth which involved transferring property to women or joint
ownership. Villages in which 100 families had done so were called Laxmi Mukti
villages. Land reform policies have not been successful in many countries as they fail
12
to recognize women‘s contributions to agricultural production and hence exclude
them from ownership."37
―Although land reforms were based on principles of
redistributive justice(no concentration of land in the hands of a few),
empowerment(control to workers over the productive asset, i.e. land) and economic
justice(control overmeans of production to reduce severe indebtedness and poverty of
a majority of the agrarian population), the principle of gender equity was ignored.‖38
―In many countries, customary and religious family law and practices
continue to privilege male rights to parental property even when legal reforms, such
as those in Hindu Reform Act, guarantee females rights of succession. In addition to
national laws on equal ownership and gender equity in land reform, there also needs
to be community based mobilization to teach women legal literacy and work with
leaders around religious and customary laws that prevent women from gaining access
to these assets.
While the trend is toward increased women‘s representation in national
parliaments, no region has yet reached the goal of 25 percent women in parliament as
set out in the Beijing Declaration and Platform for Action 1995. In 2008, Rwanda
became the first parliament with a majority of women members 56.25% , followed by
Sweden (47%), Cuba (43.2%) Finland (41.5%), and Argentina (40%). Given this
pace, a critical mass of 30% will not be achieved by2015. As per CSW 2009 the target
of 30% representation has been met in only 24 countries in Africa, Asia, Europe, and
Latin America. Overall, 60% of countries have achieved gender parity in primary
school, 30% in secondary school, and only 6% in tertiary education.
Negative attitudes and practices towards girls‘ education, valuing sons over
daughters, early marriage (particularly in South Asia) and pregnancies continue to
lead to high drop-out rates. Lack of safety on the way to school remains a disincentive
as well.‖39
―Women‘s unemployment rates will be higher than men‘s and up to 22
million will join the ranks of the poor in 2010.The impact on women‘s employment
will be longer than men‘s.‖40
―Women‘s health is not only influenced by genetics. biology and physiology
but also by women‘s role in society. The paper further highlights that in Non western
countries like china, Korea and India, male off springs are preferred. In these
countries girls are considered as a burden because they have low status and require a
dowry for marriage. Female fetuses are selectively aborted. Where such technology is
13
not applied, female children will be discreetly killed shortly after birth. In countries
where there is a strong preference for males, the rate of neonatal death in girls is more
than six times that of boys: there is also a higher neonatal mortality for girls born to
families with no sons. Sex Selection continues after birth by means of preferential
allocation of food and access to needed medication. Population Studies estimates that
as a result of these practices at least 100 million women were ‗missing‘ from world
population primarily from China, Korea and India.‖41
―The enjoyment of highest
attainable standards of health is one of the fundamental rights of every human being
without distinction of race, religion, political belief, economic or social
conditions.Health is defined not only by the absence of disease or illness, but by
physical, mental and social well being, It involves all aspects of life and is affected by
more than access to health care: biological, psychological and sociological influences
play a critical role.‖42
―Judiciary and law enforcement remain male domains though women have
made some in roads in appointments as judges, including in the Supreme court. The
International Criminal Court has 50% women among its 19 judges Women make-
up30% of the police force in Australia and South Africa, with the global average of
10%.‖43
―There is a direct correlation between women‘s health and economic
empowerment. At all stages women and girls in developed countries fare better than
women and girls in poorer countries, though there is variation within countries based
on urban/rural location as well as class and minority status. Access to education,
household wealth, and place of residence are important factors in women‘s and girls‘
health outcomes in developing and developed countries. Women and girls in wealthier
households have lower mortality and higher use of health care services than those
living in poorer house-holds.In most cases, lack of health education and access to
affordable health care continue to prevent women from enjoying good health. Women
generally live longer than men but in parts of Asia, particularly China and India due to
gender-based discrimination female life expectancy is lower that for males .Factors
that affects women‘s health is their lack of autonomy to make health decisions. In
sub-Saharan Africa and South Asia over50% of married women have no say in their
health care. Among the reasons for this are pervasive patriarchal practices that shape
gender roles and attitudes that are slow to change. In South Asia and China, where
sons are valued over daughters, this lack of autonomy is particularly evident in the
14
increase in sex-selective abortions, often against women‘s wishes. Women‘s
movements in India have been successful in getting legislation against such abortions
and have also focused on public awareness campaigns that promote the value of
daughters. ‖44
―Institutional delivery rose from 53.3% in 2005 to 72.9 % in 2009. The 11
States which had the weakest performance at the baseline, i.e. States with less than
national average of 53%institutional delivery showed substantial increase.
Institutional Delivery in rural areasimproved from 39.7% in 2005 to 68% in 2009
resulting in a jump of 28.3% (all India increase 19.6%). In urban areas, where access
to facilities is much easier and where Janani Suraksha Yojana is also available, the
increase was from78.5% to 85.6%- a mere 7.1% increase. Though Janani Suraksha
Yojana is a major contributor to improvements in institutional delivery, other
dimensions of NRHM listed below also contributed significantly to the increase in
institutional44 delivery in rural areas. This trend is also confirmed by District Level
Health Survey (DLHS) which shows an all India increase in institutional delivery
from40.5% in 2002-03 to 47% in 2007-08.‖45
―Overall sex-ratio for the rural as well as for the urban population showed a
decline between 2004-05 and 2009-10.The current attendance rates in educational
institutions were higher among males than females and also higher in urban areas than
in rural areas. Worker Population Ratios (WPR) for male was much higher than
female for all the religious groups - the differential being greater in the urban areas. In
rural areas, majority of male workers belonged to the categories not literate (28 per
cent) or literate and up to primary (28 per cent) while majority of female workers
belonged to the category not literate (59 per cent). In rural areas, majority of
employed persons belonged to the employment category self employment. The
proportion of self-employment among male workers was about 54 per cent and that
among female workers was about 56 per cent. In rural areas, a significant portion of
workers among male (38 per cent) and female (40 per cent) were engaged in casual
labour employment. The unemployment rate in rural areas is less than that of urban
areas. ‖46
―Family Planning is one of the best investments we can make-it has enormous
social and economic benefits for women, their families and communities. A woman‘s
ability to use contraceptives to determine whether and when to have children
improves her chances of getting an education and finding employment. It is also a
15
major positive impact on both maternal and infant mortality. Family planning
contributes to her productivity, mental, physical health and stability of her family and
well being of her children. With this access women have the ability to plan their lives
and future. ‖47
―We need to populate all institutions with women and ensure that 33% of
parliament comprises women. The representation of women in Judiciary is also
woefully inadequate at only 5.6%.The same is the case with police force where we
really need all women police stations and contingents. We also need to sensitize these
institutions by stressing on empathy and responsiveness. She also mentions that
economic empowerment is key. Such empowerments‘ help deter violence and also
free women who are able to seek help instead of suffering violence. Overall we have
to make sure that culture and religion are not interpreted in ways that devalues
women. This is one of the most vicious causes for violence against women. She
emphasized on the need to examine power relations within the family and include
care burden sharing, value underpaid work, provide for sexual and reproductive
rights.‖48
―On the health front implementation of the National Rural Health Mission has
resulted in an improvement in many development indicators related to women.
Fertility Rates have come down and have reached replacement levels in a number of
states; Maternal Mortality Rate (MMR) is improving, from 301 per 100,000 live
births in 2003 it has come down to 212 in 2009; Infant Mortality Rate, though still
high, has reduced to 50 per 1000 in 2009. Further, institutional deliveries have risen
from 39 percent in 2006 to 78 percent in 2009, and availability of HIV/AIDS
treatment has been enhanced. The vision for the XII Five Year Plan is to ensure
improving the position and conditionof women by addressing structural and
institutional barriers as well as strengthening gender mainstreaming. Goals for the XII
Five Year Plan includeCreating greater ‗freedom‘ and ‗choice‘ for women by
generating awareness and creating institutional mechanisms to help women question
prevalent ―patriarchal‖ beliefs that are detrimental to their empowerment and
Improving health and education indicators for women like maternal mortality, infant
mortality, nutrition levels, enrolment and retention in primary, secondary and higher
education. The Plan advocates a shift from mere ‗income‘ poverty of women to the
adoption of a ‗multi-dimensional‘ approach to poverty and wellbeing. The Multi
Dimensional Poverty Index (MPI) complements the income poverty measures by
16
reflecting all the other deprivations with respect to education, health and living
standard that a poor person simultaneously faces. On Economic Empowerment the
plan document emphasizes on recognizing that economic independence is the key to
improving the position of women within the family and in the society, the Plan would
need to focus on enhancing women's access to and control over resources. Amongst
others, this would entail not only increasing their presence in the work force but, more
importantly, improving the quality of women‘s work and ensuring their upward
mobility on the economic ladder. With the specific objective of ensuring convergence
and better coordination among the schemes/programmes of various
Ministries/Departments, the Ministry launched the National Mission for
Empowerment of Women. The Mission would work to achieve convergence at all
levels of governance. It would have an overarching role in promotion of women‘s
issues across economic, social, legal and political areas.‖49
India is a country with more than seventy percent of its population residing in
rural areas, it is therefore important to examine the condition of women in our
villages. Women are considered to be the agents of change but a large number of rural
women live in abject poverty and are subjected to various forms of exploitation
women which also leads to decreased productivity. Uttarakhand is the 27th state of
the Indian Union carved out of U.P. in November 2000. According to the 2011 census
report the total population of the state was 101,16752with 963females per 1000 males.
About 75% population of the state resides in the rural areas. The demographic
profile of the state reveals that the major part of the state lies in the hilly region which
has its unique socio-economic and socio-cultural legacy. ―On an average, households
in Uttarakhand are comprised of five members. About 1 in 6 households (16%) are
headed by women. Eighty percent of households (95% ofurban households and 74%
of rural households) have electricity, up from 53 percent at thetime of NFHS-2. Fifty-
seven percent of households have toilet facilities, up from 39 percent atthe time of
NFHS-2. In rural areas, 58 percent of households do not have any toilet
facilities.Eighty-seven percent of households use an improved source of drinking
water (99% of urbanhouseholds and 83% of rural households), but only 44 percent
have water piped into theirdwelling, yard, or plot. Twenty-one percent of households
treat their drinking water to make it potable; 49 percent of those that treat their water
use ceramic, sand, or other water filter and 43 percent boil the water.In rural areas of
Uttarakhand, 58% of householdsdo not have any toilet facilities.‖50
17
Most of the agricultural, horticultural and house hold works are carried by the
women in the hills. Fetching drinking water and fuel wood from the forest and nearby
areas are also primarily done by the women. It is therefore socially very relevant and
important to study the status of rural women. In the present study attempts would be
to carry out a scientific and systematic social research to gain knowledge of the issues
related to the empowerment of the rural women of district Almora, one of the typical
hill districts situated in the middle Himalayas. It is expected that based on the study
some meaningful suggestions would emerge which may provide useful input for
improvement policy and programme planning and implementation strategy.
Sex-ratio (number of female per 1,000 male) is an important indicator of
women's status in the society. At national level, in 1901 there were 972 females per
1,000 males, while by 1971; the ratio has come down to 930 females per 1,000 males.
In 1981 there has been only a nominal increase in the female sex ratio within 934
females to 1,000 males. There were only 926 females per 1000 males in India
according to 1991 census. The sex ratio was 933 in 2001 which has slightly improved
in 2011 with 940 females per thousand males. As per the census report 2011
(March2011) the female population stands at 586.5 million out of total 1210.2
million Indian population. For Uttarakhand over all sex ratio has improved by only
one point to become 963 in 2011 as compared to 962 in 2001. District Almora and
Pauri have registered negative growth in population in the decade 2001-2011. Over all
sex ratio has marginally improved in the state but Child Sex ratio (0-6 years) has
declined in hill districts also. Champawat, Almora, Bageshwar, Pauri and Pithoragarh
are such hill districts where child sex ratio has declined as compared to 2001.
Rural women of Uttarakhand are back bone of state as they look after
young and old. Also most of the agricultural, horticultural and house hold works are
carried out by the women in the hills. Fetching drinking water and fuel wood from the
forest and nearby areas are also primarily done by the women .Thus they do multiple
task. Hence their health becomes core issue. Government of India has launched many
schemes for the betterment of their health but the ―National Family Health Survey III
(2005-06) for Uttarakhand provided a gloomy picture of the status of maternal health
indicators in the state. The state has witnessed a higher proportion of high risk
pregnancies. Home delivery constitutes a substantial proportion (67.4 percent) in the
state, the majority being attended by untrained dais (midwives). These have resulted
in higher maternal morbidity and mortality.‖51
18
1.02 Key Concepts and Conceptual Analysis:
Empowerment :
According to Wikipedia, encyclopedia the term empowerment covers a vast
landscape of meanings, interpretations, definitions and disciplines ranging from
psychology and philosophy to the highly commercialized self-help industry and
motivational sciences. Sociological empowerment often addresses members of groups
that social discrimination processes have excluded from decision-making processes
through - for example - discrimination based on disability, race, ethnicity, religion, or
gender. Empowerment refers to increasing the spiritual, political, social, or economic
strength of individuals and communities. It often involves the empowered developing
confidence in their own capacities.
According to World bank Empowerment is the process of enhancing the
capacity of individuals or groups to make choices and to transform those choices into
desired actions and outcomes. ―The expansion of assets and capabilities of poor
people to participate in, negotiate with, influence, control, and hold accountable
institutions that affect their lives.‖ In essence empowerment speaks to self determined
change. It implies bringing together the supply and demand sides of development –
changing the environment within which poor people live and helping them build and
capitalize on their own attributes. Empowerment is a cross-cutting issue. From
education and health care to governance and economic policy, activities which seek to
empower poor people are expected to increase development opportunities, enhance
development outcomes and improve people's quality of life.‖52
―Altering relations of powerwhich constrain women‘s options and autonomy
and adversely affect health and well-being.‖53
―Empowerment is about
participation in which actions and decisions must be by people, not only for them;
People must participate fully in the decisions and processes that shape their lives.‖54
―Empowerement is the expansion in people‘s ability to make strategic life
choices in a context where this ability was previously denied to them.‖ 55
―Empowerment is the enhancement of assets and capabilities of diverse
individuals and groups to engage, influence and hold accountable the institutions
which affect them.‖56
19
―Expanding empowerment to include six dimensions: economic, socio-
cultural, family/interpersonal, legal, political, and psychological. They also identify
three levels for measuring empowerment, household, community and broader
areas.‖57
―Women‘s Empowerment Matrix that consists of six dimensions -- physical,
socio-cultural,religious, economic, political, legal – and six levels: individual,
household, community, state, region, and global. Gender Empowerment Measure
(GEM) is essentially a measure of three indicators: control over economic resources,
measured by men and women‘s earned income; economic participation and decision
making, measured by women and men‘s share of administrative, professional,
managerial, and technical positions; and political participation and decision making,
measured by male and female share of parliamentary seats.‖58
. ―Incorporating
indicators of gender gaps in disposable time and care responsibilities. As a radical
alternative, she suggests a Gender Care Empowerment Index which would be the
mirror of GEM and measure men‘s participation in ―feminine‖ domains of care rather
than women‘s participation in ―masculine‖ activities as measured by the GEM.‖59
―Empowerment is ―how much influence people have over external actions that
matter to their welfare.‖60
―Gender equality is about women‘s status relative to men while women‘s
empowerment is about women‘s ability – in an absolute sense - to exercise control,
power, and choice over practical and strategic decisions. Three domains of
empowerment (adopted by the Millennium Project Task Force on Education and
Gender Equality): the capabilities domain, which evaluates knowledge and health
factors through indicators of education, health, and nutrition; the access to resources
and opportunities domain, which primarily refers to access to political decision
making and economic assets; and the security domain, which considers violence and
conflict matters.‖61
―The Analysts have also suggested to devise new indices, the most important
being the Social Watch‘s Gender Equity Index, the World Economic Forum‘s Global
Gender Gap, and the OECD‘s Social Institutions and Gender Index (SIGI); (3) to
move away from a composite index and instead focus on a series of indicators.‖62
―Women empowerment is one of the momentous issues of contemporary
development policies in developing countries. Since empowerment is considered a
20
multidimensional concept, it is determined by many socio-economic factors and
cultural norms.‖63
According to Ministry of Social Justice and Empowerment, Government of
India, Sociological empowerment often addresses members of groups that social
discrimination processes have excluded from decision-making processes through - for
example - discrimination based on disability, race, ethnicity, religion, or gender.
Social empowerment is understood as the process of developing a sense of autonomy
and self-confidence, and acting individually and collectively to change social
relationships and the institutions and discourses that exclude poor people and keep
them in poverty. Poor people‘s empowerment, and their ability to hold others to
account, is strongly influenced by their individual assets (such as land, housing,
livestock, savings) and capabilities of all types: human (such as good health and
education), social (such as social belonging, a sense of identity, leadership relations)
and psychological (self-esteem, self-confidence, the ability to imagine and aspire to a
better future). Also important are people‘s collective assets and capabilities, such as
voice, organisation, representation and identity.
For the purpose of this study research scholar has proposed following definitions:
Empowerment has been defined in terms of social aspects especially with
socio-cultural factors related to health problems which effect status of women in the
society. Health is not only a biological phenomenon but also a sociological issue.
Social empowerment in turn would include both qualitative as well as quantitative
parameters which have been assessed during the field study. Social empowerment
would include parameters like education, health, nutrition, decision making ability
and access to and affordability of health care services, status of institutional delivery,
Ante-Natal Check-ups, Post natal check up, immunization of mother and child etc and
socio-cultural factors which affect the health conditions of rural women in the area.
Rural women: Rural women means women living in the revenue villages
falling within some Gram Panchayat of district Almora, Kumaon Mandal, as notified
under U.P. Panchyati Raj Act 1947 (presently as applicable in Uttarakhand with its
state amendments from time to time) . Further, only adult married women in
reproductive age group (18-49 years) and residing normally in the village formed the
sample for the study.
Health Programmes : Health programmes are launched by govt. for
betterment of health of women. Major programmes studied are Janani Suraksha Yojna
21
and Reproductive and Child Health (RCH), school health programme, Village Health
and Nutrition Day(VHND) and other components of National Rural Health Mission
(NRHM).
1.03Relevance of the study:
The title of the present study is ―Health Programmes and Empowerment
of Rural Women: An Evaluation‖. During the study an attempt has been made to
evaluate the status and impact of different rural health programmes on the health of
rural women of the 6 villages of district Almora, selected following sound statistical
sampling techniques. According to Census2011, the percentage of rural population in
Almora is 89.98% and only10.02% comprises the urban population. The National
Rural Health Mission (NRHM), initially mooted for 7 years (2005-2012) has a
special focus on 18 states including Uttarakhand where health indicators were poor.
The 12th Five Year Plan also underlines that efforts will be made to consolidate the
gains and build on the successes of NRHM to provide accessible, affordable and
quality universal health care, both preventive and curative. Under Janani Suraksha
Yojana(JSY) the states with low rate of Institutional deliveries are classified as 'Low
Performing States(LPS)' and Uttarakhand is one such state. According to AHS report
2011-12 the over all rate of institutional delivery for district Almora was 45.1% as
against the target of 80% in NRHM. The present study has attempted to evaluate
different aspects of health programmes under NRHM including JSY and status of
institutional delivery.
Not much work has been done on the field based study to know the impact of
mother and child health related components of NRHM in district Almora, particularly
assessing their impact on the rural women with respect to their educational status, the
remoteness of the location of their villages, and density of health facilities available in
the development blocks. All these aspects have been studied by the research scholar
with intensive field work and interaction with the respondents. Therefore the present
study is unique, relevant and purposeful. The findings of the study may help in
formulating need based health programmes for rural women and provide inputs for
suitable changes in the sector policy to enhance and improve the implementation
strategy for the sector. It is well known that there is intrinsic relation between
women‘s health and their empowerment. The present study is an attempt to examine
22
the impact of health programmes on rural women in three different stages of her life,
as a mother, as a wife and as a daughter, and through this an attempt has also been
made to know the roles of these programmes in empowering rural women.
1.04 OBJECTIVES: The objectives of the present study are as follows:
1. To evaluate awareness level of rural women about health
2. To examine the impact of health schemes
3. To examine the awareness, participationanddecision making of women in
family planning.
4. To ascertain the availability of accessible and affordable health care
5. To analyse the impact of education,caste and age of rural women and their
empowerment.
6. To develop and generate women empowerment index for the rural women
with reference to the selected parameters
7. To suggest recommendations for better empowerment of rural women
The present study has been divided into seven chapters:
Chapter 1 : Introduction.
Chapter 2 : Research Methodology and Profile of Respondents.
Chapter 3 : Various Health schemes under National Rural Health Mission
(NRHM).
Chapter 4 : Impact of health programmes on mother and child health (Women as
mother).
Chapter 5 : Family Planning and rural women (Women as wife).
Chapter 6 : Health Programmes and status of rural girl child (Women as Daughter).
Chapter 7 : Conclusions and Suggestions.
* * * * *
23
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28
Chapter 2
Research Methodology and Profile of Respondents
2.01 PROFILE OF THE AREA OF STUDY:
The study has been undertaken in district Almora, located in Kumaon division
of Uttarakhand. "Almora, middle Himalayan District, comes under Kumaon division
of Uttarakhand. In the east, it is bordered by Champawat and Pithoragarh, in the north
by Bageshwar, Chamoli and Rudraprayag, in the west by Pauri and in south by
District Nainital. The total area of the district is 3689.4 sq km. The administrative set
up comprises of 9 Tehsils, 11 Development Blocks, 3 Nagar Panchayat, 1146 Gram
Panchayats and 2249 Revenue Villages."1"Ramganga,Kosi and Suyal are important
perennial rivers flowing in the district. Almora was founded in 1568.It is considered
the cultural heart of the Kumaon region of Uttarakhand. Nearest railway station is
Kathgodam which is 85 km from district head quarter.The latitude and longitude of
the geographical location of its head quarter is 29°37′N 79°40′E29.62°N 79.67°E .
Almora city has an average elevation of 1,651 meters (5,417 feet). In the shape of a
horse saddle shaped hillock, it is surrounded by thick forests of pine with sporadic
presence of devdar trees. The snow capped Himalayas can be seen in the background.
As per wikipedia, Almora got its name from "Kilmora" a short plant found nearby
region, which was used for washing the utensils of KatarmalTemple. The people
bringing Kilmora were called Kilmori and later "Almori"and the place came to be
known as "Almora". Almora has many noted temples, including Kasar Devi, Nanda
Devi, Doli Daana, Shyayi Devi, Khakmara, Asht Bhairav, Jakhandevi, Katarmal (Sun
Temple), Pataal Devi, Raghunath Mandir, Badreshwar, Banari Devi, Chitai,
Jageshwar, Binsar Mahadev, Garhnath and Baijnath. Kasar Devi temple was visited
by Swami Vivekananda . Rudreshwar Mahadev Temple, near Sanara Ganiya, is
dedicated to Lord Shiva. It is situated beside the river Ram Ganga. A sun temple (only
the second in the world) is located at Katarmal within a short distance from the
district head quarter.
29
The famous temple of Manila Devi, Devi Maa, the family goddess of the
Katyuri clan, lies around 85 km from Ranikhet. Udaipur a famous temple of Golu
devta is situated 5 km. from Binta near Dwarahat. Dunagiri has the highly revered
temple of Shakti or Mother Goddess. Dunagiri is also known as the birthplace of
modern day Kriya Yoga."2
2.02 Socio-demographic profile of the district:-
The district has 11 development blocks. "As per census 2011, the total
population of district Almora was 622506 consisting of 291081 males and 331425
females, with nearly 90 percent population residing in rural areas. The district has
5.76 percent of the state‘s geographical area and 6.15 percent of its population. The
sex ratio in the district is 1139 females per 1000 males as compared to the State
average of 963.Only 10 percentof the population lives in urban areas. The overall
literacy level of Almora stood at 81.06 percent, which is higher than the state literacy
rate of 79.63 percent. As per the 2011 census, Almora district comes second just to
Mahe district in Highest Sex Ratio among all the Districts in India.i.e. 1142 females
per 1000 males, whereas that of Mahe being 1147."3The social profile of the district
is given below:
30
Table 2.1: Demographic profile of district Almora
Background
Characteristics
ALMORA
UTTARAKHAND
Number Percent to
total Number
Percent
to total
1 Geographic Area
(in sq.kms) 3083 5.76 53483 100
2 Number of blocks 11 -- 95 100
3 Total Population
(2011) 622506 6.15 101,16752 100
Male 291081 5.66 513,7773 100
Female 331425 6.69 4948519 100
Urban 62314
Rural 560192
4
Sex Ratio
(F/M*1000)
Over all Sex Ratio
1139
--
963
--
Child Sex Ratio 922 -- 890 --
5 Child population 0-
6 years (Total) 80082 1355814
A)Male 41672 717199
B)Female 38410 638615
5 Population Growth (-)1.28% - 19.17% -
6 Average Literacy % 81.06 -- 79.63 -
Male % 93.57 -- 88.33 -
Female 70.44 -- 70.70 -
7 Percent of SC/ST
population
SC- 24.26
ST- 0.21 -- 17.6
8 Population density
per sq. km 198 189
31
The population of the blocks in Almora varies considerably. For the 11 blocks
of the district the demographic profile is given below:
Table 2.2: Blockwise demographic details of district
Blocks Name of Tehsil Total Population 2001 % of
Population
Hawalbagh Almora 67258 10.67
Lamghara Jainti 47347 7.51
Takula Almora 45325 7.19
Bhasiyachana Almora 26410 4.19
Tarikhet Ranikhet 69092 10.96
Dholadevi Bhanoli 62842 9.97
Chakhutiya Chakhutiya 49020 7.77
Bhikiyasen Bhikiyasen 37893 6.01
Dwarahat Dwarahat 61556 9.76
Syaldey
(Deghat)
Syaldey 49262 7.81
Salt Salt 61540 9.76
Almora Urban Almora 53022 8.40
Total 630567 100.00
Source: Census 2001
"The profile of health facilities as shown in the map of the district is given below"4:
Fig: Map of district Almora showing location of public health institutions.
32
2.03 Administrative Setup in the district
"The District has 9 tehsils with 11 development Blocks. There is 1 Nagar
Palika Parishads, and 1 Municipality. Three-tier Panchayat system consisting of Zilla
Panchayat (District Panchayat),Kshetra Panchayat (Block Panchayat) and Gram
Panchayat (Village Panchayat) is in place. Elections for 1 Zilla Panchayats, 11
Kshetra Panchayats and all Gram Panchayats, were held in 2009"5 and next panchayat
elections are expected to be conducted in June 2014.
2.04 Research Design :
For the purpose of study Exploratory cum Descriptive Research Design has
been used to achieve the objectives of the study. The study aims to develop an
understanding of the subject and the manner in which the selected parameters and
health schemes affect the women‘s empowerment in the rural areas of district Almora.
Empowerment as such a very broad concept, encompasses host of factors such as
social, cultural, economic and political. Health of a women is one of the most
important social indicator of women‘s empowerment. If a women is healthy she will
be more productive and will be in better position to contribute towards the
development and welfare of her family, society and nation at large. Empowerment is
also the ability of an individual to make decisions and exercise choices on different
social, economic and political aspects affecting her life. Keeping in mind the
relevance of intrinsic relationship between health and empowerment of women,
during the present study, efforts have been made, to evaluate impact of some
important rural health schemes (under NRHM ) and thereby assessing the women
empowerment affected by them.
In the present study woman has been viewed in three very important roles in
the family as mother, as wife and as daughter. Health of women is very important
and crucial issue at all stages of her life as she passes through the transition from
daughter to wife to mother. The health requirements at different phases of life varies
from each other and therefore need to be addressed accordingly. Different
schemes/programmes evaluated in the present study for women in different roles are
given below:
33
Table 2.3Different schemes/programmes evaluated in the present study for women in
different roles
Role of Woman in family Schemes/programmes studied
As a mother Janai Suraksha Yojna(JSY),Village
Health and Nutrition
Day(VHND),Reproductive and Child
Health (RCH), Janani Shishu Shuraksha
karyakram(JSSK).
As a Wife Health related awareness and Family
Planning Programme.
As a Daughter School Health Programme, Adolscent
Reproductive and sexual Health
(ARSH),Weekly Iron and folic acid
supplement (WIFS)programme, Rastriya
Bal Swasthya Karyakram(RBSK).
Universe for the purpose of study is District rlmora.
2.05 Sampling and sample size:
The following steps have been followed for unbiased sampling for the study.
Step-I: Health facilities sanctioned in terms of CHCs, PHCs, APHCs, Sub-centres and
AaganWadi Centres for each development block was assessed on the basis of
secondary data taken from the medical departments.The data for health facilities
available in different development blocks was taken from the office of C.M.O.
Almora.
Step-II: Number of health facilities in all 11 blocks of the district varied from 30.6 to
47.6 per ten thousand females for Chukhutia and Bhikiasain development blocks. On
the basis of health facility density the blocks were stratified into three strata viz:
blocks having health facility density of 30 to 36, 36.1 to 42 and 42.1 to 48 as first,
second and third strata. Chaukhutia, Takula, Deghat and Hawalbagh are in the first
Strata, Lamgarah, Dhauladevi, Bhaisiachhana, Sult and Dwarahat are in the second
strata where as Tarikhet and Bhikiyasain constituted the third strata. Stratified random
34
sampling was resorted to for the random selection of one block from each strata. The
outcome of this sampling was the selection of Hawalbagh, Tarikhet and Sult
development blocks.
Step-III: Keeping in view the resource constraints in terms of time and money two
Gram Panchayats from each block were selected using simple random sampling .
This process gave rise to the random selection of two gram panchayats from each of
Hawalbagh, Tarikhet and Sult development blocks. The details of selected gram
panchayats/villages is as follows:
Table 2.4: Description of sample blocks and villages
Sl.No. Development Block Gram panchayat Revenue-villages
1 Hawalbagh Udiyari Udiyari
Kayala Kayala
2 Tarikhet
Walna Walna
Uprari Uprari
Pipalkhand
3 Sult Barkinda Barkinda
Dadholi Dadholi
Step-IV: From within the selected Gram Panchayats all the married women of
reproductive age group 18-49 years were interviewed.
2.06 Sample size determination:
Determining sample size is a very important issue because samples that are too
large may waste time, resources and money, while samples that are too small may
lead to inaccurate results.For the purpose of study universe is District Almora. Using
the following formula we determined the sample size necessary to produce results
accurate to a specified confidence and margin of error. For this study the confidence
level of 95% and confidence interval of 6% has been determined keeping in view the
limitation of resources like finance and time available.
35
Sample Size (SS) - Infinite Population (Where the population is greater than 50,000)
Z 2 x (p) x (1-p)
C2
SS= Sample Size
Z = Z values which is 1.96 for a 95 percent confidence level.
P= Percentage of population picking a choice, expressed as decimal (0.5)
C= Confidence interval, expressed as decimal ( .06 =+/- 6 percentage points)
Z - Values (Cumulative Normal Probability Table) represent the probability
that a sample will fall within a certain distribution.
The Z- value for confidence levels is 1.96 for 95 % confidence level
(1.96) 2 x .5 x .5
(.06) 2
SS = 266.777 or say 267
From above it is thus clear that in order to achieve at least 95% level of
confidence with 6% confidence interval for sampling efficiency, keeping in view the
total population of rural women (302833 in 2011 census ) in district Almora ,the total
sample size in terms of number of women participants for the study was determined to
be 267 and actually 280 rural women were interviewed for collection of primary data
from the sample villages. It is also important to mention that as per the 2011 census
results the total rural female population of district Almora is 302833 but this includes
female of all age group. The number of rural girls in 0-6 years of age group (35770)
are also included in the above figures. Besides this, girls aged between 6-18 years of
age and old women also form sizable number in the area. It is thus clear that the total
population of target rural women is less than 267063.This implies that the actual
confidence interval would be less than 6 and confidence level more than 95%.
The details of actual sample villages and number of respondents are given
below :
SS =
Sample Size(SS ) =
36
Table2. 5 :villagewise sample profile
Development Block Village No.of
Respondents
Hawalbagh Udyari 50
Kayala 46
Tarikhet
Valna 50
Uprari 28
Peepalkhand 21
Sult Dhadoli 50
Barkinda 35
Total 280
During the field visit for collection of primary data, the selected Gram
panchayats were visited and the married women of reproductive age group 18-49
years were interviewed.
2.07 Tools of data collection:
Both primary and secondary data was collected and used for the research
study. The following major tools were used to obtain the desired data and
information:
A.Primary Data:To ascertain the qualitative and quantitative aspects of primary
data the following tools were used :
1.Interview Schedule-The interview schedulein Hindi wasprepared and the
questions were drafted and chosen keeping in view the objectives of the study. The
schedule was then pre-tested in the field in the month of May 201 . On the basis of
feedback and experience the interview schedulewas modifiedi finetuned and finalized
for the collection of data in the field. The final version of interview schedule
contained 77 appropriate questions to obtain primary data pertaining to identified
parameters and issues.The schedule contained questions for both qualitative and
quantitative data. During the field study interviews wereconducted across different
37
age and social groups of participants to have as wide spectrum of datai knowledge and
attitudes as possible amongst the respondents.
2.Informal interviews and discussions -With the help of ASHA workers
informal interviews and discussions were held with the respondents. Six such
meetings were conducted at Panchayat Ghar, Aaganwadi Centres. Besides this, efforts
were also made to have informal interactions with the women at places like public
drinking water stand posts, where they come to fetch drinking water and also at fields
where women were harvesting potatoes, wheat and other agriculture crops.Some
women also came in contact when they were returning from adjacent forests from
where they collected grasses, fuelwood and pirul etc. Also detailed
meetings,discussions with health care providers like ASHA, ANM, HV, Pharmacist
andMedical Officer Incharge of the respective health facility were conducted to get
indepth knowledge about the various issues related with maternal and child
health.Discussions on other key aspects about overall health of women was carried
out with CMO,Dy.CMO,CMS and other higher Authorities of the medical department
in district Almora. To increase the participation level of rural women, assistance of
reputed local persons like Gram Pradhan,ASHA,Ward Member was also sought for
rapport building. After rapport building with the people their free and unrestricted
participation was encouraged to get the real and unbiased insight of the issues
involved and relevant to achieve the objectives of study.
3.Non-participant observation- Observation by far is one of the most effective
and useful PRA tools which was used for the study. During field visits from time to
time observation related to the study parameters were taken and noted. These unbiased
observations helped in corroborating and validating the reliability of data collected
through other tools. Thishas resulted in developing better understanding of the
problems and find out need based solutions.
4.Participatory Rural appraisal (PRA)- During field study P.R.A. tools like
social and resource mapping were used to obtain information on medical facilities in
terms of infrastructure and trained man power availably and time line survey was
used to know the changes over time with respect to gender role,social customs and
behavior in the study area.
38
B.Secondary Data:Secondary data was mainly collected from the following
organizations:
Govt. Department
Panchayati Raj
Social welfare
Economicsand statistics
Medical and Health (CMO Almora and other offices)
Block Development Officer Hawalbagh, Sult and Tarikhet
Booklets published by department of Economics and statistics
Rural development departments
Census handbooks of district Almora and Uttarakhand.
Central library of Kumaon University Nainital;
Library of Sociology department of KU, Nainital;
Websites.
2.08 Analysis of data and their presentation:
The systematic compilation, classification, and tabulation of data is of utmost
importance for systematic analysis of data as it helps in getting realistic interpretation
of the facts and observations. The main function of analysis is to summarise the data
in such a manner that they provide meaningful scientific knowledge to address the
objectives of the research study. The data collected through different tools mentioned
above was scrutinized, compiled and tabulated in the suitable formats. The data was
processed and analysed using excel and other appropriate software. Use of visual
presentation aids like pie charts, graphs and histograms etc. has also be done for
improving the presentation of the research findings. Some of the primary research
data collected compiled and tabulated on the spatial distribution of sample villages
and socio-economic parameters are given below:
39
Table2.6 : Geographical Location of sample villages
Development
block
Name of
the G.P.
Name of
the village
Altitude
(mts.)
Lattitudeandlongitude
Tarikhet
Uprari
Uprari 1470 N 29degree35.218 minutes
E 79 degree 28.174 minutes
Peepal
khand 1354 N 29degree35.043 minutes
E 79 degree 28.110 minutes
Walna Walna 1376 N 29degree41.o66 minutes
E 79 degree 25.427 minutes
Hawalbag
Kayala Kayala 1426 N 29degree39.037minutes
E 79 degree 34.936 minutes
Udiyari Udiyari 1225 N 29degree 38.137 minutes
E 79 degree 38.101 minutes
Sult
Barkinda Barkinda 830 N 29degree 43.937 minutes
E 79 degree 15.201 minutes
Dadholi Dadholi 1738 N 29degree 44.746 minutes
E 79 degree 11.472 minutes
The above table shows the geographical distribution of sample villages in
three development blocks of district Almora. As has been mentioned earlier in this
chapter, the developments blocks represent different statistical strata as per the density
of govt. health facilities within the blocks of the district. The above table shows that
the villages are fairly well distributed in terms of their spatial locations.
Table 2.7 : Education- profile of the sample
S.N
o
Dev
elopm
ent
Blo
ck
Nam
e of
Sam
ple
Vil
lages
Illi
tera
te
Lit
erat
e/
Pri
mar
y
Eig
hth
pas
ses
Hig
hsc
hool
Inte
rmed
iate
Gra
duat
e/P
G
Tota
l
1 Hawalbagh Kayala 5 9 17 6 6 3 46
Udiyari 9 16 9 1 6 9 50
2 Tarikhet
Walna 7 10 9 8 8 8 50
Uprari 0 3 11 3 7 4 28
Peepalkhand 4 3 6 5 2 1 21
3 Sult Barkinda 11 9 12 2 0 1 35
Dadholi 26 3 13 2 4 2 50
Total 62
(22.1%)
53
(18.9%)
77
(27.5%)
27
(9.7%)
33
(11.8%)
28
(10%)
280
(100%)
40
The above data shows that 22.1% respondents were illiterate which indicated
low literacy level among the rural women. The percent of respondents with primary,
middle, high school, intermediate and graduate andand post graduates was 18.9,
27.5,9.7,11.8 and 10% respectively. The literacy rate of respondents was 77.9%
which is higher than the average literacy rate for women in Uttarakhand and district
Almora which was 70.70 and 70.74% respectively.
Table 2.8: Social profile of the sample
S.No Development
Block
Sample
Villages
General SC Total
1 Hawalbagh Kayala 30 16 46
Udiyari 8 42 50
2 Tarikhet
Valna 37 13 50
Uprari 16 12 28
Peepalkhand 17 4 21
3 Sult Barkinda 23 12 35
Dhadoli 38 12 50
Total 169
(60.4%)
111
(39.6%)
280
(100)
The above data shows that the sample consists of 111 Scheduled Caste
(SC)respondents and 169 General caste respondents. In terms of percentage there
were 39.6% Scheduled caste respondents and 60.4% general caste respondents.
Table 2.9: Age gradation in the sample
S.No Development
Block
Sample
Villages
18-28
years
28-38
years
38-49
years
Total
1 Hawalbagh Kayala 12 19 15 46
Udiyari 20 20 10 50
2 Tarikhet
Walna 24 22 4 50
Uprari 14 13 1 28
Peepalkhand 10 6 5 21
3 Sult Barkinda 7 13 15 35
Dadholi 12 15 23 50
Total 99
(35.4%)
108
(38.6%)
73
(26.0%)
280
(100%)
41
The above table shows that majority of respondents i.e. about 64.6% were in
the age groups of 28-38 and 38-49 years of age. A large proportion i.e. 35.4%
respondents represented the youngest age group of 18-28 years of age among the
respondents. The sample thus has fair representation of women from different age
gradations.
Table 2.10: Family types for the respondents in sample
S.No Development
Block
Sample
Villages
Joint Nuclear Total
1 Hawalbagh Kayala 17 29 46
Udiyari 23 27 50
2 Tarikhet
Walna 31 19 50
Uprari 20 8 28
Peepalkhand 15 6 21
3 Sult Barkinda 13 22 35
Dadholi 14 36 50
Total 133
(47.5%)
147
(52.5%)
280
(100%)
The profile of respondents for family type i.e. joint family or nuclear family
was also compiled and studied and the figures in the above table show that 47.5%
respondents belonged to joint families and 52.5% respondents had nuclear families.
Even though nuclear family is primarily considered to be an outcome of urbanization
but this social trend of nuclear family was found to be marginally on rise among the
respondents in the rural areas also.
Table 2.11: Number of children and their gender profile(for sample)
S.No Development
Block
Sample
Villages
Total
Children
Male
children
Female
children
1 Hawalbagh Kayala 108 54 54
Udiyari 115 56 59
2 Tarikhet
Walna 115 56 59
Uprari 61 31 30
Peepalkhand 50 24 26
3 Sult Barkinda 108 53 55
Dadholi 162 74 88
Total 719 (100%) 348 (48.4%) 371 (51.6%)
42
The number of children for respondents and their gender wise profile was
compiled and the figures are shown above. There were 13 respondents with no
children and most of them were recently married. The over all 267 respondents with
2.69 children per couple had in all 719 children with 48.4% boys and 51.6% girls.
Over all sex ratio among the respondents was very healthy but detailed scrutiny of
data revealed that some individual respondents has skewed sex ratio.
* * * * *
43
References:
1. District Health Action Plan(DHAP) , District: Almora ,2013-14,p10
2. www.wikipedia.com
3. Census Report Almora and Uttarakhand,2011,
4. District Health Action Plan(DHAP) , District: Almora ,2013-14,p11
5. Ibid.p 12
44
Chapter 3
Various Health Schemes under
National Rural Health Mission (NRHM)
―National Rural Health Mission (NRHM) is a national health program for
improving health care delivery across rural India. The mission, initially mooted for 7
years (2005-2012) has been extended to 12th five year plan period by the Ministry of
Health GoI. The scheme proposes a number of new mechanism for healthcare
delivery including training local residents as Accredited Social Health Activists
(ASHA), and the Janani Surakshay Yojana (motherhood protection program). It also
aims at improving hygiene and sanitation infrastructure. The mission has a special
focus on 18 states Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh,
Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh,
Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh. In the
12th Five Year Plan period, efforts will be made to consolidate the gains and build on
the successes of NRHM to provide accessible, affordable and quality universal health
care, both preventive and curative, which would include all aspects of a clearly
defined set of healthcare entitlements including preventive, primary and secondary
health services. The main targets for mother and child health care at the national level
for 12th five year plan period which are also in consonance with Millenium
development Goals(MDGs)have been set as follows‖1:
Reduction of Maternal Mortality Ratio (MMR) to < 109 per 100000 live
births, by 2015
Reducing Infant Mortality Rate(IMR) to < 27 per 1000 live births, by 2015
Reduction in Neo-Natal Mortality Rate(NMR) to < 18 per 1000 live births, by
2015
Reducing Total Fertility Rate(TFR) to 2.1 by 2017
Raising child sex ratio in the 0-6 year age group from 914 to 935
Prevention and reduction of anemia among women aged 15-49 years-
Reducing anemia to 28%,by the end of the 12th Plan(2017)
45
Prevention and reduction of underweight children under 3 years- Reducing
undernourished children under 3 years to 26% by 2015
There are many programmes under NRHM, but for the purpose of present
study only programmes directly related to rural women‘s health in three important
stages of her life as a mother, as a wife and as a daughter are focussed upon. The brief
details of these programmes has been given below:
3.01 Maternal Health
―About 56,000 women in India die every year due to pregnancy related
complications. Similarly, every year more than 13 lacs infants die within 1year of the
birth and out of these approximately 9 lacs i.e. 2/3rd of the infant deaths take place
within the first four weeks of life. Out of these, approximately 7 lacs i.e. 75% of the
deaths take place within a week of the birth and a majority of these occur in the first
two days afterbirth. In order to reduce the maternal and infant mortality,
Reproductive and Child Health (RCH) Programme under the National Rural health
Mission (NRHM) is being implemented to promote institutional deliveries so that
skilled attendance at birth is available and women and new born can be saved from
pregnancy related deaths. Several initiatives have been launched by the Ministry of
health and Family Welfare (MoHFW) including Janani Suraksha Yojana (JSY) a key
intervention that has resulted in phenomenal growth in institutional deliveries. More
than one crore women are benefitting from the scheme annually and the outlay for
JSY has exceeded 1600 crores per year.
3.02 Janani Suraksha Yojana (JSY)
JSY is a scheme supported and funded by the Government of India. It was launched
on 12 April 2005 by the Prime Minister of India. Its aim is to decrease the neo-natal
and maternal deaths happening in the country by promoting institutional delivery of
babies. It is a 100% centrally sponsored scheme it integrates cash assistance with
delivery and post-delivery care. The success of the scheme would be determined by
the increase in institutional delivery among the poor families. Under the scheme
ASHA activists have been assigned the responsibility to encourage the people in the
rural areas for institutional delivery, with particular focus on poor women. Under the
scheme, the states with low rate of Institutional deliveries are classified as 'Low
Performing States(LPS)' which include Uttar Pradesh, Uttaranchal, Bihar, Jharkhand,
46
Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa and Jammu and Kashmir,
whereas the remainingstates are termed as High Performing States(HPS). The details
of Cashbenefits under this scheme are as under‖2:
Rural Areas:
Table3.1 JSY Package for rural areas.
Category Mother’s
Package
ASHA’s
Package
Total Package
(in Rs.)
LPS 1477 677 2777
HPS 777 - 777
Urban Areas:
Table3.2 JSY Package for urban areas
Category Mother’s
Package
ASHA’s
Package
Total
Package
(in Rs.) LPS 1000 200 1200
HPS 600 - 600
The sheme has been operational in Uttarakhand and the status of implementation in
Uttarakhand and district Almora is given below:
Table3.3 Implementation status of JSY in Uttarakhand and Almora
State/District Mothers who
availed financial
assistance for
Delivery under
JSY(%)
Mothers who
availed financial
assistance for
institutional
Delivery
underJSY(%)
Mothers who
availed financial
assistance for
Government
institutional
Delivery under
JSY(%)
Total Rural Urban Total Rural Urban Total Rural Urban
Uttarakhand 30.1 30 30.2 54.3 61.4 41.2 84.7 86.5 80.4
Almora 35.4 34.8 46.8 76.5 78.5 56.4 85.3 86.7 69.9
Source (Annual Health Survey Fact Sheet, Uttarakhand (2011-12)
47
According to 42 Point report for March 2013of Almora District out of 6761
expected beneficiaries of JSY Scheme 5485 beneficiaries have availed the benefits
under the scheme during the year 2012-13. In view of the difficulty being faced by the
pregnant women and parents of sick new- born along-with high out of pocket
expenses incurred by them on delivery and treatment of sick- new-born, Ministry of
health and Family Welfare (MoHFW) has taken a major initiative to evolve a
consensus on the part of all States to provide completely free and cashless services to
pregnant women including normal deliveries and caesarean operations and sick new
born(up to 30 days after birth) in Government health institutions in both rural and
urban areas.
3.03 Janani Shishu Suraksha Karyakaram (JSSK)
Government of India , after reviewing the implementation and impact of JSY
has launched JSSK on 1st June, 2011 with free entitlements to pregnant women and
new born. The main features of the scheme includes free and cashless delivery, free
caesarian-Section, free drugs and consumables, free diagnostics, free diet during stay
in the govt. health institutions. Other benefits under the scheme are free provision of
blood, exemption from user charges, free transport from home to govt. health
institutions, free transport between facilities in case of referral, free drop back from
institutions to home after 48hrs of institutional delivery by Khusiyon Ki Sawari (104
service). If the need arises, the scheme also has provision for above mentioned free
entitlements for Sick newborns till 30 days after birth‖3. According to Uttarakhand
Health And Family Welfare Society‘s (UKHFWS‘s ) report for 2011-12 pertaining to
District Almora 4654 women and 4654 children had availed different entitlements
under Janani Shishu Suraksha Karyakaram (JSSK). As per the report of CMO Almora
1836 women were given drop back home facility during 2011-12 under the scheme.
3.04 Village Health and Nutrition Day (VHND)
The basic objective of organizing Village Health and Nutrition Day in Agan
Wari Centres (AWCs) is to create awareness among the pregnant women, lactating
mothers and children and to encourage them for early registration, ANC checkups,
counseling on institutional deliveries, counseling on breastfeeding, family planning,
immunization, menstrual hygiene etc. with an objective to achieve better maternal
48
and child health. Weight Monitoring of underweight children usually 3 years of age is
done and efforts are made to improve their weight to healthy category through
counseling of parents and providing fortified food to such children. Village Health
and Nutrition Days are also a platform for creating awareness among the community
about importance of girl child,various health and social security schemes launched
especially targeting the girls as well as disseminating information about The Pre-natal
Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994, and
provisions of punishment under the act so that sex ratio between 0-6 years of age
group can be increased. Village Health and Nutrition Days are organized once in a
months at each Anganwadi Centre. ANM, Anganwadi Worker and ASHA workers
have been given the responsibility to ensure the presence of target group on Saturday
(as per Schedule) to make this activity at village level an effective intervention.
During the VHN Day, CHC/PHC wise supervisor/ HealthVisitor(HV)/Block
Programme Management Unit(BPMU)will be responsible for Supervision/monitoring
of VHND activities in their respective area4.
According to report of CMO Almora(
March 2013) District out of 7000 VHNDs 6674 VHNDs has been organized.
3.05 Reproductive and Child Health (RCH) Camps
Reproductive and Child Health (RCH) camps, which are popular as Parivar
Swasthya Sewa Divas (Family Health Day) organized at CHCs and PHCs, provide an
opportunity to integrate the efforts of providers and increase access to reproductive
health services. Each camp includes a gynecological check-up, child examination and
immunization, family planning counseling and services and transportation for
sterilization clients.
Though sterilization camps have been part of the family planning programme
for many years, these RCH camps are different in that they:
Provide assured services as per a pre-determined calendar.
Combine benefits of rural outreach and high quality services.
Provide an array of maternal, child health and family planning services under
one roof.
The organization of camps involves detailed planning relating to publicity,
manpower deployment, camp arrangements, and post-camp services including
49
transportation, availability of consumables and medical equipment. Each camp is
scheduled in advance and publicized. Specially designed banners and handbills
promote them as Pariwar Swasthya Sewa Divas. In rural areas, playing attractive
jingles on audio cassettes carried around in hired rickshaws or vehicles spreads the
word. Since most of these camps are in remote rural areas, the availability of a team
of surgeons, anesthetist and female gynecologist has to be ensured from the district
level. Enhanced budget for maintenance and fuel for vehicles is provided so that an
adequate number of vehicles can be deployed to transport doctors to RCH camp sites
and sterilization clients to their homes.5
3.06 Family planning
In 1952, India launched the world first national program emphasizing family
planning to the extent necessary for reducing birth rates and to stabilize the
population at a level consistent with the requirement of national economy. Since then,
the family planning program has evolved and the program is currently being
repositioned to not only achieve population stabilization but also to
promote reproductive health and reduce maternal, infant and child mortality and
morbidity.
The objectives, strategies and goals of the Family Planning have been stated
in various policy documents like National Population Policy (NPP) 2000, National
Health Policy (NHP)2002, National Rural Health Mission (NRHM) and Millennium
Development Goals (MDG). Crucial factors influencing population growth can be
grouped into following 3 categories-
1. Unmet need of Family Planning : This includes the currently married
women, who wish to stop child bearing or wait for next two or more years for the next
child birth, but not using any contraceptive method. Total unmet need of Family
Planning is 21.3% (DLHS-III) in our country.The findings of AHS 2011-12 for
Uttarakhand and district Almora are given below:
50
Table 3.4Unmet need of Family Planning for Uttarakhand and District Almora
Unmet need for Family Planning(2011-12)
State/District Unmet Need For
Spacing(%)
Unmet Need For
Limiting(%)
Total Unmet
Need(%)
Total Rural Urban Total Rural Urban Total Rural Urban
Uttarakhand 8.4 8.9 7.2 9.7 9.4 10.3 18.1 18.2 17.6
Almora 12.3 12.8 6.0 15.0 14.9 17.1 27.4 27.7 23.1
Source {Annual Health Survey Fact Sheet, Uttarakhand (2011-12)}
2. Age at Marriage and first childbirth: Age at marriage and first child
birth are important indicators of the status of family planning and health of women.
This has gradually increased over the years. According to SRS 2012 and census 2011,
the earlier custom of teen marriage and teen motherhood has declined by over 32% in
a decade.
3. Spacing between Births : Healthy spacing of 3 years improves the
chances of survival of infants and also helps in reducing the impact of population
momentum on population growth. NFHS III data shows that in India, spacing between
two childbirths is less than the recommended period of 3 years in 61% of births.
According to SRS 2012, only 40.3% rural women maintained the gap of 36 months
between the current birth and previous ones
3.07 Total Fertility Rate (TFR)
The Total Fertility Rate (TFR), is the average number of births a women would have
by the time they reach 50 years of age.The TFR is expressed as the average number of
births per woman.Total Fertility Rate (TFR) in the country has recorded a steady
decline to the current levels of 2.4 (SRS 2011).Table below shows the declining TFR
over that years.
Table No.3.5 Total Fertility Rate (TFR) in the country
2775 2776 2777 2778 2779 2717 2711
2.9 2.8 2.7 2.6 2.6 2.5 2.4
51
Nationwide, the small family norm is widely accepted (the wanted fertility rate
for India as a whole is 1.9: NFHS-3) and the general awareness of contraception is
almost universal (98% among women and 98.6% among men: NFHS-3).
Both NFHS and DLHS surveys showed that contraceptive use is generally
rising. Contraceptive use among married women (aged 15-49 years) was 56.3% in
NFHS-3 (an increase of 8.1 percentage points from NFHS-2) while corresponding
increase between DLHS-2 and 3 is relatively lesser (from52.5% to 54.0%).Strategies
under family planning programme is given below:
Policy Level Service Level
Target free approach Equal emphasis on both spacing and limiting
methods
Voluntary adoption of Family Planning
Methods
Assuring Quality of services
Based on felt need of the community Expanding Contraceptive choices
Children by choice and not chance
The public sector provides the following contraceptive methods at various levels of
health system6:
Spacing Methods Limiting Methods
IUCD 380 A and Cu IUCD 375 Female Sterilization:
Oral Contraceptive Pills Laparoscopy
Condoms Minilap
Emergency Contraceptive Pills Male Sterilization (No Scalpel Vasectomy)
The TFR for Uttarakhand and district Almora as studied during 2011-12 are given
below:
52
Table No.3.6 TFR for Uttarakhand and District Almora
State/District Total Fertility Rate
Total Rural Urban
Uttarakhand 2.1 2.3 1.6
Almora 1.9 - -
Source(Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)
Current Family Planning Practices used by currently married Women in the
age group of 15-49 years in the state of Uttarakhand and district Almora have been
given below:
Table No.3.7 Current Family Planning Practices and Female sterlization
Current Family Planning Practices(Currently married Women)aged 15-49
years(2011-12)
State/District Any method% Any modern method
%
Female Sterlization %
Total Rural Ur1ban Total Rural Urban Total Rural Urban
Uttarakhand 61.7 60.3 65.1 54.1 53.6 55.3 28.1 32.4 17.2
Almora 70.5 70.9 66.4 67.5 67.9 62.8 46.1 47.7 27.0
Source(Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)
Current Family Planning Practices like male sterilization, copper-T and pills
used by currently married Women in the age group of 15-49 years in the state of
Uttarakhand and district Almora are given below:
Table No.3.8 Current Family Planning Practices and Male sterlization
Current Family Planning Practices(Currently married Women)aged 15-49
years(2011-12)
State/District Male sterilization% Copper-T/IUD% Pills %
Total Rural Urban Total Rural Urban Total Rural Urban
Uttarakhand 1.6 1.9 1.1 1.0 0.7 1.7 4.6 4.2 5.5
Almora 5.1 5.4 1.9 0.5 0.4 1.2 2.9 2.6 5.5
Source {Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)}
53
Current Family Planning Practices like male condom, emergency
contraceptive pills and any other traditional methods used by currently married
Women in the age group of 15-49 years in the state of Uttarakhand and district
Almora are given below:
Table No.3.9Current Family Planning Practices through Temporary Methods
Current Family Planning Practices(Currently married Women)aged 15-49 years (2011-12)
State/District
Male
Condom/Nirodh%
Emergency
Contraceptive Pills%
Any Traditional
Method%
Total Rural Urban Total Rural Urban Total Rural Urban
Uttarakhand 18.0 13.8 28.7 0.6 0.5 0.6 7.6 6.8 9.9
Almora 12.8 11.6 27.1 0.1 0.1 00 3.0 3.0 3.5
Source {Annual Health Survey Fact Sheet,Uttarakhand( 2011-12)}
3.08 Adolescent Health
Persons in age group of 10-19 years are known as adolescents which
comprises of individuals in a transient phase of life requiring nutrition, education,
counseling and guidance to ensure their development into healthy adults.
Government of India has recognized the importance of influencing health-seeking
behaviour of adolescents. The health situation of this age group is a key determinant
of India's overall health, mortality, morbidity and population growth scenario.
Therefore, investments in adolescent reproductive and sexual health will yield
dividends in terms of delaying age at marriage, reducing incidence of teenage
pregnancy, meeting unmet contraception need, reducing the maternal mortality,
reducing STI incidence and reducing HIV prevalence in. It will also help India realize
its demographic bonus, as healthy adolescents are an important resource for the
economy. In keeping with the spirit of convergence under NRHM, the RCH-II ARSH
strategy emphasizes the need for inter-sectoral linkage with other Departments at the
policy and programme levels to create a supportive environment for adolescent
interventions and to improve awareness levels among adolescents. Relevant schemes
under different departments of the government are mentioned below:
54
Women and Child Development:- Kishori Shakti Yojna, Balika Samridhi
Yojana, Rajiv Gandhi Scheme for Empowerment of Adolescent Girls
(SABLA);
Human Resource Development:- Sarva Shiksha Abhiyan; National Population
Education Project , (NPEP); Adolescence Education Program (AEP)
Youth Affairs and Sports:- Adolescent Empowerment Scheme; National Service
Scheme; Nehru Yuva Kendra Sangathan (NYKS) Programs, National Program
for Youth and Adolescent Development (NPYAD).
3.09 Adolescent Reproductive and Sexual Health (ARSH)
The goals of the Government of India RCH-II programme are reduction in
IMR, MMR and TFR. In order to achieve these goals, RCH-II has four technical
strategies. One of these four is Adolescent and reproductive Health. Adolescents are
nation's future and investment in their development is critical. The government of
India has a comprehensive package for meeting the multiple health needs of the
adolescents and offers a roadmap for programmes and priorities that aim to address
adolescent health.The National Adolescent Reproductive and Sexual Health strategy
provides a framework for a range of sexual and reproductive health services to be
provided to the adolescents. The strategy incorporates a core package of services
including preventive, promotive, curative and counseling services. Effective
implementation of policies and programmes has progressed from the past few years
and has lead to strengthening of Adolescent Friendly Counselling centers
(AFCCs)and subsequently the outreach programmes7.
3.10 School Health Programme
The School Health Programme was launched to address the health needs of school
going children and adolescents in the 6-18 year age groups in the Government and
Government aided schools. The programme entails biannual health screening and
early management of disease, disability and common deficiency and linkages with
secondary and tertiary health facilities as required. The School health programme is
the only public sector programmespecifically focused on school age children. Its main
55
focus is to address the health needs of children, both physical and mental, and in
addition, it provides for nutrition interventions, yoga facilities and counseling. It
responds to an increased need, increases the efficacy of other investments in child
development, ensures good current and future health, better educational outcomes and
improves social equity and all the services are provided for in a costeffective manner.
The decentralized framework of implementation under NRHM has enabled
various states to devise and implement their own version of School Health
Programme. Components of School Health Program include Health service provisions
like , Micronutrient (Vitamin A andIron Folic
Acid(IFA) management, De-worming, Counseling services, Regular practice of Yoga
and Physical education.Health Management Structure has been provided for in the
guidelines at national, State and District levels.
The NRHM convergence mechanism will apply to this programme as well.
The involvement of MSG, State Health Mission and District Health Mission has been
ensured by placing the school health programme management committees under the
overall supervision/guidance of these overarching structures.
has been placed at making these management committees multi-departmental
involving the functionaries of various related departments/organisations such as
Committees recommended at State, District, Block and School levels is detailed in the
enclosed write-up of the programme. School Health Coordinator on contract basis at
the State and District levels has been provided to support the programme in the areas
of coordination and monitoring and evaluation.
These management committees have been proposed in a manner that they
bring in convergence between related departments/organizations. The main
convergence required in the programme is between the Ministry of Health and Family
Welfare, Ministry of Human Resources Development (MHRD) and Ministry of Rural
Development (MRD). MHRD will be partner in capacity building, IEC, Monitoring
and Evaluation. MRD needs to take care of water, safety education, Sanitation
Education and Garbage disposal waste management. The MoHFW will take care of
screening, health care services, immunization, referral, micronutrient management,
health education, capacity building, monitoring and evaluation, etc.8
56
3.11 Rastriya Bal Swasthya Karyakram (RBSK)
RBSKhas been launched in 2013 for child health screening with an objective of
early intervention services to provide comprehensive care to all children in the
community. The purpose of these services is to improve the overall quality of life of
children through early detection of birth defects, diseases, deficiencies, development
delays including disability. Health screening of children is a known intervention is
now being expanded to cover all children from birth to 18 years of age. The
Programme has been initiated as significant progress has already been made in
reducing child mortality under the National Rural Health Mission. However, further
gains can be achieved by early detection and management of conditions in all age
groups. There are also groups of diseases which are very common in children e.g.,
dental caries, otitis media, rheumatic heart disease and reactive airways diseases
which can be cured if detected early. It is understood that early intervention and
management can prevent these conditions to progress into more severe and
debilitating forms, thereby reducing hospitalisation and resulting in improved school
attendance. The ‗Child Health Screening and Early Intervention Services‘ will also
translate into economic benefits in the long run. Timely intervention would not only
halt the condition to deteriorate but would also reduce the out-of-pocket (OOP)
expenditure of the poor and the marginalized population in the country. Additionally,
the Child Health Screening and Early Intervention Services will also provide country-
wide epidemiological data on the 4 Ds (i.e., Defects at birth, Diseases, Deficiencies
and Developmental Delays including Disabilities). Such a data is expected to hold
relevance for future planning of area specific services.9
3.12 Weekly Iron Folic acid Supplementation (WIFS)
Adolescent Anemia is a long standing public health problem in India. Anemia
is caused by Iron deficiency and adolescents are at high risk of Iron deficiency and
thereby anemia due to accelerated growth and body mass building, poor dietary intake
of iron and high rate of worm infestation In girls deficiency of iron is further
aggravated with higher demands with onset of menstruation and also due to the
problem of adolescent pregnancy and conception. The Programme envisages
administration of supervised weekly IFA Supplementation and biannual deworming
57
tablets to approximately 13 crore rural and urban adolescents through the platform of
Govt./Govt. aided and municipal school and Anganwadi Kendra and combat the
intergenerational cycle of anemia10
. WIFS Programme has been Started at District
Almora since 2012-13.
3.13Immunization:
Intensification of Routine Immunization, eliminating measles and Japanese
encephalitis related deaths and Polio eradication are the key area to be covered under
universal immunization programme. The strategies for child health intervention
focuses on improving skills of the health care workers, strengthening the health care
infrastructure and involvement of the community through behaviour change
communication.11
During the current study attempts have been made to assess the
implementation and impact of some schemes directly related to the rural women‘s
health in three important stages of her life as a mother, as a wife and as a daughter in
selected villages of district Almora in three development blocks namely Hawalbagh,
Tarikhet and Sult. The details of the findings have been mentioned in the relevant
chapters.
* * * * *
58
References :
1. National Health Mission(NHM),Ministry of Health and Family
welfare(MoHFW), Govt of India. Website: nrhm.gov.in
2. Janani Suraksha Yojana (JSY),NHM, MoHFW, Govt of India. Website:
nrhm.gov.in
3. Janani Shishu Suraksha Karyakaram (JSSK),NHM,(MoHFW),Govt of India.
Website: nrhm.gov.in
4. Village Health and Nutrition Day(VHND),NHM,(MoHFW),Govt of India.
Website: nrhm.gov.in
5. Reproductive and Child Health (RCH) camps,NHM,(MoHFW),Govt of India.
Website: nrhm.gov.in
6. Family planning,NHM,(MoHFW),Govt of India. Website: nrhm.gov.in
7. Adolescent Reproductive and Sexual Health (ARSH),NHM,(MoHFW),Govt
of India. Website: nrhm.gov.in
8. The School Health Programme,NHM,(MoHFW),Govt of India. Website:
nrhm.gov.in
9. Rastriya Bal Swasthya Karyakram (RBSK),NHM,(MoHFW),Govt of
India.Website: nrhm.gov.in
10. Weekly Iron Folic acid Supplementation(WIFS),NHM,(MoHFW),Govt of
India.Website: nrhm.gov.in
11. Immunization,NHM,(MoHFW),Govt of India.Website: nrhm.gov.in
59
Chapter 4
Impact of Health Programmes on Mother and Child Health
(Women as Mother)
Women are the backbone of every family. They play very vital roles in
keeping the family together. Women play many roles in a family like mother, sister,
daughter, wife and daughter-in-law. The status of women as mother has been highly
honoured and respected in our society. The most important role that a woman plays is
that of a mother. The privilege of motherhood is bestowed by nature only on women
By virtue of being mother the women is gifted with the power of creator by nature.
She is also known as ―janani‖. It has been mentioned in Mahabharata that "there was
no sacred lore like the vedas,'' there was no preceptor like the mother. She was
mentioned first among the three 'Atigurus'.1 At one place, she has been compared to
one of three holy fires to be tended, for casteing off the three fires was a great sin. In
the history of mankind, the fire has contributed towards the preservation and
protection of mankind just like a mother 2.
Manu emphatically declares that she is a
thousand times more honourable than the father. According to Manu Smriti "From the
point of view of reverence due, a teacher is ten fold superior to a mere lecturer, a
father is a hundred fold superior to a teacher, and a mother is a thousand fold superior
to a father.3 In modern times, eulogising the high status of woman as mother, Swami
Vivekananda writes" It is the mother, not the father, who comes to the mind first
whenever the world 'creation' is mentioned. It seems to me that if God is love, He
should be conceived of as Mother and not father. It is motherhood more than
womanhood, that the Hindus glorify.
"As the ideal of Hindu womanhood has differed at many places in real
practice, so also the ideal concept of motherhood has remind a far-off-dream. In
practical and daily life, her function of motherhood was simply keeping the children
fed and clothed. She was not responsible for the education of boys and had little to
say in the education of girls. A mother had limited role in her child‘s upbringing,
education, marriage settlement, etc. Gradually, there came a striking change in the
pattern of the family. With the growth of urbanization, industrialization, education
and individualism, the small family size replaced the large family pattern the science
60
of child rearing has been revolutionized and is still changing. The modern mother can
interact with a young child in three ways; as a playmate; as a care taker attending the
child routine needs for food and clothing; and finally as a sensitive respondent to the
signals of the child emotional needs. Socialization is a mother‘s dominated process
now being a good mother no longer means simply keeping the children fed and
clothed but implies that once is skilled in a mysterious and difficult art. In modern
times the mother‘s role as creator of the race is losing importance. Knowledge now
bring the understanding that every normal woman is a potential mother. Her greatness
now lies not so much in bearing a child as in excellent rearing her task therefore, is to
develop the physical, mental and emotional powers of the child, in perfect balance.
The modern young mother is neither drudge nor disciplinarian but warm, active and a
companion to her children. The children are not as subordinate in the household as
they were in times past. They are more in the nature of junior partners, who are
wanted and needed and whose opinions are sought and given careful consideration. It
is not the amount but the quality of maternal care that counts. "4
The bond between the mother and child begins with the pregnancy. A mother
introduces her child to all the family members and society and teaches life skills.
While the mother is at home, she feeds her children, takes care of them, she
socializes, teaches, inculcates values, good habits, passes on customs ,traditions and
cultural values to her children. Good habits, right conduct and formation of good
character can be created in children by the family in which the role of mother is most
important. The love , kindness and gentleness of the mother develops good character
and the natural talent in the child and gradually introduces him to the realities of the
world .The role of mother in nation building is thus very prominent particularly in
terms of nurturing responsible citizens. She provides the psychological and emotional
support to the child throughout her life. The mother teaches her children to walk, talk,
take care of themselves, respect their elders and other important social values, ethos
and norms. When a child is unwell, she takes care of him both physically and
emotionally. During such time she spends all her time taking care of children and
feeding them appropriately well. As a child grows up, she understands her/his need
better than any one else. She helps the child to solve his problems with his friends or
talks to the teachers if child is not satisfied with his school-life. She also intervenes
effectively to resolve conflicts arising out of insecurity or otherwise among siblings
61
and teaches them the importance of sharing and caring attitude for each other. This
goes a long way in shaping the personality and developing confidence in the child
throughout his life.
As the child reaches adolescence mother gets protective and tenderly teaches
him how to control or get rid of his fears, anxieties and insecurities and get along well
with the society and friends and also how to handle peer group pressures. The
significance and importance of mutual trust, friendship, brotherhood, compassion,
character and other moral values relevant to the society are understood and
internalized by the child only after they have been shared and learning lessons are
drawn after thorough, free and frank discussions with parents and mother‘s role in this
process is of paramount importance. Mother helps the child to overcome his/her
conflicts of adolescent age and this is also the stage when she teaches the child to
straighten his strained relationship, if any, with other siblings, father and grandparents
due to sibling rivalry and generation gap. As a child enters into the adulthood she
supports him in his office life, personal life by taking care of his children, wife and
home. She also provides care for the grand children and also guides them how to take
care of their children.
4.01 Scenario in Study area
During the present study it was found in all the sample blocks that as a mother
rural women have many responsibilities and duties like taking care of children and
raising them up. Woman takes care of child and the family but in shouldering all these
responsibilities she often neglects her health, where as other times she is neglected by
her own family and society. During the study it was observed that rural women carry
out most of the household works in addition to dairy and agriculture related activities.
All these activities contribute to the family income but the decision making power to
spend income lies mainly with the male members of the family. Even for expenses
related to health care she is dependent on the male members of the family. When a
women gets sick she is usually not taken to hospital immediately. She is given some
local treatment and house hold remedies. Usually only on getting critical or not
getting well for long, she is taken to hospital. Access to health services in rural area is
very low for the women mainly because of distance of health facility centers and lack
of time, awareness and adequate financial resources. Cultural norms in the area still
62
expect women to do everything with the permission of male members or some adult
member of the family. Preference for male child is wide spread in the area and is an
established social norm. A woman, on joiningthe family of her husband after
marriage, is often given the impresson, directly or indirectly that she should give birth
to a baby boy who will take care of family in future. In fulfilling this desire of her
family she, sometimes, undergoes forced pregnancies and at times abortions. She is
not in a position to resist forced pregnancies and abortions.This in addition to
increasing the family size, puts negative impact on both mother and child health. As a
mother she becomes physically and emotionally weak and as a result in her future
delivery she gives birth to a weak progeny. Studies in developing countries indicate
that the risk of death for children under five years doubles or triples if their mother
dies. Other studies estimate that children whose mothers have died are 3-10 times
more likely to die within two years than those whose parents are both alive.
Motherless children are likely to get less healthcare and education as they grow up.
Girls, in particular, suffer because they are forced to drop out of school to look after
younger siblings. Maternal death is thus, almost inevitably, a double tragedy. Looking
at these social, economical and psychological aspects prevalent in the society, women
at times , as mother themselves feel disempowered. Despite all the important roles
she plays, the mother who is still a women also undergoes the discrimination and
associated difficulties and hardships. This is primarily because of gender bias
engrained in social attitudes.
Social, cultural and economic factors continue to inhibit women from gaining
adequate access even to the existing public health facilities. This handicap does not
merely affect women as individuals; it also has an adverse impact: on the health,
general well-being and development of the entire family, particularly children. This
area is of grave concern in the public health domain. In the vulnerable sub-category of
women and girl child, this has a multiplier effect for the future generations. 5
Rural women as mothers shoulders major responsibility in the family and is
busy taking care of children, cooking, cleaning, going to field, feeding animals,
collecting grasses, fodder, fuel wood, water. Though woman as a mother takes care of
her family and children but in the process she often neglects her health or even many
a time she is neglected by family and society as the tasks that she performs are
invariably undervalued or not valued at all and are rather projected as works she is
bound to do because of the social system and stereo type mind set of society based on
63
gender inequality. The household chorus she performs is taken for granted as her day
to day normal functions. The importance of this can be realised only when she stops
to work for some reason, but that too is quickly forgotten, as soon as work is resumed
by her.
4.02 Data analysis and findings
Women empowerment and their health are very closely related.Disease and
poverty form a vicious circle. "Men and women were sick because they were poor;
they became poorer because they were sick and sicker because they were poor"6
One of the indicators of status, empowerment and health of women is
Maternal Mortality Ratio (MMR) which is defined as Ratio of the number of
maternal deaths to the number of live births in a given year, expressed per 100,000
live births. High rate of MMR is indicative of neglect of women‘s health. Generally
the rural women are more acutely affected by this neglect. Attitude of society in
general towards the women has been one of the primary reasons for this. It is
therefore obvious that promoting women‘s right, facilitate the informed choices by
them and reducing the economic and social inequalities are vital for safe motherhood.
Safe motherhood is directly related to social and economic well being of society as
she is productively contributing to the economy. As per the data from the Registrar
General of India, at national level, the figures of 2007 -09, there was a decline of
about 17 per cent reported in the maternal mortality rate, which came down to 212
between 2007 and 2009 compared to 254 between 2004 – 2006. According to Annual
Health Survey (AHS) conducted by Ministry of health GoI for 2010-11, MMR for
district Almora is 183. The factors influencing MMR include Ante-natal check Up
(ANC), institutional delivery status and immunization. Awareness about the health
and various programmes and facilities under schemes like JSY, JSSK, RCH and
VHND significantly influence MMR. During the present research study attempts
have been made to evaluate the status and impact of these parameters for the rural
women of district Almora. The details of data and findings are given in the
subsequent paras:
The Mother and child protection(MCP) card/jachcha-Bachcha cards has been
introduced through a collaborative effort of the Ministry of Women and Child
Development and Ministry of Health and Family Welfare, Govt. of India. The MCP
64
card is a tool for informing and educating mother and family on different aspects of
maternal and child care and linking maternal and childcare into a continuum of care
through the Integrated and Child development scheme(ICDS) scheme of Ministry of
Women and Child Development and the National Rural health Mission(NRHM) of
Ministry of Health and family welfare (MoHFW). The card also captures some of the
key services delivered to the mother and baby during Antenatal, and Post Natal care
for ensuring that the minimum package on services are delivered to the beneficiary.
The MCP card helps in timely identification, referral and management of
complications during pregnancy, child Birth and post natal period. The card also
serves as a tool for providing complete immunization to mother and child , early and
exclusive breastfeeding, complementary feeding and monitoring their growth.7During
the field study it was found that only 85.36% respondents had MCP/jachcha-
Bachcha cards and out of these almost all availed most of the services on time.
1.Ante-Natal Check-up (ANC)
"ANC refers to regular medical checkups during pregnancy including
Collection of (mother's) medical history, Checking (mother's) blood
pressure,(Mother's) height and weight, Pelvic exam, Doppler fetal heart rate
monitoring,(Mother's) blood and urine tests, Tetanus Toxoid (TT) injections received
and status of consumption of Iron and Folic Acid (IFA) tablets/syrup, and discussion
with caregiver."8Antenatal care of every women is must during pregnancy . Ideally a
women should undertake at least 3 Ante-natal check ups (ANCs) one in each
trimester during pregnancy. If a women goes through ANCs. her chances of
complications during child - birth are reduced and as a result maternal death can be
prevented. Proper ANCs check ups during pregnancy is also important for both
maternal and child health. Ante-natal care constitutes one of the key elements
towards initiatives to promote safe motherhood.
According to Annual Health Survey(AHS) Data 2011-12 for district Almora,
% of women who received 3 or more ANC check ups was 49% . There was wide
gap between the rural and urban population availing this facility which was 47% and
86.8% respectively. The analysis of the primary data collected during the present
study revealed that only 23.6% respondents had undertaken three ANC. The
65
percentage of respondents who received only two ANCs was 46.8%. It was found
that 22.9% respondents did not receive any ANC during their last pregnancy.
Table 4.1 shows that across castes only 18.3% of general caste women took
full ANC check ups, whereas 31.5%of SC women took full ANCs during their last
pregnancy. The study also revealed that overall 31.5% of Schedule caste availed three
ANCs whereas this figure was only18.3% for general caste rural women. The tables
showing compiled data for ANCs have been given below in table 4.1 and 4.2
indicating social profiles with varying aspects like caste and education. Also
development bloc-wise position has been shown with the help of histogram.
Table 4.1 Castewise frequency of ANC done
CASTE ONCE TWICE THRICE NON TOTAL
GENERAL 13 82 31 43 169
(7.7%) (48.5%) (18.3%) (25.4%) (100.0%)
SC 6 49 35 21 111
(5.4%) (44.1%) (31.5%) (18.9%) (100.0%)
Total
19 131 66 64 280
(6.8%) (46.8%) (23.6%) (22.9%) (100.0%)
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
ONCE TWICE THRICE NON
general
Sc
Caste - wise ANC status
66
The education level of the women was found to have significant impact on the
access to the facility of ANC by the women. All the women with educational
qualification with intermediate or higher received ANC. Even for those with high-
school education the facility of ANC was availed by 96% women. The Percentage of
rural women who did not take any ANC was highest for illiterate at 61% followed by
those with primary and middle level education at 23.7% and11.95% respectively. The
study clearly establishes that the access to ANC facility drastically improve with the
improvement of education level of rural women. This provides hope for better access
to this facility by the rural women in future as education level among the females is
gradually improving over the years.
Table 4.2ANC not done caste vs education
ANC NOT DONE CASTE Vs EDUCATION
Cast
e
Illi
tera
te
Pri
mary
Eig
ht
Hig
hsc
hool
Inte
rmed
iate
Gra
du
ate
PG
To
tal
Gen
eral
31 6 4 2 0 0 0 43
68.4% 15.8% 10.5% 5.3% 0.0% 0.0% 0.0% 100.0%
SC
10 8 3 0 0 0 0 21
47.6% 38.1% 14.3% 0.0% 0.0% 0.0% 0.0% 100.0%
Tota
l 41 14 7 2 0 0 0 64
61.0% 23.7% 11.9% 3.4% 0.0% 0.0% 0.0% 100.0%
6.8%
46.8% 23.6%
22.9% ONCE
TWICE
THRICE
NON
Over all status of ANC
67
Another finding of the present study is that the access to the facility of ANC
by the rural women has been also adversely affected by the remoteness of their
villages from the district headquarter. This health facility was availed thrice during
pregnancy only by 18.8% women in block Sult, followed by 22.2%in Tarikhet Block
and 33.3% in hawalbagh. The inter-situation in this regard has gradually improved
with the nearness of the places from district headquarter Almora. This has been
graphically depicted below :
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Educational qualification & ANC not done
ANC not done
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
one twice thrice non
HAWALBAGH
TARIKHET
SULT
Block-wise status of ANC
68
2.Institutional Delivery
Institution Delivery (ID) is very important to avoid maternal and neo-netal
mortality. Delivery at health institutions is conducted by qualified health personnels
and if certain complications arise during delivery these can be dealt with,effectively
by the doctors and paramedical staff. If necessary, the case can be referred to the
higher centre with adequate facility to handle the complexities. Institutional delivery
also provides Post natal care. Therefore necessary and urgent medical health care can
save the precious life of mother and child. One of the major goals of National Rural
Health Mission (NRHM) was achieve 80% institutional delivery by 2012.
Janani Suraksha Yojana (JSY) launched by Government of India in 2005
for enhancing the rate of safe delivery is one of the major schemes under NRHM, the
details of which are given in the subsequent para below. Information about place of
delivery, type of delivery (normal / caesarean / assisted) and the personnel conducting
delivery in case of domiciliary births, type of transport facility availed for reaching
the institution, length of stay in the institution after delivery constitute important
parameters of delivery care.
Institutional deliveries and home deliveries conducted by doctor/ nurse / ANM
can be termed as Safe delivery. According to AHS report 2011-12 the over all rate of
institutional delivery for district Almora was 45.1%. The rate of ID for rural and
urban areas of the district was 43% and 83.4% respectively indicating huge gap
between the two. If the deliveries at home conducted by skilled health personnels are
also taken into account then the overall percentage of safe delivery for the district was
63.4%. This figure was 61.7% and 94.3% for rural and urban areas respectively. This
indicates huge gap between institutional delivery percentage in rural and urban areas.
The primary data on the status of institutional delivery was collected during the
present study from the sample villages and has been compiled and is given in Table
4.3.
69
Table 4.3 Status of delivery
STATUS OF INSTITUTIONAL DELIVERY
Caste Delivery at
home by
ANM/Dai
Delivery at
home without
ANM/Dai
Institutional
delivery
Total
GENERAL 64 (37.9%) 39(23.1%) 66(39.1%) 169(100%)
SC 37(33.3%) 22(19.8%) 52(46.8%) 111(100%)
Total 101(36.1%) 61(21.8%) 118(42.1%) 280(100%)
The depiction of the findings related to ID by caste has been shown by
histogram below:
36%
22%
42%
Over all Status of delivery
Delivery at home by ANM/Dai Delivery at home without ANM/Dai
Institutional delivery
70
It is revealed from the analysis of the above data shown in table above that the
overall rate of institutional delivery was 42.1% . The social profile of the data also
showed that 46.8% of scheduled caste rural women availed the facility of institutional
delivery whereas this figure was 39.1% for general caste rural women in the sample
villages. Adding delivery at home conducted by ANM/Dai to the institutional
deliveries 78.2% deliveries can be termed as safe delivery rate in the sample villages.
The rate of safe delivery was thus found to be 80.1% and 77% respectively for SC and
general caste rural women respectively. Creating awareness about the benefits of
Institutional Delivery like cash incentive, free medication, hygiene, safe delivery, post
natal chekup, immunization of new born ,advice on family planning etc and referral
facility if need arises and free transport by 108 service, can bring about change in
social attitude and improve the percentage of institutional delivery in the rural areas.
Presently all the sub centres located in rural areas are not providing the
services of institutional delivery for variety of reasons. To increase the proportion of
institutional delivery, all the existing Sub Centers in the rural areas should be
equipped with necessary facilities and trained man power to make them functional.
The process of training of ANMs and Staff Nurses for Skilled Birth attendant(SBA)
should be carried in time bound manner.SBA training is prerequisite for safe delivery.
Availability of basic health facility infrastructure with adequately trained medical
staff, doctor's especially female doctors and equipments etc., are important and crucial
factors that influence delivery of and access to health services.
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Delivery at home byANM/Dai
Delivery at homewithout ANM/Dai
Institutional delivery
General
Sc
Caste wise status of Delivery
71
The data was also compiled and analysed to study the impact of education
level of respondent women on institutional delivery. The details are given below in
Table 4.4
Table 4.4 Education level and its effect on Institutional Deliveryand safe delivery
Educational
Qualification
Delivery at
home without
ANM/Dai
Delivery at
home by
ANM/Dai
Institutional
delivery Total
Illiterate 27(43.5%) 27(43.5%) 8(12.9%) 62(100.0%)
Primary 16(30.2%) 25(47.2%) 12(22.6%) 53(100.0%)
Eight 13(16.9%) 26(33.8%) 38(49.4%) 77(100.0%)
Highschool 3(11.1%) 11(40.7%) 13(48.1%) 27(100.0%)
Intermediate 0(0.0%) 7(21.2%) 26(78.8%) 33(100.0%)
Graduate 1(5.0%) 5(25.0%) 14(70.0%) 20(100.0%)
PG 1(12.5%) 0(0.0%) 7(87.5%) 8(100.0%)
Total 61(21.8%) 101(36.1%) 118(42.1%) 280(100.0%)
The above data revealed that the rate of institutional delivery was found to be
almost positively correlated with the level of educational qualification of the rural
women and showed that the rate of institutional delivery was least (12.9%) for
illiterates and highest for post graduates (87.5%). Institutional delivery added to
delivery at home by trained
health personnel together
form the rate of safe delivery.
It has been found that the
percent of safe delivery is
improving with the
improvement in educational
qualification of respondents.
This has been visually
represented by histogram.
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Educational qualification & Safe
delivery
%Safe delivery
72
The rate of safe delivery and level of educational qualification were thus
found to be positively correlated.In order to study the possible impact of the location/
remoteness of the sample blocks on the rate of ID, the primary data was compiled
and analysed on the basis of all three sample blocks. The data is given below in table
4.5.
Table 4.5 Remoteness of the sample blocks and status of Delivery
The above data revealed that the rate of institutional delivery varied between
34.1% to 46.5% among the three development blocks. These figures were 44.8%,
46.5% and 34.1% respectively for Hawalbagh, Tarikhet and Sult blocks of the district
for the sample villages. The rate of total safe deliveries was found to be directly
affected by the remoteness of the block from district head quarter and the density of
health facility within the block. The rate of safe delivery was 92.and%, 83.8% and
55.3% respectively for Hawalbagh, Tarikhet and Sult blocks which are respectively
about 14Km, 55 Km and 160 km away from Almora and have density of health in
descending order. The visual representation of this has been shown below by
histogram:
Blocks Caste
Delivery at
home
without
ANM/Dai
Delivery at
home by
ANM/Dai
Institutional
delivery Total
HAWALBAGH
GEN 2(5.3%) 23(60.5%) 13(34.2%) 38(100%)
SC 5(8.6%) 23(39.7%) 30(51.7%) 58(100%)
TOTAL 7(7.3%) 46(47.9%) 43(44.8%) 96(100%)
TARIKHET
GEN 11(15.7%) 27(38.6%) 32(45.7%) 70(100%)
SC 5(17.2%) 10(34.5%) 14(48.3%) 29(100.0%)
TOTAL 16(16.2%) 37(37.4%) 46(46.5%) 99(100.0%)
SULT
GEN 26(42.6%) 14(23.0%) 21(34.4%) 61(100.0%)
SC 12(50.0%) 4(16.7%) 8(33.3%) 24(100.0%)
TOTAL 38(44.7%) 18(21.2%) 29(34.1%) 85(100.0%)
G.TOTAL 61(21.8%) 101(36.1%) 118(42.1%) 280(100.0%)
73
Chi square (χ2) Test for Institutional Delivery
Chi square test was conducted to test the hypothesis whether the status of
institutional delivery is independent of Caste or not.
Null Hypothesis H0 : Institutional Delivery is independent of caste.
Alternative Hypothesis H1 : Institutional Delivery is not independent of caste.
Observed frequency
Caste Delivery at home
by ANM/Dai
Delivery at home
without ANM/Dai
Institutional
delivery Total
General 64 39 66 169
SC 37 22 52 111
Total 101 61 118 280
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Delivery at home byANM/Dai
Delivery at homewithout ANM/Dai
Institutional delivery
HAWALBAGH
TARIKHET
SULT
Block wise Status of Delivery
74
Expected frequency
Caste
Delivery at
home by
ANM/Dai
Delivery at
home without
ANM/Dai
Institutional
delivery Total
General 60.961 36.818 71.221 169
Sc 40.039 24.182 46.779 111
Total 101 61 118 280
∑ ∑ (Eij-Oij)2
/ Eij
Caste
Delivery at
home by
ANM/Dai
Delivery at
home without
ANM/Dai
Institutional
delivery Total
General 0.152 0.129 0.383
Sc 0.231 0.197 0.583
Total 1.674
χ2
Cal. = ∑ ∑ (Eij-Oij)2 / Eij = 1.674
χ2
Tab. α=0.05, df=2 = 5.991
χ2
Cal. < χ2
Tab. α=0.05, df=2
==>Not significant
we accept H0 by rejectinng H1 at 0.05 level of significance and conclude that the
Institutional Delivery is independent of caste
75
Chi square test was also conducted to test the hypothesis whether the status of
institutional delivery is independent of Educational qualification of respondents or
not.
Null Hypothesis H0 :Institutional Delivery is independent of educational status.
Alternative Hypothesis H1 :Institutional Delivery is not independent of educational
status.
Observed frequency
Qualification
Delivery at home by
ANM/Dai
Delivery at home
without ANM/Dai Institutional delivery
Total
Illiterate 27 27 8 62
Primary 25 16 12 53
Junior 26 13 38 77
Middle 11 3 13 27
Intermediate 7 0 26 33
Graduate 5 1 14 20
Post Graduate 0 1 7 8
Total 101 61 118 280
Expected frequency
Qualification
Delivery at home by
ANM/Dai
Delivery at home
without ANM/Dai
Institutional
delivery Total
Illiterate 22.364 13.507 26.129 62
Primary 19.118 11.546 22.336 53
Junior 27.775 16.775 32.450 77
Middle 9.739 5.882 11.379 27
Intermediate 11.904 7.189 13.907 33
Graduate 7.214 4.357 8.429 20
Post Graduate 2.886 1.743 3.371 8
Total 101 61 118 280
76
∑ ∑ (Eij-Oij)2
/ Eij
Qualification
Delivery at home by
ANM/Dai
Delivery at home
without ANM/Dai
Institutional
delivery Total
Illiterate 0.961 13.479 12.578
Primary 1.810 1.718 4.783
Junior 0.113 0.850 0.949
Middle 0.163 1.412 0.231
Intermediate 2.020 7.189 10.515
Graduate 0.680 2.587 3.683
Post Graduate 2.886 0.317 3.905
Total 72.828
χ2
Cal. = ∑ ∑ (Eij-Oij)2 / Eij = 72.828
χ2
Tab. α=0.05, df=12 = 21.026
χ2
Tab. α=0.01, df=13 = 26.217
χ2
Cal. > χ2
Tab. α=0.05, df=12
χ2
Cal. > χ2
Tab. α=0.01, df=12
= > Highly significant
we accept H1 by rejectinng H0 at both level of significance i.e. 0.05 and 0.01 and
conclude that the Institutional Delivery is highly dependent on educational status.
3.Post-natal Care
Getting a Post partum / Post-natal check-up soon after the birth of baby or
within 48 hours is crucial for the health of both the mother and the child. On the issue
of post natal check ups of mother and child in the sample villages, overall it was
found that only 47.86% respondents got post-natal checkups done and about 48.21%
did not get post-natal check-ups done. This shows low level of awareness, in general,
among rural women about the importance of post natal checkups.
77
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Yes No/NA
general
Sc
4.Janani Suraksha Yojana (JSY):JSYwas launched by Government of India
on 12th
April 2005 with the main objective is to decrease maternal and neonatal
deaths by improving and enhancing the rate of institutional deliveries both in rural
and urban areas. It is a 100% centrally sponsored scheme and integrates cash
assistance with delivery and post-delivery care. The success of the scheme would be
determined by the increase in institutional delivery among the poor families. The
scheme envisages that the ASHA workers would be actively associated for motivating
people in the field to encourage institutional deliveries, particularly, among the poor
women. Under the scheme Uttarakhand has been identified as one of the 'Low
Performing States(LPS)' because of low rate of institutional delivery. The cash
incentive/financial assistance for rural areas consist of Rs1400 for the mother and Rs
600 for the ASHA worker for each institutional delivery.9
During the present study
primary data was collected from sample villages to study the level of awareness about
and availing the facilities under JSY. The data has been compiled and shown below
in Table4.6 :
Table 4.6Awareness about JSY across the castes
The above data revealed that only 29.6% respondents in sample villages were
aware about JSY indicating very low level of awareness about the scheme. It was
found that the awareness
level about JSY was 12 %
higher among SC as
compared to general caste
respondents in the sample
villages. This has been
shown below with the
help of histogram:
Caste Yes No/NA Total
General 42(24.9%) 127(75.1%) 169(100.0%)
SC 41(36.9%) 70(63.1%) 111(100.0%)
G. Total 83(29.6%) 197(70.4%) 280(100.0%)
Caste wise Awarness about JSY
78
On the analysis of the data ,it was found that across all the three blocks the
awareness level was not much different as it varied between 28.1% to 31.3%.Data
analysed to study the impact of education level of respondent on availing the facilities
under JSY indicated that the education level of respondent had direct bearing on the
access to benefits under the scheme as the % of benefitted women increased with the
increase in their education level. The data is given below in table 4.7.
Table 4.7Availing incentive of JSY across Education levels
Availing incentive from JSY across Education levels
Education status YES NO/NA TOTAL
Illiterate 4(6.5%) 58(93.5%) 62(100.0%)
Primary 9(17.0%) 44(83.0%) 53(100.0%)
Middle 33(42.9%) 44(57.1%) 77(100.0%)
Highschool 11(40.7%) 16(59.3%) 27(100.0%)
Inter 16(48.5%) 17(51.5%) 33(100.0%)
Graduate 5(25.0%) 15(75.0%) 20(100.0%)
PG 5(62.5%) 3(37.5%) 8(100.0%)
TOTAL 83(29.6%) 197(70.4%) 280(100.0%)
The visual representation of the finding above has been shown below with histogram:
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
YES
NO/NA
JSY Benefits across Education levels
79
On the analysis of the data, it was found that across all the three blocks the
awareness level was not much different as it varied between 28.1% to 31.3%.
To study the impact of remoteness of the location of the sample villages on the
status to avail the facilities under JSY the blockwise data was compiled and has been
given in table 4.8.
Table 4.8 JSY benefits availed across the Blocks
AVAILING INCENTIVE FROM JSY
Block Caste YES NO/NA TOTAL
Hawalbagh
General 7(18.4%) 31(81.6%) 38(100.0%)
SC 20(34.5%) 38(65.5%) 58(100.0%)
S. Total 27(28.1%) 69(71.9%) 96(100.0%)
Tarikhet
General 18(25.7%) 52(74.3%) 70(100.0%)
SC 13(44.8%) 16(55.2%) 29(100.0%)
S. Total 31(31.3%) 68(68.7%) 99(100.0%)
Sult
General 17(27.9%) 44(72.1%) 61(100.0%)
SC 8(33.3%) 16(66.7%) 24(100.0%)
S. Total 25(29.4%) 60(70.6%) 85(100.0%)
Total 83(29.6%) 197(70.4%) 280(100.0%)
Histogram below is showing the status to facilities availed under JSY across
the blocks
Proportion of overall number of respondent women taking benefits under the
scheme across the caste and remoteness of the sample villages was low. Other than
low level of awareness, one of the reasons for this could be that deliveries of many
0.0%
1000.0%
2000.0%
3000.0%
4000.0%
5000.0%
6000.0%
7000.0%
8000.0%
HAWALBAGH TARIKHET SULT
YES
NO/NA
JSY Benefits Across Blocks
80
respondent women were conducted before the beginning of JSY, which was launched
in 2005. Efforts to improve awareness among the people about JSY is expected to
facilitate higher access to the benefits of the scheme.
5. Village Health and Nutrition Day (VHND)
The regular and proper organization of the Village Health and Nutrition Day
(VHND) is the most crucial component of NRHM for guaranteeing service provision
at the village level. In district Almora VHND is usually organised on Saturdays in
convergence with ICDS at AWC in the selected villages. This is expected to bring
about the much needed behavioural changes in the community, and can also induce
health-seeking behaviour in the community leading to better health outcomes.
Adequate publicity about day, time, site and key services available on VHND is
supposed to be done by ASHAs, AWWs, and others to mobilize the villagers,
especially women and children, to assemble at the nearest Agan Wadi Centre (AWC).
Creating awareness especially among the women from vulnerable sections and other
stakeholders in the community about service availability right in the village on fixed
days at AWC plays very important role in providing health services to them. One of
the out comes of VHND is hundred per cent coverage with preventive and promotive
interventions, especially for pregnant women, children, and adolescents. The VHND
programme under NRHM has been implemented in district Almora also. During the
present research study data on awareness level and benefitsand services availed under
VHND were also collected from the sample villages. The consolidated data has been
given in table 4.9
Table 4.9 Overall Awareness about VHND
Caste Yes No Total
General 60(35.50%) 109(64.50%) 169(100.00%)
SC 44(39.64%) 67(60.36%) 111(100.00%)
Total 104(37.14%) 176(62.86%) 280(100.00%)
81
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%
Yes NO
general
SC
The overall awareness level
was found to be only 37.14% which
is dismally low and was correlated
with the success and impact of the
programme. This has been shown by
pie chart:
The data shows that the
awareness level for VHND was found
to be 4.14% higher among SC than
general caste respondents.Visual
representation of the status of
awareness across the caste has been
shown with histogram:
The primary data collected was analysed for any possible impact of education
level with the awareness about programme. The data showed that awareness level was
significantly higher than the average for women with educational qualification as
high school and above . the data has been given below in table 4.10.
Table 4.10 Awareness about VHND across education level
Education status Yes NO Total
Illiterate 15(24.2%) 47(75.8%) 62(100.0%)
5th 7(13.2%) 46(86.8%) 53(100.0%)
8 th 30(39.0%) 47(61.0%) 77(100.0%)
10 th 11(40.7%) 16(59.3%) 27(100.0%)
12 th 25(75.8%) 8(24.2%) 33(100.0%)
Graduate 12(60.0%) 8(40.0%) 20(100.0%)
Post graduate 4(50.0%) 4(50.0%) 8(100.0%)
Total 104(37.1%) 176(62.9%) 280 (100%)
37%
63%
Yes
No
rwareness about VHND across castes
Overall Awareness About VHND
82
The pictorial depiction of the awareness level across the education level of
respondents is shown below with histogram:
The data was analysed for assessing any possible influence of
location/remoteness of the sample blocks. This data has been compiled and given in
table 4.11
Table 4.11 Awareness about VHND across the blocks
The above data clearly showed that the awareness level was inversely
proportional to the remoteness of the block from district head quarters and density of
health facilities in them. This has been pictorially shown below:
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Iletrate 5th 8 th 10 th 12 th Graduate Postgraduate
Yes
NO
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
HAWALBAGH TARIKHET SULT
YES
NO
Block Yes No Total
Hawalbagh 47(49.0%) 49(51.0%) 96(100.0%)
Tarikhet 38(38.4%) 61(61.6%) 99(100%)
Sult 19(22.4%) 66(77.6%) 85(100%)
Total 104(37.1%) 176(62.9%) 280(100%)
rwareness about VHND across Education Levels
rwareness about VHND across Blocks
83
Table 4.12Various services availed during VHND castewise
Ser
vic
es
avai
led i
n
VH
ND
General SC Total
Yes No Total Yes No
Tota
l Yes No Total
BP
m
easu
rem
en
t
4
2.4%
165
97.6%
169
100%
4
3.6%
107
96.4%
111
100%
8
2.9%
272
97.1%
280
100%
Wei
ght
mea
sure
men
t
1
0.6%
168
99.4%
169
100%
2
1.8%
109
98.2%
111
100%
3
1.1%
277
98.9%
280
100%
TT
inocu
lati
on
11
6.5%
158
93.5%
169
100%
7
6.3%
104
93.7%
111
100%
18
6.4%
262
93.6%
280
100%
IFA
tab
lets
usa
ge
64
37.9%
105
62.1%
169
100%
51
45.9%
60
54.1%
111
100%
115
41.1%
165
58.9%
280
100%
Obta
ined
info
rmat
ion a
bout
fam
ily p
lannin
g
2
1.2%
167
98.8%
169
100%
5
4.5%
106
95.5%
111
100%
7
2.5%
273
97.5%
280
100%
Got
chil
dre
n
Imm
unis
ed
10
5.9%
159
94.1%
169
100%
7
6.3%
104
93.7%
111
100%
17
6.1%
263
93.9%
280
100%
84
The primary data thus collected has been analysed and it revealed the following:
i) The overall awareness level in the sample villages was low at 37.14%.
Across castes also there was not much difference with awareness level at
35.5% and 39.64% for general and SC rural women.
ii) Across education level of respondents it was found that women with high
school or lower level of education had lower awareness level (40.7% or less )
which ranged between 13.2% to 40.7%. Awareness level was at 50% or more
for women with qualification intermediate or higher, with peak level at 75.8%
for women who were with intermediate qualification. It is thus inferred that
better level of education among the rural women had higher level of awareness
about VHND compared to women who were illiterate or had lower education.
iii) Analysis of data across the development block revealed that the awareness
level has been adversely affected with increase in remoteness of the area from
district head quarter and decrease in the density of health facilities in the
block. The awareness level was at 49%, 38.4% and 22.4% respectively for
Hawalbagh, Tarikhet and Sult blocks.As far as the status of availing the
services during VHND is concerned, the study revealed that services like BP
and weight measurement, TT inoculation, immunization, or obtaining
information about family planning and taking IFA tablet during VHND were
received only by very few. This rate was less than 6.4% except for IFA
tablets for which this rate was 41.1%.
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
Over all status of services availed during VHND
Yes
No
85
iv) Regarding utilization of maternal and child health care service during VHND
it was found that maximum women (41.1%) took Iron folic Acid (IFA) tablets,
followed by TT inoculation (6.4%), Immunization of children (6.1%), blood
Pressure measurement (2.9%), whereas only (1.1%) had their weight
measurement.
v) When data was compared across the castes, it was found that generally the
ratio of SC respondents who utilized VHND services was higher than that for
general caste respondents.
One of the major activities of VHND is also to create awareness among the
women about family planning and importance of safe delivery. Both of these along
with timely immunization of mother and child have direct and positive relationship
with the mother and child health. The low level of awareness about VHND and other
health programmes can be improved by publicity with appropriate means. Like Janani
Shishu Suraksha Karyakram(JSSK) and Janani SurakshaYojna (JSY) the use of
television and radio for wider publicity should be started and encouraged for VHND
and other lesser known health programmes.
6.REPRODUCTIVE AND CHILD HEALTH (RCH) PROGRAMME
World Health Organization (WHO) has defined reproductive health as
follows:
"Within the framework of WHO's definition of health as a state of complete physical,
mental, and social well-being, and not merely the absence of disease or infirmity;
reproductive health addresses the reproductive processes, functions and systems at all
stages of life. Reproductive health therefore implies that people are able to have a
responsible, satisfying and safe sex life and that they have the capability to reproduce
and the freedom to decide, if when, and how often to do so. This definition focus on
right of men and women to be informed of and to have access to safe, effective,
affordable, and acceptable methods of fertility regulation of their choice, and the right
to access to appropriate health care services that will enable women to go safely
through pregnancy and childbirth and provide couples with the best chance of having
a healthy infant"10
.
86
RCH Programme is one of the important intervention under NRHM, which
was launched in 2005 by GoI. Prevention and management of unwanted pregnancy
and maternal care that includes antenatal, delivery and postpartum services, child
survival services for newborns and infants and management of Reproductive Tract
Infection (TRIs) and Sexually Transmitted Infections (STIs).are essential components
of RCH programme. The strategy for RCH programme includes decentralised
Participatory bottom-up Planning and implementation along with strengthening
infrastructure and improved management with integrated Training Package. Major
Elements of RCH Programme includes Interventions to Promote Safe Motherhood.
Reproductive and Child Health (RCH) Camps: RCH camps were organised to provide
to provide Maternal,Child Health and family services in outreach areas..RCH Camps
are either organized at PHC or CHC. The aim of these camps were to provide
maternal and child health services to people in areas where there is shortage of
manpower, health facilities and are hard to reach areas.RCH Camps are scheduled in
advance after consultation with Medical Officer In Charge(MOIC) and CMO and are
widely publicized . Majority of women were sterilized in these camps. These camps
are popular as ―Family Planning Camps‖ among women. Almost all women availed
sterilization services at these camps, but did not know about these camps as RCH
camps. However these camps have been stopped by govt. from 2011. Family planning
operations remained the dominant activity under RCH camps. Different services
provided under this banner are now available to the people under other relevant
schemes.
The primary data collected during the present study revealed that the overall
level of awareness about RCH camps among the respondents was dismally low at
11.4%. Across the caste also the awareness level was not significantly different. The
rate was 11.2% and 11.7% for general and scheduled caste rural women respectively.
Table 4.13 Overall awareness about RCH Camps and Caste-wise
Caste Yes No Total
General 19(11.2%) 150(88.8%) 169(100.0%)
SC 13(11.7%) 98(88.3%) 111(100.0%)
G. Total 32(11.4%) 248(88.6%) 280(100.0%)
87
The study found no definite pattern about awareness and education level upto
highschool level in general but the awareness level was comparatively higher with
respondents who had educational qualification as intermediate or higher. The
awareness level among women with different educational level ranged between 3.8%
and 37.5%. It was lowest among women with primary education and highest among
women who were post graduates.
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
YES NO
General
Sc
11%
89%
Yes
No
rwareness about RCH Camps across Castes
Overall rwareness about RCH Camps
88
Table 4.14 Awareness about RCH Camps across Education levels
Awareness about RCH camps across Education levels
Education level Yes No/NA Total
Illiterate 4 (6.5%) 58(93.5%) 62 (100%)
Primary 2(3.8%) 51(96.2%) 53 (100%)
Middle 11(14.3%) 66 (85.7%) 77(100%)
Highschool 2 (7.4%) 25(92.6%) 27 (100%)
Inter 6 (18.2%) 27(81.8%) 33(100%)
Graduate 4(20.0%) 16 (80%) 20(100%)
PG 3 (37.5%) 5(62.5%) 8(100%)
TOTAL 32 (11.4%) 248(88.6%) 280 (100%)
The blockwise analysis of data showed that Tarikhet block had highest rate of
awareness with 18.2% followed by Hawalbagh and Sult with 9.4% and 5.9%
respectively.
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Illiterate Primary Middle Highschool Inter Graduate PG
YES
NO/NA
Awareness about RCH Camps across Education levels
89
Table 4.15 Awareness about RCH Camps across Blocks
AWARENESS ABOUT RCH CAMPS
Block Caste YES NO TOTAL
Hawalbagh
General 2 (5.3%) 36(94.7%) 38 (100%)
SC 7(12.1%) 51(87.9%) 58(100%)
S.Total 9 (9.4%) 87(90.6%) 96 (100%)
Tarikhet
General 13(18.6%) 57(81.4%) 70(100%)
SC 5 (17.2%) 24(82.8%) 29(100%)
S.Total 18(18.2%) 81(81.8%) 99(100%)
Sult
General 4 (6.6%) 57(93.4%) 61(100%)
SC 1(4.2%) 23(95.8%) 24(100%)
S.Total 5 (5.9%) 80(94.1%) 85(100%)
Grand Total 32(11.4%) 248(88.6%) 280(100%)
7.Breast-feeding
Breast-feeding of child immediately after birth with clostrum (mothers highly
nutritious first milk) is important as it contains antibodies that provide immunity to
the child .Also a deep bond between mother and child develops through breast
feeding. It has also been indicated that when a mother breast feeds her child, she
holds the child close to her body and provides the baby necessary warmth that
regulates the body temperature of child and prevents hypothermia(lowering of body
temperature dangerously as a result of being in severe cold for long time) which is
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
YES NO
HAWALBAGH
TARIKHET
SULT
Overall Awareness about RCH Camps Across blocks
90
also a cause of infant mortality. Under modern health care, human breast milk is
considered the healthiest form of milk for babies. Breastfeeding promotes the health
of both mother and infant and helps to prevent disease. Longer breastfeeding has also
been associated with better mental health through childhood and into adolescence.
The WHO recommends exclusive breastfeeding for the first six months of life, after
which "infants should receive nutritionally adequate and safe complementary foods
while breastfeeding continues up to two years of age or beyond".
According to AHS report 2011-12, the overall ratio of children breastfed
within one hour of birth in Uttarakhand was 63.7% which was higher in rural areas at
66.6% compared to urban areas at only 55.6% . The ratio of children breastfed within
an hour of birth for district Almora was 80.9%, 81.4% and 70.6% for the district, rural
and urban areas respectively.
The primary data was tabulated and the tables for overall, caste profilewise,
blockwise and educational qualification wise details on the status of breast feeding are
shown below.
Table 4.16Overall status of breast feeding practices
Breast feeding status Gen SC Total
Immediately/ within 1 hour of
birth 131(77.5%) 80(72.1%) 211(75.4%)
Within 1-5 hours of birth 12(7.1%) 8(7.2%) 20(7.1%)
On first day of birth 3(1.8%) 2(1.8%) 5(1.8%)
On second day of birth 9 (5.3%) 5(4.5%) 14(5.0%)
On third day of birth 11 (6.5%) 15(13.5%) 26(9.3%)
After third day of birth 3(1.8%) 1(0.9%) 4(1.4%)
Grand Total 169 (100%) 111(100%) 280(100%)
91
Table 4.17 Blockwise status of breast feeding practices
Blo
ck
imm
edia
tely
/ w
ith
in
1 h
ou
r of
bir
th
wit
hin
1-5
hou
rs o
f
bir
th
on
fir
st d
ay o
f b
irth
on
sec
on
d d
ay o
f
bir
th
On
th
ird
day o
f
bir
th
Aft
er t
hir
d d
ay o
f
bir
th
Tota
l
Hawalbag
71
(74%)
3
(3.1%)
2
(2.1%)
7
(7.3%)
13
(13.54%)
0
(0%)
96
(100%)
Tarikhet
63
(63.7%)
12
(12.1%)
2
(2.0%)
7
(7.1%)
11
(11.1%)
4
(4%)
99
(100%)
Sult
77
(90.5%)
5
(5.9%)
1
(1.2%)
0
(0%)
2
(2.4%)
0
(0%)
85
(100%)
Total
211
(75.4%)
20
(7.1%)
5
(1.8%)
14
(5.0%)
26
(9.3%)
4
(1.4%)
280
(100%)
Table 4.18 Status of breast feeding practices by educational qualification
Qu
ali
fica
tion
imm
edia
tely
/
wit
hin
1 h
ou
r of
bir
th
wit
hin
1-5
hou
rs
of
bir
th
on
fir
st d
ay o
f
bir
th
on
sec
on
d d
ay o
f
bir
th
On
th
ird
day o
f
bir
th
Aft
er t
hir
d d
ay
of
bir
th
Gra
nd
Tota
l
Iletrate 43 4 1 3 11 0 62
5th
39 5 2 2 5 0 53
8 th 66 1 1 4 3 2 77
10 th 16 6 1 2 2 0 27
12 th 28 3 0 0 1 1 33
Graduate 12 1 0 2 4 1 20
Post
graduate 7 0 0 1 0 0 8
Total 211 20 5 14 26 4 280
92
The above analysis data collected during the present study for sample villages
revealed that overall 75.4% children were breastfed within an hour of their birth.
The percentage for breast feeding within an hour of birth were at 74.0%,
63.7% and 90.5% for Hawalbagh, Tarikhet and Sult blocks respectively, indicating
towards very healthy trend for this parameter in the interior areas like Sult. It was
found during the study that across caste 77.5% general caste children were breastfed
within an hour of birth whereas this figure was 72.1% for Scheduled caste.
The significant finding of the study was that overall by second day of birth
89.3% and by third day 98.6% children were breast fed. It can thus be concluded that
the awareness level about breast feeding the children in the study area was very high
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Immediately/within 1 hour of
birth
Within 1-5hours of birth
On first day ofbirth
On second dayof birth
On third day ofbirth
After third dayof birth
Gen
SC
Caste-wise status of breast feeding
75.40%
7.10%
1.80% 5%
9.30% 1.40%
Immediately/within 1 hour of birth
within 1-5 hours of birth
On first day of birth
On second day of birth
On third day of birth
After third day of birth
BREAST FEEDING STATUS
93
irrespective of caste, education and location of the sample villages. Good old social
traditions in this respect also appear to have played significantly vital role to pass on
this healthy habit from generation to generation and is still continuing well. Graphical
depiction of block wise status of breast feeding are shown here:
8.Immunization
Immunization of a women during pregnancy is important as it immunes her
against deadly infection like Tetanus Toxoids(TT).Immunization of child is vitally
important to reduce neo natal mortality rate. Infectious diseases cause much illness,
death and may result in disabilities .Immunization of children with
OralPolioVaccine(OPV),BCG,DPT increases their chances of survival and prevent
infant mortality from diseases like tuberculosis, Pertussis, Diphtheria , Measles etc.
and deformities arising from polio virus. In view of the importance of immunization
for both mother and child, govt. has launched Universal Immunization Programme
not only for child survival but also for promoting primary health care. Under
Universal Immunization Programme (UIP) vaccines for six vaccine-preventable
diseases (tuberculosis, diphtheria, pertussis (whooping cough), tetanus, poliomyelitis,
and measles) are available for free of cost to all.
AHS report 2011-12 indicates that the rate of children aged 12-23 months who
were fully immunised was 77.9% and 83.1% for Uttarakhand and district Almora
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
immediately/within 1 hour
of birth
within 1-5hours of
birth
on first dayof birth
on secondday of birth
On third dayof birth
After thirdday of birth
HAWALBAGH
TARIKHET
SULT
Block-wise status of breast feeding
94
respectively. This rate of full immunisation was in general found to be higher for
urban population compared to the rural and the gap between the two was 6.5% for
district Almora. Overall rate of women in rural areas who received at least one TT
injection was 87.5% as against the desired rate of 100%.
Table 4.19Overall status of immunization among Pregnant mothers and their children
castC Yes No Total
General 145(85.8%) 24(14.2%) 169(100%)
SC 101(91.0%) 10(9.6%) 111(100%)
G.Total 246(87.9%) 34(12.1%) 280(100%)
88%
12%
Yes
No
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
YES NO
General
Sc
Overall Status of Immunization
Overall Status of Immunization across caste
95
Table 4.20Block wise Immunization Coverage ofPregnant mothers and their children
Block wise Immunization Coverage
Block Caste YES NO TOTAL
Hawalbagh
General 36(94.7%) 2(5.3%) 38(100%)
SC 57(98.3%) 1(1.7%) 58(100%)
Total 93(96.9%) 3(3.1%) 96(100%)
Tarikhet
General 68(97.1%) 2(2.9%) 70(100%)
SC 26(89.7%) 3(10.3%) 29(100%)
Total 94(94.9%) 5(5.1%) 99(100%)
Sult
General 41(67.2%) 20(32.8%) 61(100%)
SC 18(75.0%) 6(25.0%) 24(100%)
Total 59(69.4%) 26(30.6%) 85(100%)
G.Total 246(87.9%) 34(12.1%) 280(100%)
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
HAWALBAGH TARIKHET SULT
YES
NO
Overall Status of Immunization across blocks
96
Table 4.21Immunisation Coverage of Pregnant mothers and their children across
Education levels
The analysis of primary data collected during the present study showed that
overall 87.9% rural women immunised themselves and their children at appropriate
time. This rate was 91% and 85.8% for SC and general caste women respectively. The
rate of immunisation was 96.9% and 94.9% for Hawalbagh and Tarikhet blocks
respectively. However this rate was abysmally low at 69.4% for Sult block, which is
the remotest of three sample blocks. Rate of immunization coverage was found to be
positively correlated with education level of the mother.
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Illiterate Primary Middle Highschool Inter Graduate PG
YES
NO
Education level Yes No Total
Illiterate 40(64.5%) 22(35.5%) 62(100%)
Primary 48(90.6%) 5(9.4%) 53(100%)
Middle 73(94.8%) 4(5.2%) 77(100%)
Highschool 26(96.3%) 1(3.7%) 27(100%)
Inter 33(100%) 0 33(100%)
Graduate 18(90.0%) 2(10.0%) 20(100%)
PG 8(100%) 0 8(100%)
Total 246(87.9%) 34(12.1%) 280(100%)
Overall Status of Immunization across Education levels
97
Immunization coverage was 64.5% for illiterates and more than 90% for
educated women. This underlines the huge awareness gap which requires to be filled
up speedily for ensuring primary health care. Across the sample villages it was found
that, out of the immunised respondents, more than 90% women had accessed the
facility of immunisation at the nearest sub-centre/PHC .
9.Janani Shishu Suraksha Karyakram (JSSK)
It has been observed that most of the times due to delay in reaching health care
facility like First Referral Unit(FRU), 24x7 PHCs, Secondary or Tertiary centers,
mothers and neonates are deprived of emergency care resulting in maternal morbidity
and mortality, still birth and neonatal deaths. To prevent all these complications, it is
important that mothers and children should be provided quality care, free of cost
including diet and transport facility on time. In order to reduce the death rate, it is
necessary that every mother and child should get the adequate treatment in time. In
order to reduce the deaths, the Govt. of India has announced the Janani Shishu
Suraksha Karyakram (JSSK). JSSK is a flagship programme of government that was
launched in June 201,for health care of mother and child. Under JSSK various
entitlements like Free drugs and consumables, free essential diagnostics (blood, urine
tests and ultra Sonography etc.), Free diet during stay in the govt. hospital (up to 3
days for normal delivery and 7 days for caesarian section, Free provision of blood,
Free transport from Home to Health Institutions, between facilities in case of referral
and drop back from institutions to home are provided for. Exemption from all kinds of
user charges is provided to pregnant women. JSSK has been launched in district
Almora since 2011. During the present study discussions with medical personnel and
rural women indicated that the pregnant women in Almora district have also started
accessing facilities under the scheme. Health department has used banners, writings
on the govt. buses, radio jingles, TV advertisements and communication with women
through ANMs and other staff for creating awareness about the scheme. The services
like drop back home after delivery, providing food to mother in hospital after delivery
and treatment for mother and child are being provided free of cost to the beneficiaries.
Primary data collected during the present study showed that overall awareness level
about the services under the scheme was found to be very low among the rural women
of the sample villages and varied between 8.21% to 12.14% for different services.
98
Among the sample blocks awareness level was lowest in Sult at 1.18% and was
highest in Hawalbagh at 14.58%. The scheme having been relatively recently
launched, it is expected to improve in times to come with increase in awareness level
by appropriate means.
Based on discussions with the respondents and health professionals and
observations made in the field the following important issues have been found to be
relevant and important:
o Even after more than 8 years since the launch of JSY ,the awareness among
the respondents about the scheme is low and this is one of the main reasons
for lower rate of institutional deliveries. Creating awareness about the benefits
of Institutional Delivery for maternal health can lead to better implementation
of the scheme.
o Presently TV and radio are widely in use by health department for enhancing
the publicity and creating awareness about the benefits of Janani Shishu
Suraksha Karyakram(JSSK) and Janani SurakshaYojna (JSY) . Similar efforts
should be made for wider publicity of VHND and other lesser known health
programmes.
o Theme based advocacy materials for maternal health and safe motherhood
should be developed and used during VHNDs and meetings of Gram
Panchaysts in rural areas to create awareness regarding different aspects of
safe motherhood incuding at least 3 ANC check Ups,institutional delivery and
timely immunization of pregnant mother and child. Such material can include
posters, folklore and plays at the community level, radio and television
messages etc.
o All the sub centres located in rural areas should be equiped with necessary
facilities and trained man power to make them functional to provide the
services of institutional delivery.
* * * * *
99
References:
1. Mahabarata, III.313.60
2. Mahabarata, XIII.93.126
3. ManuII.145
4. Jain Shashi, ―Status and role perception of middle class women‖,Delhi,Puja
publishers,1988,pp 147-148
5. Patra Nilanjan,―Universal immunization programme in India: the
determinants of childhood immunization‖,2005
6. Winslow, P.H ―The Cost of Sickness and the Price of Health‖,WHO,
Geneva,1951.
7. http:/hetv.org/programmes/mother-child-protection-card-cbt.htm
8. www.wikipedia.com
9. Janani Suraksha Yojana (JSY),National Health Mission (NHM),Ministry of
Health and Family welfare (MoHFW), Govt of India. Website: nrhm.gov.in
10. www.who.in/topics/reproductive health/in
11. Annual Health Survey(AHS)2010-11 and 2011-12.
100
Chapter 5
Family Planning and Rural women (Women as wife)
The Rig Veda says ― The home has, verily, its foundation in the wife". Since
Vedic era marriage has been a very important social institution for a women.Marriage
provides a women with social and economic security. According to Hinduism one
must marry. ―To be mother, were women created and to be fathers, men; the Veda
ordained that Dharma must be practiced by man together with his wife‖. ―Those who
have wives can fulfill their due obligations in this world; those who have wives, truly
have a family life; those who have wives, can be happy; those who have wives can
lead a full life.”
At any rate, the institution of marriage enjoins and obliges both husband and
wife to live together under the same roof and by common effort to achieve the good of
both. According to Vedas, one of the characteristic features of marriage was not a
contract but an indissoluble tie. In the Ramayana, the wife is said to be the very soul
of her husband. The wife is not just ‗patni‘ (wife) but ‗Dharmapatni‘ (partner) in the
performances of duties; religious, spiritual and other.
Men may have greater physical energy than women, the women clearly have
more internal and emotional energy. It is not without reason then that women are
identified with shakti in Vedic civilization. If women are kept suppressed, this shakti
will be denied to the family and the society, thus weakening all of them.
When the position of women declines, then that society loses its equilibrium
and harmony. In the spiritual domain, men and women have an equal position. Men
and women are equal as sons and daughters of the same Supreme Father. However
society‘s consciousness is focused on the differences of the sexes, and thus treats
women poorly. One is not superior to the other, but each has particular ways or talents
to contribute to society . But the point is that women and men must work
cooperatively like the twin wings of a bird, together which will raise the whole
society.‖1
But today with westernization, modernization, and urbanization, change in
education system, impact of media and social changes over a period of time, the
relationship between husband and wife has changed significantly. The relationship
101
between husband and wife has become comparatively much more equalitarian and
egalitarian now. With the improvement in the literacy and education level of women,
wife is now no more looked at as subservient to her husband but as his partner and
companion in every sphere of life. Unlike earlier times women today are better
educated and few of them are having good careers. Many wives today themselves
want to work and are earning well to support their family. In present times social
transformation is visible when most of the women are supported by their spouse in
every sphere of life. They are encouraged to take up jobs or continue job even after
marriage. Unlike earlier times husbands now also help their wives in different aspects
of domestic life. In fact social change is evident in many ways. Many educated men
now prefer employed girls as their wife. Most of the husbands are proud of their
wives for keeping a balance between their professional and personal life.
5.01 Scenario in Study Area
The relationship between husband and wife is largely different in rural areas
than that in urban areas. In district almora the literacy level of women (2011 census)
is7 0.44%. Among the respondendants in the sample the literacy level of rural women
was 77.9%, out of which only 10 % were graduates and post graduates. It has been
observed , during the study that whether uneducated or highly educated, all women
perform domestic as well as farm activities in the study area. Rural women are the
backbone of the social, economic and cultural structure of the area. They not only
look after the young and the old in the household, but also carry out a number of
chores and are consistently put to arduous multi-tasking. By and large land based
economic activities in the villages are carried out by women, but wife still depends on
her husband for decision making in financial matters. Work division among men and
women is sharp and well defined in the area. There is still a mindset that whatever a
woman earns, all her earnings belong to her husband and decision with regard to
expenditure for various activities is largely taken by husbands, though wife is also
consulted at times. Wife still largely depends on her husband for food, clothes,
housing, health services and other day to day expenses. Wife is still subservient and
subordinate to her husband in that sense. At the same time this is also a fact that
condition of women in the rural areas has improved compared to earlier times but the
pace is slow. For example it has been observed that males are given preference for
102
vocational and professional education if the financial resources are scarce and
limited.
Land ownership: During field study it was revealed that even after amendment
in The Hindu Succession Act, 1956 in 2005, which now has the provision that men
and women have the same right to property , all the ancestral land titles are in the
names of males except in case of widows or family with only girl children. Usually
the ancestral land in inherited fully by the male heirs and is seldom shared with sisters
(married or unmarried). It was also observed that in cases of new purchase of land,
particularly in urban areas now some males are buying lands in the name of their
spouse, mainly to avail lower stamp duty benefits and partially due to gradual change
in their attitude towards the women.
It was observed that though being literate or educated is necessary for
empowerment but it does not necessarily ensure it to the desired level. Good quality
education which promotes critical thinking is seldom available in rural areas and the
study area was not an exception. Ability of critical thinking empowers the women to
analyze their situation, raise questions about their subordination and help them make
informed choices. Education has positively impacted the health awareness and
nutritional level. 73rd
constitutional amendment has benefited the women in study area
also and has resulted in improvement in the political participation of women in Gram
Panchayat and other institutions of three tier Panchayati Raj System. Women today
are politically more aware and empowered. They have now started getting greater
social importance but still proxy politics and gender discrimination continues in some
cases, particularly if the woman is not well educated and informed.
There has been a gradual social change in the lives of rural women as their
roles and functions have also changed over the time. According to an old women
about 67 years old in village Valna , she has witnessed tremendous change in life of
rural women. Some thirty years back the life was very tough and different, when rural
woman was confined to household chorus like cooking food ,collecting fodder , fire
wood, milking animals, grinding and thrashing the grains. Things have gradually
changed and now besides performing the role of house wives, they are actively
participating in other spheres of social life outside their homes. With increase in
education and literacy level women are now taking up other activities like knitting,
tailoring and joining SHGs. They are taking up both govt. and private jobs in schools,
working with health department (ASHA), Mahia Samakhya, Education department
103
(as Bhojan Mata), Swajal (Motivator), ICDS (Aanganwadi Sahayika) and NGOs at
local level. Some of them have vocational education like BTC, B.Ed etc. and are
gainfully employed. With improved income levels they are taking their children to
Block/Tehsil/district headquarter for better education. There is out migration from
villages, for variety of economic reasons which is indicative of social change, viewed
differently by people with different school of thoughts. The revolution in transport
and communication facilities have transformed the lives of the people in rural areas.
More people have access to TV programmes which has impacted the life style and
increased awareness level among rural people including women leading to
improvement in their quality of life. The continuously changing social scenario has
brought about some positive change in the attitude of society towards women. But
still there is lack of appropriate facilities at village level which limits the development
and growth opportunities.
5.02 Data Analysis and Discussions
In this chapter to analyse the role of rural women as a wife,we have taken
programmes related to her sexual and reproductive health launched by govt. National
Family Health Survey (NFHS-3) Uttarakhand conducted during 2005-06 shows
that“median age at marriage among women in age group 25-49 years in Uttarakhand
is 18 years.”2“An early age at marriage of women is an indicator of the low status of
women in society and reduces women‘s access to education and cuts short the time
needed to develop and mature without the responsibilities of marriage and children .
It also has many negative health consequences like early childbearing with increased
risk of maternal and child mortality. An early age at marriage for a woman is related
to lower empowerment and increased risk of adverse reproductive and other health
consequences.”3
According to Annual Health Survey (AHS) conducted by GoI for 2011-12
total fertility rate (TFR) for Almora is 1.9. “The TFR is expressed as the average
number of births per woman by the time they reach 50 years of age”4. During study it
was found that the average number of children per family was 2.6 for the sample.
Preference for son has bearing on TFR.As per AHS 2011-12 the unmet need for
Family Planning is a crucial indicator of women‘s reproductive health indicating
104
unwanted pregnancies, abortions that a women undergoes ,which negatively affect
their health. “Currently Married Women who are not using any method of
contraception but who do not want any more children are defined as having an unmet
need for limiting and those who are not using contraception but want to wait for two
years or more before having another child are defined as having an unmet need for
spacing. The sum total of unmet need for limiting and spacing is the unmet need for
Family Planning. The rate of total unmet need for family planning is 27.4% in Almora
District. Reproductive and sexual health also have a direct bearing on general health
condition of rural women, as many health problems of rural women are due to high
levels of fertility. ”5
As a wife role of women is primarily viewed in terms of reproduction and
family planning. Under these circumstances, it was considered worthwhile to take a
stock of the health status of rural women. With this background, the present research
study was undertaken on the factors affecting reproductive and sexual health of rural
women including knowledge, advice on family Planning and adoption of various
family planning measures by women .Also an attempt has been made to know about
level of understanding among rural women about health in general, timely diagnosis
and treatment of ailments, accessibilityand affordability of health care services and
the medium through which information about various schemes launched by
Government regarding health, reaches rural women have been analyzed . The data
and detailed findings on the above parameters are given in the following paragraphs.
1. Perception about health
“Health is not only by the absence of disease or illness, but by physical,
mental and social well being.‖6 The analysis of primary data on the perception of
respondents about health revealed that overall 46.07% respondents perceive health
as not falling ill. Only 20% women understood health as being physically, mentally
and socially healthy. 21.43% respondents were of the opinion that health was being
physically healthy and 12.5% considered health as being physically and mentally
healthy.
105
Across the caste profile also, 46.15% General Caste women and45.95%
Schedule Caste women consider health as not falling ill which does not show
significant difference on caste basis. However, there was considerable difference of
perception about health as being physically, mentally and socially healthy across the
caste profile of respondents. The data showed that 24.26% General Caste respondents
perceived health as being physically, mentally and socially healthy, whereas this
percentage was 13.5% for Schedule Caste respondents.
Table 5.1 Overall Perception about Health among respondents
Caste Not Falling
ill
Being
physically
healthy
Being
physically,
mentally
healthy
Being
physically,
mentally
and
socially
healthy
Total
General 78
(46.15%)
27
(15.98%)
23
(13.61%)
41
(24.26%)
169
(100%)
SC 51
(45.95%)
33
(29.73%)
12
(10.81%)
15
(13.51%)
111
(100%)
Total 129
(46.07%)
60
(21.43%)
35
(12.50%)
56
(20.00%)
280
(100.00%)
Among the illiterates only 6.45% respondents understood health rightly as
being physically, mentally and socially healthy.
46%
21%
14%
20%
Perception about Health
Not Falling ill
Being physically healthy
Being physically,mentally healthy
Being physically,mentally ,sociallyhealthy
106
Even among educated respondents, no definite pattern was observed on the
understanding about health .The perception about health being physically mentally
and socially healthy varied between 10.39% to 55% among them.
Across all the age groups of the respondents no definite pattern based on age
group was found about the perception of health as being physically, mentally and
socially healthy. This ranged between 16.82% to 25% among different age group of
women with minimum and maximum values for 28-38 years age group and 38-49
years respectively.
About the frequency of health check-up it was found that 91.79% women get
their health examined only when they fall ill and only 6.07% women get their health
checked-up twice a year. No significant variation was found across the caste or
education level of respondents in this respect.
Treatment of ailments at the appropriate time is very important before it
reaches a critical or fatal stage. The data on at what stage of illness do the respondents
start their treatment was also collected. The analysis of primary data collected during
study revealed that overall only 42.9% respondents sought treatment on being highly
ill, whereas 29.7% women sought treatment in beginning of illness and about 27.50%
did so in middle of their sickness. This is indicative of lower level of awareness
among respondents about their health. Most of illiterates (48.39%) sought health
check up only on being highly ill. There is need to improve the education level of the
rural women for better health awareness and empowerment. Creating environment for
healthy living in the family and society is very important.
30%
27%
43%
Treatment of ailments at different stages
In the beginning phase of illness
In the middle phase of illness
On being highly ill
107
Across the castes , no considerable difference was found among the
proportion of respondents who sought treatment in the middle phase of illness. This
proportion of respondents was 27.22% and 27.93% for General Caste and Schedule
Caste respondents respectively. Caste profile in this case was not found to have any
significant difference in the awareness level among respondents about their health.
Table 5.2Treatment of ailments at various stage of illness by responents across castes
Caste
In the
beginning
phase of
illness
In the middle
phase of
illness
On being
highly ill Total
General 54
(31.95%)
46
(27.22%)
69
(40.83%)
169
(100.00%)
SC 29
(26.13%)
31
(27.93%)
51
(45.95%)
111
(100.00%)
Total 83
(29.64%)
77
(27.50%)
120
(42.86%)
280
(100.00%)
The primary data from the field revealed that among the respondents with
qualification level of highs school and above there was direct relationship between
education level of women and importance given by them to timely diagnosis and
treatment of illness. This shows that the critical level of education to trigger
awareness in this regard was found to be high school for the respondent rural women.
Table 5.3: Education level of respondents andtreatment of ailments at various stage
of illness by them
Educational
Status
In the
beginning
phase of
illness
In the middle
phase of
illness
On being
highly ill Total
Illiterate 10(16.13%) 22(35.48%) 30(48.39%) 62(100.00%)
5th and 8th
25(19.23%) 37(28.46%) 68(52.31%) 130(100.00%)
10th
and 12th
29(48.33%) 13(21.67%) 18(30.00%) 60(100.00%)
Graduate and
Post graduate 19(67.86%) 5(17.86%) 4(14.29%) 28(100.00%)
Total 83(29.64%) 77(27.50%) 120(42.86%) 280(100.00%)
108
Chi square ( χ2 ) test :
Chi square test was conducted to test the hypothesis whether Stage at which
checkup is done for treatment of illness is independent of educational status of the
respondent. The details are given below:
Null Hypothesis H0 : Stage of checkup is independent of educational status.
Alternative Hypothesis H1 : Stage of checkup is not independent of educational
status.
Observed Frequency
Educational
status
In the beginning
phase of illness
In the middle
phase of illness
On being
highly ill Total
Illiterate 10 22 30 62
Primary 9 16 28 53
Junior 16 21 40 77
Middle 10 8 9 27
Intermediate 19 5 9 33
Graduate 16 0 4 20
Post Graduate 3 5 0 8
Total 83 77 120 280
Expected frequency
Qualification
In the beginning
phase of illness
In the middle
phase of illness
On being
highly ill Total
Illiterate 18.379 17.050 26.571 62
Primary 15.711 14.575 22.714 53
Junior 22.825 21.175 33.000 77
Middle 8.004 7.425 11.571 27
Intermediate 9.782 9.075 14.143 33
Graduate 5.929 5.500 8.571 20
Post Graduate 2.371 2.200 3.429 8
Total 83 77 120 280
109
∑ ∑ (Eij-Oij)2
/ Eij
Qualification
In the beginning
phase of illness
In the middle
phase of illness
On being
highly ill Total
Illiterate 3.820 1.437 0.442
Primary 2.866 0.139 1.230
Junior 2.041 0.001 1.485
Middle 0.498 0.045 0.571
Intermediate 8.686 1.830 1.870
Graduate 17.109 5.500 2.438
Post Graduate 0.167 3.564 3.429
Total 59.168
χ2
Cal. = ∑ ∑ (Oij-Eij)2 / Eij = 59.168
χ2
Tab. α=0.05, df=12 = 21.026
χ2
Tab. α=0.01, df=13 = 26.217
χ2
Cal. > χ2
Tab. α=0.05, df=12
χ2
Cal. > χ2
Tab. α=0.01, df=12
==> Highly significant
we accept H1 by rejecting H0 at both level of significance i.e. 0.05 and 0.01 and
conclude that the Stage of checkup is highly dependent on educational status.
Further Chi square test was also conducted to test the hypothesis whether
Stage at which checkup is done for treatment of illness is independent of caste of the
respondent. The details are given below:
Null Hypothesis H0 : Stage of checkup is independent of caste.
Alternative Hypothesis H1 : Stage of checkup is not independent of caste.
110
Observed Frequency
Caste In the beginning
phase of illness
In the middle
phase of illness
On being
highly ill Total
General 54 46 69 169
SC 29 31 51 111
Total 83 77 120 280
Expected frequency
Caste In the beginning
phase of illness
In the middle
phase of illness
On being
highly ill Total
General 50.096 46.475 72.429 169
SC 32.904 30.525 47.571 111
Total 83 77 120 280
∑ ∑ (Eij-Oij)2
/ Eij
Caste In the beginning
phase of illness
In the middle
phase of illness
On being
highly ill Total
General 0.304 0.005 0.162
SC 0.463 0.007 0.247
Total 1.189
χ2
Cal. = ∑ ∑ (Eij-Oij)2 / Eij = 1.189
χ2
Tab. α=0.05, df=2 = 5.991
χ2
Cal. < χ2
Tab. α=0.05, df=2
==>Not significant
we accept H0 by rejecting H1 at 0.05 level of significance and conclude that the
Stage of checkup for treatment is independent of caste.
111
The primary data also revealed that about 70.36% women are always eager,
curious and interested to know and discuss health related issues but are not always
able to do so due to lack of accessibility to the services of professional health
workers. Around 9.64% respondents were not eager to discuss their health related
issues. During discussions with the respondents in the field it was found that the
professional health workers usually focus only on the lactating mother and child
health care, where as there is felt need to focus on entire women health issues of the
women of varying age profile.
On the issue of actual discussions of rural women with ANM/ASHA it was
found that overall about 26.43% respondents discussed health related problems with
ANMs on every possible opportunity whereas proportion of respondents
occasionally discussing health related issues was 31.79% . Data also revealed that
16.43% respondent women shyed away from discussing their health related problems
and 18.93% did it only on falling ill.
The perception of respondents about the necessity of the female doctors and
others for treatment of their gynecological problems in the society was also studied
in the sample villages. Over all 82.86% respondents perceived that female doctor
was necessary for consultation/treatment of women health related issues whereas
11.43% felt that this could be done by any qualified doctor. No significant variation
in this regard was found across castes or education level of respondents in the
sample villages.
26%
16%
32%
18%
8%
Frequency of discussion about health with health workers(ASHA /ANM)
On every opportunity
Never discuss
Seldom
Only on having any health
problem
Cannot contact ANM/ASHA as
thay do not come to our area
112
Table 5.4 Perception of respondents about their need for different Health Services
Provider for treatment of gynecological problems
Caste Female
Doctor
Male
doctor
Neem
/haakeem
ANM/
ASHA Pharmacist
Any
qualified
Doctor
Total
General 138 0 1 8 0 22 169
% 81.66% 0.00% 0.59% 4.73% 0.00% 13.02% 100.00%
SC 94 2 0 5 0 10 111
% 84.68% 1.80% 0.00% 4.50% 0.00% 9.01% 100.00%
Total 232 2 1 13 0 32 280
% 82.86% 0.71% 0.36% 4.64% 0.00% 11.43% 100.00%
By and large the modern medicine system is considered to be the best system
of medicine for treatment and health care. The faith and confidence of the
respondents on various system of medicines was also studied and the analysis of
primary data indicates that overall 61.79% respondents, showed their main faith in
modern system of medicine for primary health care, followed by 27.86% and
10.35% respondents who had main faith in traditional treatment through home
remedies and natural therapy respectivey. It was also found that, in general,
improvement in the education level resulted in higher proportion of respondents with
faith in modern medicine system.
Mass media exposure is an effective instrument to gain knowledge about the
outside world. Media exposes women to important information and increases
awareness of health and family welfare issues, in addition to a variety of social issues.
To some extent, media exposure can compensate for a lack of education if there is
regular exposure to educational media messages. With this context in view the
important aspect of how rural women get information about health related issues and
services , was also studied in sample villages. There are different agencies like Health
Department, Integrated Child Development Scheme(ICDS Department )and Non
government organizations , in the study area, which disseminate information about
health related issues and services among people through audio-visual aids, TV,
periodic meetings and interaction with communities, news papers, pamphlets
,posters, advertisement on buses and public places etc.
The study revealed that the two major usual sources of information
dissemination on health related issues and services were Television /Newspapers and
113
Health department and other government agencies which covered 41.47% and
28.6% respondents respectively. 5.6% respondents did not get information about
health related issues and services through any medium.
TVand news papers and health dept./govt. agencies have been found to be
major means of communication with respondents for dissemination of information
related to health services, these should be utilised more to create awareness and
disseminate relevant information on health related issues of women in rural areas.
Most of the respondents who had no or negligible information on health
related issues and services were also both uneducated and remotely located with
negligible interaction with any agency involved in information dissemination related
activities. Women with no education, were thus in a disadvantageous position.The
primary data underlines that better educated respondents had comparatively higher
degree of awareness and better level of relevant information about health related
issuesand services.
Table 5.5 Usual Sources of Information about healthrelated issuesand services
Usual Sources of Information
about health related issues and services
No. of respondents
Newspaper/Television 116 (41.47%)
Health Department/other govt.
agencies 80 (28.6%)
Family and friends 52 (18.6%)
N.G.O.s 18 (6.4%)
Do not get information 14 (5.6%)
Total 280 (100%)
3. Access to Health Care facilities
One of the objectives of National Rural Health Mission(NRHM) is to provide
accessible and affordable health care to all. To achieve the said objectives government
is expected to put in place a network of health services and trained medical personnel.
Health services can broadly be divided into: Rural Health care and Urban Healthcare
Services. The hierarchical structure of these services(starting from lowest to highest)
is shown below:
114
Sub-Centre(SC),Primary Health Centre(PHC),Community Health
Centre(CHC),Sub-District Hospital(SDH),District Hospital(DH).
Rural health care consists of 3 tier health services viz (a) Sub Centre(SC) (b)
Primary Health Centre(PHC) and (c) Community Health Centre(CHC).‖7
The primary data from the field survey revealed that 48.9% respondents
usually sought health care services from their nearest Sub-Centres(SCs), 19.6 % from
Primary Health Centre(PHC)and (3.6%) from Community Health Centre(CHC) and
rest 27.9% from private hospitals in the sample villages. The lower percentage for
accessing health services from CHC is due to fewer CHCs available near the sample
village. 27.9% respondents sought health care services from private hospitals/Doctors.
During the study it was found that an amount of Rs.1000 as untied fund is available
with the ANMs of the Sub-Centers for carrying out need based requirements to
provide heath services but this was decentralised power was not utilised fully by
many AMNs. There is need for capacity building of ANMs to facilitate and speed up
the process of utilizing this untied fund. This will further improve the standard of
services provided by Sub centre.
The health facilities in rural areas are few and far in between. For providing
quality health care, existence of appropriate health care infrastructure is a
precondition Availability of basic health facility infrastructure with adequately trained
medical staff, doctors especially female doctors and equipments etc., are important
and crucial factors that influence delivery of and access to health services. Lack of
doctors in PHC and CHC has hampered the implementation of rural health
programmes. There is need to start special drive to improve health service
infrastructure and put in place adequate medical professional including female doctors
in the rural areas. This could be started by providing adequate and appropriate
incentives to the doctors and other medical staff to compensate for serving in rural
areas. Monetary incentives should be given to medical personnel‘s who are serving in
remote areas to provide health facilities. More female doctors should be put in place
in health care centres so that rural women can discuss about their health related issues
freely and fearlessly with them.
115
Table 5.6 Health Facility Usually Accessed by Respondents for Primary Health Care
Blocks Sub-Center PHC CHC
Private
Hospital Total
Hawalbagh 46(47.90%) 45(46.90%) 0(0.00%) 5(5.20%) 96(100.00%)
Tarikhet 27(27.30%) 0(0.00%) 0(0.00%) 72(72.70%) 99(100.00%)
Sult 64(75.30%) 10(11.80%) 10(11.80%) 1(1.20%) 85(100.00%)
Total 137(48.90%) 55(19.60%) 10(3.60%) 78(27.90%) 280 (100.00%)
The other findings after analysis of primary data from the sample villages
revealed the following:
(i) Comparing data across the three sample blocks, regarding provision of
health care services it was found that (i)Sub –Center is visited by maximum
proportion of respondents women from sample villages of block Sult 75.3%,followed
by 47.9% in block Hawalbagh and 27.3% in block Tarikhet.
(ii) (46.9%) women respondents sought health care services from Primary
Health Centre (PHC) in block Hawalbagh and the figure was 11.8% for sample
villages of block Sult. However none of the respondent in sample villages in block
Tarikhet could seek health services from Primary Health Centre(PHC) because of
absence of PHC within reasonable distance from the selected villages.
(iii) In the absence of government health facility or lack of availability of
doctors and other medical professionals in the govt. hospitals in nearby area of the
sample villages private hospitals catered health services to more than 70% respondnts
in sample villages of block Tarikhet. However services of private hospitals were
available only by 5.2% women in block Hawalbagh and 1.2% in block Sult. This
indicates that SC/PHC/CHC in vicinity of the villages can provide primary health
services to the local people if professional personnel‘s are manning the facilities.
Sub-Centres were found to be most frequently visited by the respondents for
primary health care facilities. It was found that usually with increase in education
level respondents seeking health care services from private hospitals also increased.
In remote areas the presence of ANM was reported to be only for few hours
during day time. The availability of ANM in Sub-Centre (SC) on 24x7 basis must be
ensured by medical department so that women can accesss their services. Extra
monetary incentives should be given to medical personnels who are serving in remote
areas.
116
For development , up gradation and maintenance of health services,
infrastructure sufficient resources are available under NRHM, but the condition of
all SC, PHCs, andCHCs are not satisfactory in the rural areas. On one hand ,in these
centres the conditions of buildings, wards, toilets, operation theatre, labour rooms,
lenin etc are mostly in pathetic condition and on the other hand budget for the same
under NRHM is not utilized fully. There is need to put in place a system which should
ensure timely implementation of planned activities for the up gradation and
maintenance of health facilities and full utilisation of NRHM funds for strengthening
the health infrastructure. Effective periodic monitoring of the implementation of the
plan prepared and approved by Rogi kalyan samitis (RKS) in the time bound manner
is the need of the hour. Medical department should start administrative reform which
will promote transparency and accountability in this regard.
During the field study it was found that an amount of Rs.10000 as untied fund
is available with the ANMs of the Sub-Centers for fulfilling need based requirements
to provide health services, but this decentralised power was not utilised fully by
many ANMs. There is need for capacity building of ANMs to facilitate and speed up
the process of utilizing this untied fund.
Satisfaction level of respondents about the infrastructure and health services
was also assessed. Majority of the respondents (79.3%) were not satisfied with the
services provided by govt. health facilities. The main reason for this was the lack of
doctors and health workers in the centres. Many Sub-Centers were running in rented
buildings. Discussions with respondents revealed that there were quite a few existing
Sub Centre buildings in the study area which were not being utilised to provide the
services of institutional delivery because of the lack of facilities like labour rooms and
basic facilities like water and electricity. It was observed during the field study that
Up-gradation of such SCs was under way. Construction and development of
infrastructure, particularly buildings is carried out by the construction agency .There
is lack of coordination between construction agency and the medical department with
regard to progress of works and more often in handing over the building which often
results in inordinate delay. A committee headed by DM at district level and SDM at
tehsil level may facilitate and speed up this process.
117
4.Access of rural women to Health Care
Factors that limit women‘s access to health care at the household level can be
gender-related, purely economic, or supply driven. Getting money needed for
treatment, having to take transport, or distance to the health facility, can be hurdles for
women because they are likely to be related, to the household‘s economic condition
and to the supply of health care. However, these hurdles are also likely to have a
gender component, because, being female, women have limited freedom of movement
and access to income.8
During the study details of govt. health facilities available in the rural areas of
district Almora were obtained from the medical and health department. The blockwise
details as on first January 2014, have been given below:
Table 5.7 Block-wise number of Health facilities in District
District Almora
S.No Block CHC PHC Additional
PHC
SAD SC
1 Hawalbagh 0 1 3 2 18
2 Lamgahrah 1 1 0 4 18
3 Takula 0 1 1 4 17
4 Bhasiyachana 0 1 1 2 11
5 Dhauladevi 0 1 3 4 21
6 Tarikhet 0 1 1 4 20
7 Dwarahat 1 0 2 7 20
8 Bhikyasen 1 0 3 4 17
9 Chaukhatiya 1 0 2 2 15
10 Deghat 0 1 1 4 19
11 Sult 0 1 3 3 19
Total 4 8 20 40 195
(Source CMO Almora 2012-13)
The above health facility centres were not utilized to the fullest capacity in the
rural areas because the frequent transfer without replacement of the specialized
doctors for providing services like male sterilization, female stylization, and Skilled
birth attended(SBA) training has hampered effective implementation of rural health
118
programmes under NRHM. Most of the times this situation is taking place because of
doctors opting out for higher studies (MD,MS),and child care leave(CCL) in case of
female doctors. This has adversely affected the access of women to health facilities.
The distance of nearest govt. health facility for the respondents in the sample
villages was also ascertained during the study. This data was compiled for all the
respondents and has been summarized below:
Table 5.8 Distance of nearest govt. health facility for the respondents
Distance of
nearest
govt. health
facility
0-1 km 1-2 km 2-3 km More than
3 kms Total
No.of
respondents 131(46.79%) 50(17.86%) 28(10.00%) 71(25.36%) 280(100.00%)
The study revealed that the nearest govt. Health facility was within 1 km
distance for 46.79% respondents, whereas 25.36% respondents had to cover more
than 3 km for accessing primary health facilities from nearest govt. health facility.The
details have been represented by the pie chart given below:
47%
18%
10%
25%
Distance of nearest Govt.Health facility
0-1 km
1-2 km
2-3 km
More than 3 kms
119
Other than the distance of health facility from the villages of respondents ,it
was found that one major issue was that of non availability of female health service
provider higher than Auxiliary Nurse Midwife (ANM) . Non-availabilty of qualified
health professional at govt. health facility in rural areas was a major problem
frequented by women to access health services from govt. health facilities. ANMs
help was obviously confined to provide help and advice on maternity issues alone.
5.Affordability of primary health services
Health is a state subject. Government is expected to provide affordable, quality
and accountable health care to all its citizens. If health care is available at
affordable/nominal rates the number of people who are likely to take early stage
treatment of illness ,will increase.
On the issue of availability of primary health care facilities to the respondents, it
was found during the study, that proportion of respondents who viewed that these
services were available to them free of cost, at affordable cost, and at higher cost from
their norms was 22.5%, 57.86% and 19.64% respectively.
Table 5.9Perception of respondents regarding affordability of primary healthcare
facilities caste wise
Caste Free of Cost At affordable
Rates At High Prices Total
General 37(21.89%) 95(56.21%) 37(21.89%) 169(100.00%)
SC 26(23.42%) 67(60.36%) 18(16.22%) 111(100.00%)
Total 63(22.50%) 162(57.86%) 55(19.64%) 280(100%)
The analysis of primary data from respondents revealed that :
(i) No significant difference was noticed across castes of respondents for
availability of health services, free of cost. Health services were available free
of cost to 21.89% General caste and 23.42% Schedule Caste respondents.
120
.
(ii) 21.89%General caste women and 16.22%Schedule caste women were of the
view that health services were available to them at high prices as per their
norms
Study across three blocks revealed that free of cost primary health services
were available to 22.92%, 5.05% and42.35% respondents in Hawalbagh, Tarikhet
and Sult block respectively. This large variation within different blocks is primarily
due to the distance of Sub-Centre/Primary Health Center /Community health Center
from the sample villages as well as lack of doctors and medical professionals in govt.
health facilities.
Analysis of data across development blocks showed that 66.67% respondents
in Hawalbagh,64.65% in Tarikhet and 40% respondents in Sult bock, perceived that
the health facilities were available to them at affordable rates.
In the opinion of 30.30% respondents from of Tarikhet Block,17.65% from
Sult and 10.42% respondents from Hawalbagh block , health services to them are
available at very high prices as per their norms. The time and transport costs were
significant factors contributing to the enhancement in the cost for accessing health
services by the rural women.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Free of Cost At affordable Rates At High Prices
General
Sc
Perception about Affordability of primary health care services Across Castes
121
These findings highlight the need for further improving the density of govt.
health facilities in the rural area to provide quality health services to larger population
including the rural women at affordable cost.
Table 5.10 Perception of respondents regarding affordability of primary healthcare
facilities across blocks
Block Caste Free of Cost
At nominal
rates At high prices Total
Hawalbagh
General 9(23.68%) 26(68.42%) 3(7.89%) 38(100.00%)
SC 13(22.41%) 38(65.52%) 7(12.07%) 58(100.00%)
Subtotal 22(22.92%) 64(66.67%) 10(10.42%) 96(100.00%)
Tarikhet
General 3(4.29%) 42(60.00%) 25(35.71%) 70(100.00%)
SC 2(6.90%) 22(75.86%) 5(17.24%) 29(100%)
Subtotal 5(5.05%) 64(65.65%) 30(30.30%) 99(100%)
Sult
General 25(40.98%) 27(44.26%) 9(14.75%) 61(100%)
SC 11(45.83%) 7(29.17%) 6(25.00%) 24(100.00%)
Subtotal 36(42.35%) 34(40.00%) 15(17.65%) 85(100.00%)
Total
63(22.50%) 162(57.86%) 55(19.64%) 280(100.00%)
The health facilities in rural areas are few and far in between. For providing
quality health care, existence of appropriate health care infrastructure is a
precondition Availability of basic health facility infrastructure with adequately trained
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Free of Cost At Nominal Rates At high Prices
Hawalbagh
Tarikhet
Sult
Perception about Affordability of primary health services Across
Blocks
122
medical staff, doctors especially female doctors and equipments etc., are important
and crucial factors that influence delivery of and access to health services. Lack of
doctors in PHC and CHC has hampered the implementation of rural health
programmes. There is need to start special drive to improve health service
infrastructure and put in place adequate medical professional including female doctors
in the rural areas. This could be started by providing adequate and appropriate
incentives to the doctors and other medical staff to compensate for serving in rural
areas.
6. The Body Mass Index (BMI):
“BMI is a measure for human body shape based on an individual's mass and
height. Devised between 1830 and 1850 by the BelgianpolymathAdolphe Quetelet
during the course of developing "social physics" it is defined as the individual's body
mass divided by the square of their height – with the value universally being given in
units of kg/m2.
BMI = [Mass (kg)]/ [Height(m)]2
The BMI is used in a wide variety of contexts as a simple method to assess
how much an individual's body weight departs from what is normal or desirable for a
person of his or her height. BMI and intake of nutrition by the individual are also
related. 'BMI' provides a simple numeric measure of a person's thickness or thinness,
allowing health professionals to discuss overweight and underweight problems more
objectively with their patients.
For these individuals, the current value settings are as follows: a BMI of 18.5
to 25 may indicate optimal weight, a BMI lower than 18.5 suggests the person is
underweight, a number above 25 may indicate the person is overweight, a number
above 30 suggests the person is obese.
The WHO regards a BMI of less than 18.5 as underweight and may indicate
malnutrition, an eating disorder, or other health problems, while a BMI greater than
25 is considered overweight and above 30 is considered obese. These ranges of BMI
values are valid only as statistical categories"9
123
Category
BMI range – kg/m2 BMI Prime
Very severely underweight less than 15 less than 0.60
Severely underweight from 15.0 to 16.0 from 0.60 to 0.64
Underweight from 16.0 to 18.5 from 0.64 to 0.74
Normal (healthy weight) from 18.5 to 25 from 0.74 to 1.0
Overweight from 25 to 30 from 1.0 to 1.2
Obese Class I (Moderately obese) from 30 to 35 from 1.2 to 1.4
Obese Class II (Severely obese) from 35 to 40 from 1.4 to 1.6
Obese Class III (Very severely obese) over 40 over 1.6
The primary data for height and weight for each respondent was taken by the
research scholar using weighing machine and measuring tape.The data thus collected
has been tabulated and summarized below:
Table 5.11 Body mass index (BMI) of respondents
Caste
Severely
Under
Weight
(SUW)
Under
Weight
(UW)
Normal
(Healthy
weight)
Over
weight Obese Total
GEN 3(1.78%) 33(19.53%) 110(65.09%) 22(13.02%) 1(0.59%) 169(100%)
SC 13(11.71%) 23(20.72%) 60( 54.05%) 12(10.81%) 3(2.70%) 111(100%)
TOTAL 16(5.71%) 56(20.00%) 170(60.71%) 34(12.14%) 4(1.43%) 280(100.00%)
124
The analysis of primary data revealed that over all 60.71% respondents were
with normal BMI. The data shows that about a quarter of sample ( 25.71% women)
had less than normal weight and 13.57% respondents were found to be over weight or
obese. Across the caste profiles, it was found that the percent of respondents with
normal weight was 65.09 and 54.04 for general and SC categories respectively. The
proportion of severely under weight respondents was higher at 11.71% for SCs as
compared to 1.78% for general category. Large proportion of underweight
respondents is also reflection of poor dietary intake with insufficient calorie intake.
This finding is also corroborated by one study conducted by the scientists of
VPKAS(ICAR), Almora. This study shows ―The consumption of pulses, green leafy
vegetables, other vegetables and fruits was less than the recommended levels among
hill farm women.‖10
The implication of being underweight can be many. Under weight women
tend to give birth to low weight babies who are usually anemic and such women are at
greater risk of maternal death due to loss of blood during pregnancy as women is
already anemic. underweight women may not be able to contribute in the household
economy to her fullest possible potential There is need on part of ICDS and health
department to create awareness among people in general and under weight persons in
particular about ill effects of being underweight along with importance of proper
dietary intake with required calorie which should include pulses, vegetables and
seasonal fruits that are locally available.
Poor economic condition, lack of adequate purchasing power and ignorance
were found to be the major reasons why many rural women were not getting proper
dietary intake in the sample villages. There is also need to sensitize their husband and
other family members about the repercussions of being underweight.The weight of
such respondents must be monitored on regular basis by ICDS and Health department.
ICDS should provide such women with fortified food and Iron Folic Acid tablets. The
local health department professionals and para-medical staff should monitor their iron
level regularly and advise them from time to time. The families of such women who
are under weight or over weight have greater responsibility to pay more attention to
the diet taken by such women.
125
7. Family planning and Perception of Rural women
Family planning allows individuals and couples to anticipate and attain their
desired number of children and the spacing and timing of their births. It is achieved
through use of contraceptive methods11
. A woman‘s ability to space and limit her
pregnancies has a direct impact on her health and well-being as well as on the
outcome of each pregnancy. Women‘s control on pregnancy is an important indicator
of women empowerment.
6%
20%
61%
12% 1%
Overall Status of BMI
SUW
UW
Normal
OverWt.
Obese
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
SUW UW Normal OverWt. Obese
General
SC
BMI Status Across Castes
126
According to AHS report 2011-12,overall ratio of women with 2 children
wanting no more children in Uttarakhand is 80.2% which is higher in urban areas at
85.8% compared to 76.5% in rural area. The ratio of women with 2 children wanting
no more children for district Almora is 56.2%.This figure was 55.2%and 68% for
rural and urban areas respectively
The analysis of primary data collected during the present study on perception
of women about family planning revealed that according to majority(55%) of women
Family Planning is limiting number of children up to two. 14.64% women were of
the opinion that family planning is keeping age gap between children. Only 30.36%
women perceived family planning as both limiting number of children up to two and
keeping age gap between them. This is indicative of low awareness among the
respondents about the right understanding of family planning.
Across three development blocks the proportion of respondents who understood
Family Planning as restricting number of children up to two and keeping age gap
between them in three development blocks was 46.46%, 22.92% and 20% for
Tarikhet, Hawalbagh and Sult block respectively.
55%
15%
30%
Perception about family planning
Limiting Family Upto two
children
Keeping age gap between them
Both limiting family upto two
children & keeping age gap
between them
127
On comparison of data across various education level of respondents it was
found that proper understanding of family planning as limiting family up to two
children and keeping age gap between them improved with improvement in
education level among the respondent women.
The concept of family planning as limiting number of children up to two was
found to be prevalent among most of the respondents at 59.81% in age group of 28-
38 years.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Limiting Family Upto two
children
Keeping age gap between
them
Both limiting family upto
two children & keeping
age gap between them
Hawalbagh
Tarikhet
Sult
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Iletrate 5th 8 th 10 th 12 th Graduate Postgraduate
Limiting Family Upto
two children
Keeping age gap
between them
Both limiting family
upto two children &
keeping age gap
between them
Perception about family planning across the blocks
Perception about family planning across Education levels
128
Understanding of family planning as limiting children up to two as well as
keeping age gap between children was found among respondents at 34.34% in age
group of 18-28 years.
As far as decision about family planning was concerned, it was found during
the study that 58% respondents took joint decision with their husbands in this regard
and 8.2% respondents took their own decision. This decision was taken by their
husbands and others for 11.1% and 2% respondents respectively. 20.7% respondents
did not take any decision about family planning.
8.Knowledge about various Family Planning methods
Knowledge about Family Planning Methods is important for women to have
control on their fertility rate. Adequate Information about different contraceptives
provide choices to the rural women to control unwanted pregnancies and abortions.
Contraceptives include temporary methods like Oral Contraceptives Pills (OCPs), the
Intra urinary devise(IUD), and condoms and permanent methods like Male
Sterilization and Female Sterilization.The knowledge and use of contraceptives have
direct bearing on health of women and their family size.
The analysis of primary data indicates that the knowledge about permanent
methods of family planning like Male and Female Sterilization was known to
majority of respondents. Female sterilization was known to 86.79% and male
sterilization to 73.21%. respondents. This is also corroborated with high rate of
female sterilization adoption as permanent method of family planning in the study
area. However the level of knowledge about Cu-T was at 52.50% and that about
OCPs was minimal at 16.79%.
Table 5.12Knowledge about various Family Planning methods among respondents
Knowledge about family
Planning Methods Yes No Total
Cu-T/IUD 147(52.50) 133(47.50%) 280(100.00)
Female sterilization 243(86.79) 37(13.21%) 280(100.00)
Male Sterlization 205(73.21) 75(26.79%) 280(100.00%)
OCPs/Condoms 47(16.79%) 233(83.21%) 280(100.00%)
129
The analysis of primary data across all the three blocks showed wide range
significant variation about the awareness level about family planning methods. The
findings are given below:
(i) Awareness level about Cu-T/IUD was maximum at 65.63% among
respondents in block Hawalbagh, followed by block Tarikhet at63.64% and was least
in Sult block at 24.71%. This shows inverse relationship between awareness level of
respondents about temporary family planning methods with remoteness of area from
district headquarter.
(ii)Awareness on male sterilization as a family planning method was 63.54%
for block Hawalbagh, 71.76% for block Sult and 83.81% for block Tarikhet.
(iii) Knowledge about OCPs,/Condoms as a family Planning measure was
29.29% in block Tarikhet followed by block Hawalbagh at 14.58% and block Sult at
4.71%.
However knowledge level about Female Sterilization as a method of Family
Planning was more than 80% across all the three selected blocks. The temporary and
permanent contraceptives were women oriented and family planning was viewed as
women‘s responsibility.This was primarily due to social and cultural norms.
The analysis of primary data also proved conclusively that the level of
awareness about both the permanent and temporary methods of family planning is
directly correlated with education level of respondents, further establishing the fact
that education of women is a very powerful and effective tool to control fertility rate
and family size.
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Cu-T/IUD Female
sterlization
Male Sterlization OCPs/Condoms
Yes
No
Knowledge about various Family Planning methods
130
9.Various Family Planning methods adopted by women
Lack of adequate knowledge about contraceptives adversely affect the health
of women in many ways including unwanted pregnancies, closely spaced births, and
abortions. Awareness and information are thus key areas to be focussed for the
betterment of women‘s health . Many health problems of rural women are due to high
levels of fertility. Closely spaced births, unwanted pregnancies, abortions negatively
affect the health of women. Reducing fertility through use of contraceptives in an
important element through which health condition of rural women can be improved.
According to AHS report 2011-12 family planning practices among currently
married women (aged 15-49 years ) for using any Family Planning method is 70.5%
in Almora District. This shows that awareness level about contraceptives is high and
women are going for sterilisation and therefore TFR is 1.9 which is even below the
national target and is quite encouraging. Women have shouldered the responsibility of
family planning. The rate of female sterilization is 47.7% in rural areas and 27% in
urban areas indicating huge gap between the two. The rate of male sterilization is
only 5.1%. In rural areas rate of male sterilization only is 5.4% and in urban areas it
is 1.9%.
Analysis of primary data from sample villages shows that over all
contraception prevalence rate was 67.85% .Among temporary methods of family
planning condoms were most widely used, whereas Female Sterilization was most
widely adopted permanent method of Family Planning. Female Sterilization was most
commonly used family planning method used by 39.29% respondents, followed by
use of condoms(11.07%),Oral pills(9.29%),Male Sterilization(6.07%) and Cu-
T(1.79%) as family planning measures
9%
6%
39%
11% 2%
33%
Adoption of various family planning methods
Oral Pills
Male Sterlization
Female sterlization
Condoms
Cu-T
Not using any Family
Planning Method
131
The rate for Male Sterilization among respondent couples was higher among
Schedule Caste (9.91%) in comparison to General Caste (3.55%). This shows that the
males of Schedule Caste respondents shared comparatively higher responsibility of
Family planning. However female sterilization is higher among General caste
respondents (41.42%) than Schedule Caste respondents (36.04).This indicates that
husbands of General Caste respondents perceived that contraception was primarily
women‘s responsibility. Higher rate of female sterilisation as family planning method
in the sample villages shows the attitude in the society that most of the males still
consider that contraception is women‘s primary responsibility. There is strong felt
need to bring about change in this attitude and both men and women should share the
responsibility to control fertility rate.
Prevalence of condom use was found to be more than thrice among general
caste couples as compared to SC couples. This rate was 15.38% and 4.5% for general
caste couples and SC couples respectively.
Over all 27.81% General Caste and 13.51% Schedule Caste couples use
different temporary methods of Family Planning such as oral pills, Copper-T,
Condoms. 32.50% respondents were not using any of the above mentioned family
planning methods.
Across the three sample blocks it was found that the rate of contraception
prevalence is highest in block Hawalbagh (71.87%),followed by block Sult (68.67%)
and block Tarikhet (63.63%).
71.87%
63.63%
68.67%
58.00%
60.00%
62.00%
64.00%
66.00%
68.00%
70.00%
72.00%
74.00%
Hawalbagh Tarikhet Sult
Contraception Prevelance Rate across blocks
132
Comparatively higher proportion of illiterate respondents had adopted Female
Sterilization (62.90%). With increase in educational level, The rate of adopting
temporary methods of family planning like Oral pills, IUD/Cu-T or Condoms was
found to be higher among educated respondents as compared to those with no
education. Female education has played a very important role in promotion, adoption
and use of contraceptives. Awareness about family planning is quite encouraging but
there is need to improve education and awareness about use and adoption of
contraceptives so that it can be achieved in totality.
Across age groups it was found that the permanent methods of family
planning, particularly female sterilization is more common among older women and
temporary methods among young women (18-28 yrs).
Gone are the days when children were considered as gods gift. This myth is
now blasted and women know that fertility rate can be controlled by adopting
suitable method of family planning and they can control their family size. The efforts
should be made to provide temporary methods of family planning easily available in
rural areas also so that women can exercise their choice of family planning method as
per their need and preference.
Access to family planning methods should be improved in rural areas to
provide optimum choices to the rural women. The health facilities in rural areas are
few and far in between. For providing quality health care, existence of appropriate
health care infrastructure is a precondition.
Based on the findings discussed above in this chapter the following important
suggestions emerged during the study:
a) There is need for adopting bottom up approach to identify the specific health
related issues of rural women and fine tune existing programmes accordingly.
b) Greater sense of ownership needs to be developed in the community about the
govt. health schemes by more frequent and effective interaction between the
health workers and the women. This is expected to improve the understanding
and confidence of the women to have better access to the facilities provided
by the govt.
c) Participatory monitoring of the health programmes at villge level by the
members of the community in the presence of field health workers at regular
intervals will improve the implementation of the programmes.
133
d) The empowerment of rural women will come only with improvement in
education and change in social attitudes.
e) For better implementation of rural health programmes periodic results based
monitoring of indicators at gram Panchayat, block , district level by public
representatives is required. Bahu uddeshiya camps orgnised by district
administration can provide an effective plateform for participatory monitoring
of the implementation of rural health schemes.
f) Decentralised planning should be encouraged and Village Health Nutrition and
Sanitation Committees (VHNSC) need to be proactive. These committees
should send timely inputs to the medical department for timely action ,to control
any out break of disease at village level.
g) Wider consultations with public at large should be done in formulating block
level action plan for health related activities. The gram panchayats should be
actively involved in this process.
h) Education level of women is vital factor which influences the access to different
health schemes and empowerment of women. Present efforts to provide
education to all needs to be sustained in future also.
i) There is need to increase awareness among the rural women about the govt.
health schemes and their benefits available to them through wide publicity.
j) Support staff should be made available at PHC and CHC level for
administrative works so that the doctors are free to devote adequate time to the
patients.
5.03Health Empowerment Index (HEI)
An attempt has been made to examine and develop Health Empowerment Index (HEI)
for the respondents with reference to the selected parameters perceived to be affecting
the health of rural women in the study area. Review of literature in this respect was of
limited help in the sense that no past published work was found on the specific issue
of health empowerment index for rural women. The nearest study was found to be
that of Chaudhry, Imran Sharif et al. (2009) from Pakistan who have developed
women empowerment index for remote areas of Pakistan on the basis of some
134
parameters. ―Women empowerment is one of the momentous issues of contemporary
development policies in developing countries. Since empowerment is considered a
multidimensional concept, it is determined by many socio-economic factors and
cultural norms.12
‖
Discussions with the respondents, villagers, social workers and health
professionals helped in developing some insight and a broad understanding of the
complex and multidimensional concept of health empowerment index for women in
the study area.The HEI would reflect the composite impact of different factors and
parameters chosen for the purpose.
Parameters such as level of education;decision making authority on matters of
family planning; availability ofaffordable primary health services; understanding of
health and institutional delivery; and body mass indexhave been found to have
positive impact on the health of women, and consequently, on health empowerment
index. Therefore, the respondents were asked to rank the relative significance and
importance of these parameters in the scale of 0-10 as per their perception. Each
parameter has thus contributedin reaching at the composite values of HEI as shown
below.Based on the findings of the present study and discussions, different
weightages have been proposed for these parameters in the scale of 0-10 points. The
weightage adopted are mentioned in the table below. As already pointed out, it is
primarily based on the perception of the respondents.
Parameters taken up and weigtage given to each parameter
Parameter Weightage proposed in the scale of
0-10 points
Level of education 3.50
Understanding of health 1.00
Availability of affordable primary health
services
0.75
Institutional delivery 1.25
Decision making authority on matters of
family planning
2.00
Body Mass Index (BMI) 1.50
135
Within each parameter mentioned above, values have been assigned using the
matrix scoring arrived at through PRA based tools.The value assigned for different
status of each parameteris given below:
Educational qualification: Scale
Educational
qualification Illiterate Primary
Middl
e
High
school Intermediate
UG
and
above
Weightage
assigned(%) 0.35 0.7 1.4 2.45 2.8 3.5
Understanding of health:
Understanding of
health
Absence
of
illness
Physically
healthy
Mentally and
physically
healthy
Physically,
mentally and
socially healthy
Weightage assigned(%) 0.75 0.4 0.8 1
Availability ofaffordable primary health services
Primary Health services
available Free of cost
At affordable
cost At high cost
Weightage assigned(%) 0.75 0.6 0.45
136
Institutional delivery:
Type of Delivery
At home without
skilled
professionals
At home with
skilled
professionals
Institutional
Delivery
Weightage assigned(%) 0.125 1.00 1.25
Decision making authority on matters of family planning
Family planning
decision was
taken by
Self Husband
Jointly by
Self and
Husband
Others
No
decision
taken
Weightage
assigned(%) 1.6 0.8 2 0.4 0
Body Mass Index
BMI category SUW UW Normal Over
Wt. Obese
Weightage assigned(%) 0.15 0.75 1.5 0.9 0.15
Index value for each parameter was calculated on the basis of above weightage as per
the primary data for the sample.
Let
I1= Calculated index value of Educational qualification amongst the respondents
I2= Calculated index value of Understanding of health amongst the respondents
137
I3= Calculated index value of Availability of affordable primary health services to the
respondents
I4= Calculated index value of Institutional delivery for the respondents
I5= Calculated index value of Decision making authority on matters of family
planning for the respondents
I6= Calculated index value of BMI for the respondents
Calculation of index value of education status (I1) is shown below:
Educational
qualification illiterate Primary Middle
High
school Intermediate
UG
and
above
Number of
respondents
Weightage
assigned (%)
(W)
0.35 0.7 1.4 2.45 2.8 3.5
% weightage 10% 20% 40% 70% 80% 100%
Hawalbagh
(X1) 14 25 26 7 12 12 96
Tarikhet (X2) 11 16 26 16 17 13 99
Sult (X3) 37 12 25 4 4 3 85
Total (X) 62 53 77 27 33 28 280
X*W X*W X*W X*W X*W X*W ∑X*W
I1= Education
Index
=∑X*W/∑X
X1*W for
Hawalbagh 4.9 17.5 36.4 17.15 33.6 42 151.55 1.58
X2*W for
Tarikhet 3.85 11.2 36.4 39.2 47.6 45.5 183.75 1.86
X3*W for
Sult 12.95 8.4 35 9.8 11.2 10.5 87.85 1.03
X*W for
all
respondents
21.7 37.1 107.8 66.15 92.4 98 423.15 1.51
Similarly Index values I2, I3, I4, I5 and I6 were calculated for each block and for
all 280 respondents. Based on the values of these indices the composite value of HEI
has been calculated for the respondents. All these values are within the weightage
assigned to each one of the parameters.
138
Health Empowerment Index (HEI) is composite index which has been calculated as
per the formula given below:
HEI =[ I1+ I2+ I3+ I4+ I5+ I6]
The values of thus calculated HEI are in the scale of 0-10 as has been assumed
in the beginning of the hypothesis. The calculated values of indices are shown below:
Blocks I1 I2 I3 I4 I5 I6 H.E.I.
Hawalbagh 1.58 0.63 0.62 1.05 1.48 1.07 6.42
Tarikhet 1.86 0.82 0.56 0.97 1.33 1.17 6.70
Sult 1.03 0.74 0.64 0.69 1.36 1.32 5.78
Total 1.51 0.73 0.60 0.91 1.39 1.18 6.32
The HEI calculated for three selected development blocks and overall value of
HEI for all 280 respondents are given below:
Block HEI in the scale of
0 to10
HEI in the scale of
0 to 1
Hawalbagh 6.42 0.642
Tarikhet 6.70 0.670
Sult 5.78 0.578
Over all (Total) 6.32 0.632
The values of composite HEI is indicator of the women‘s health
empowerment. The calculated values of HEI, based on primary data and assumptions
mentioned above, show that it had highest value for Tarikhet block followed by
Hawalbagh. The value of HEI was least for Sult block which is the remotest of the
three selected blocks. Overall value for all 280 respondents was 0.632 in the scale of
0-1.
* * * * *
139
References:
1 http://sanatana-dharma.tripod.com/women_in_hinduism.htm
2 “National Family Health Survey (NFHS-3), India, 2005-06:Uttarakhand”,
May2008,p 4.
3 Kishor Sunita and Gupta Kamla “Gender Equality and Women’s
Empowerment in India. National Family Health Survey (NFHS-3)”,August
2009, pp38.
4 Annual Health Survey ,2011-12,pp vi
5 Ibid.p.viii
6 Health,(websitewww.who.int/en).
7 District Level Household survey(DLHS-3),Uttarakhand.
8 Kishor Sunita and Gupta Kamla ,op.cit(p 64)
9 Body mass index,www.wikipedia.com
10 Jethi, Renu etl. ―Nutritional status of farm women in hills of Uttarakhand”:
Indian res. J. Ext. Edu. 13(3),2013.
11 Family planning,(websitewww.who.int/en).
12 Imran Sharif Chaudhry and Farhana Nosheen: The determinants of women
empowerment in southern Punjab (pakistan): an empirical analysis European
Journal of Social Sciences – Volume 10, Number 2 (2009)
140
Chapter 6
Health Programmes and status of rural girl child
(Women as Daughter)
According to a report of planning commission related to 12
th five year plan
"nineteen per cent of world‘s children live in India. India is home to more than one
billion people, of which 43 crores are children, defined as persons under18 years of
age. In articulating its vision of progress, development and inclusion, India has
reaffirmed its commitment to fulfilling children‘s rights, recognizing them as the
nation‘s supreme asset. The Constitution of India accords a special status to children
as deserving of special provisions and protections to secure and safeguard the
entitlements of ‗those of tender age."1
"The status of the Girl child is the key to achieving women‘s equality, dignity.
The mould of a women is set in her childhood"2. "Girls are asset to nation .Their
welfare strengthens socio-economic development."3
"However in reality we see lot of
gender based discrimination against the girls in the society. Women have suffered
centuries-long deprivation both within households as well as in the society. Their
marginalization is obvious in their poor status in work, education, politics, economy
and all other spheres. It is also increasingly being realized that until and unless they
are given due place in the society whereby they enjoy equal status with men in all
terms, no development is possible in a society, for no country or society can call itself
developed if half of its population suffers from neglect and remain powerless and
marginalized. This has necessitated making efforts for their well-being, and thereby
initiate the process of their empowerment.The existing bias in the minds of the people
in society is the main reason for discrimination against girls‖.4 There is old age
conditioned mind set and belief system which assumes that continuation of family,
old age care of parents and performance of last rites are possible only by sons. The
situation of girls in rural and urban areas are different.The status of rural girl child is
usually lower compared to urban girl child because of prevailing social, cultural and
economic factors. According to Census2011,the percentage of rural population in
Almora is 89.98% and only10.02% comprises the urban population.It was found
during the study, in the sample villages that majority of village girls may contribute
141
by carrying out household choruses like cooking, cleaning, sibling careand agriculture
activities in addition to fetching fuel wood, fodder water and tending animals.Woman
as a daughter, sister , wife, daughter in law does a major part of domestic as well as
farm work but gets food last and the least. Even girl child in some families are not
given nutritious food like her male counterpart. If a girl is not fed well during her
growing years she is more likely to be anemic and in future will be an anemic mother
giving birth to a weak child and risking her own life during delivery. Even in studies
girl child is not given equal opportunities. The education of girl child gets lower
priority. If a women is not educated or less educated she is less likely to understand
the importance,long term implications and benefits of good health for her andher
daughters. Girls are usually sent to government schools while boys are sent to English
medium public school. Even when girls are given higher education, which is
uncommon, there if fear in the minds of parents that they will not be able to find a
suitable match for her.Gender inequality is a function of the social attitudes in any
society."Gender equality does not imply that all women and men must be the same.
Instead, it entails equipping both with equal access to capabilities; so that they have
the freedom to choose opportunities that improve their lives. It means that women
have equal access to resources and rights as men, and vice versa5.12
th five year plan
document mentions that the breaking an intergenerational cycle of multiple
deprivations faced by girls and women is critical for more inclusive growth. This
cycle is epitomized by the adverse sex ratio in young children in the 0-6 years age
group, denying the girl child her right to be born and her right to life. Ensuring Care
and Protection of the Girl Child will be a strategic direction of the Twelfth Plan.
Empowerment of women is closely linked to the opportunities they have in education,
health, employment and for political participation6.
During the present study efforts have been made to assess the status of health,
education and other related social issues pertaining to the girls in the sample villages.
Some important related govt. schemes have also been studied in this regard. The
details are given in the subsequent paras:
6.01 Sex ratio : Sex-ratio (number of female per 1,000 male) is an important
indicator of women's status in the society. For Uttarakhand over all sex ratio has
improved by only one point to become 963 in 2011 as compared to 962 in 2001 but
142
Child Sex ratio (0-6 years) has declined from 908 in 2001 to 886 in 2011 for the
state. Child (0-6 Y) sex ratio in Uttarakhand is 894 in rural areas as against 864 in
urban areas.Sex ratio for district Almora is much above the national and state average
and stands at 1142 in 2011 and is slightly less than 1145 in 2001.
Comparison of AHS 2010-11 and AHS 2011-12 revealed that there is slight
improvement of 4 points in the sex ratio in 0-4 years age group for district Almora
which improved to 900 from earlier figure of 896 .AHS 2011-12 showed that the sex
ratio in 0-4 years is 903 in rural areas and 849 in urban areas of district. This is
indicative of slightly better situation in rural areas as compared to the urban areas.
One reason for the adverse juvenile sex ratio is the prevalent social attitude of
preference for male child.Dominant Patriarchy system is primarily responsible for
gender inequality . During the field study it was revealed that there still exists a very
strong preference for male child among both parents across different social groups.
This attitudinal problem was rampant in the whole area and was not found to be
affected even by higher education level or better economic condition of the family. In
one case (village-Valna) an women had given birth to 11 girls with 10 of them
surviving and had not yet adopted any family planning measure to stop further
pregnancy. Similarly another women with 4 children including 1 male child wanted
one more male child as she believed that it is better to have at least 2 sons to ensure
against unforeseen death of a male child in future. The above finding is also
substantiated by the NFHS-3 report for Uttarakhand which reveals that there is a
strong preference for sons inUttarakhand. "About one in five women and one in seven
men in Uttarakhand want more sons than daughters, but only a negligible proportion
of women (2%) and men(1%) want more daughters than sons. However, most men
and women would like to have at least one son and at least one daughter. Notably,
however, the proportion of currently married women with two children who want no
more children (86%) is substantially higher in NFHS-3 than it was in NFHS-2 (72%),
irrespective of women‘s number of sons.The desire for more children is strongly
affected by women‘s number of sons. For example, among women with two children,
those with one or two sons are more than one and a halftimes as likely to want no
more children as those with two daughters."7The attitude of respondents about the
preference for son was also studied in the field. Based on the primary data the
perception of respondents showed that 83.9% respondents had preference for male
child and who wanted at least one son among their children. The reasons for this
143
attitude was strong belief among them that son is necessary for continuity of lineage,
old age care of parents and performance of last rights and rituals. This showed still a
strong preference for sons in the study area. Existing govt. schemes targeted at
welfare and support of girl child should be made universally available to all girls
without riders attached to them. This is expected to improve the social attitude
towards the girl child and achieving gender equity. Attitudinal change in society is
precursor to social and gender equity.
6.02 The Pre-natal Diagnostic Techniques (PNDT) (Regulation and
Prevention of Misuse) Act, 1994:
PNDT act was enacted and brought into operation from 1st January, 1996, in
order to check female foeticide. Rules have also been framed under the Act. The Act
prohibits determination and disclosure of the sex of foetus . It also prohibits any
advertisements relating to pre-natal determination of sex and prescribes punishment
for its contravention. The PNDT Act 1994 has very strong provisions that pre natal
test for sex determination is an offence . The offence under the act is cognizable, non-
bailable and noncompoundable ,but its weak implementation has been a major area of
concern. There are three committees at national, state and district level to
monitor/implement the act. During the study the implementation status of the PNDT
act was also discussed with CMO and District Magistrate Almora.Some major
shortcomings in the effective implementation of the act which were identified during
the study include lack of regular meetings, nonsubmission of report in form-F by the
diagnostic centres . In the absence of regular reports in form-F , no meaningful and
effective monitoring and resulting action is possible. It seems PCPNDT Act has had
limited impact. The effective implementation of this act along with attitudinal
changes in the society has the potential to stabilise the population growth with gender
balance. Effective communication campaign at block and district level can serve as an
effective tool to make service providers and the general population aware of PNDT
Act. Periodic review of Implementation of PNDT ,strict enforcement of act by
regular monitoring and inspection of all ultrasound clinics along with sensitization of
officials of enforcing agencies and educational institutions can play an important role
in achieving the objectives of the Act.
144
Arrival of kits based on DNA analysis techniques in the market has the danger
of undermining this legislation as ultrasound may not be the preferred route to abort
female foetuses. The kit could diagnose the sex of the unborn within about seven
weeks of pregnancy. Access to the kits, though limited at present, can become mass
based, unless corrective steps are taken effectively.
6.03 Number of children in family and their gender-wise details
The primary data from the sample villages regarding the number of children
and gender-wise details are given below.
Table 6.1 Number of children and their Gender-wise details
No
. o
f
chil
dre
n p
er
cou
ple
No
ch
ild
1 c
hil
d
2 c
hil
dre
n
3 c
hil
dre
n
4 c
hil
dre
n
5 c
hil
dre
n
6 c
hil
dre
n
7 c
hil
dre
n
To
tal
No. of
families 13 47 79 84 36 11 7 3 280
Total No. of
children 0 47 158 252 144 55 42 21 719
Total No.of
boys 0 26 89 130 64 21 11 7 348
Total No.of
girls 0 21 69 122 80 34 31 14 371
Average no.
of boys per
family
0 .55 1.13 1.55 1.78 1.91 1.57 2.33 1.24
Average no.
of girls per
family
0 .45 .87 1.45 2.22 3.09 4.43 4.67 1.33
A visual depiction of the above data showing number of girl and boys across
different family sizes is given below with the help of histogram:
145
The analysis of the primary data clearly shows that the family size is
determined by number of sons and the sequence of their birth in the family. Later the
birth of male child in the sequence of children‘s birth in family,larger is the family
size and more are the number of girls in the family. This indicates strong preference
for the male child in the study area. This underlines the strong need to create
continuous awareness in the society about gender equality and importance of girl
child as an asset who contributes to the social and economic well being of the family
and society.
There is further need to increase awareness among the people about the govt.
schemes which are targeted to improve the social and economic status of females and
their benefits available to them through more and more decentralized camps in the
rural areas after wide publicity through appropriate means. All awareness
programmes should also be in local dialect to increase the participation of the local
community. Sensitization of both men and women to develop positive attitude
towards the girl child and to stop discrimination between son and daughter. With
increase in education level among women and exposure to audio-visual means have
set-in social change and the society is now more aware about women‘s status which
is gradually improving, though the pace is low. There is need to devise innovative
means to continue this effort on sustained basis.
0
1
2
3
4
5
6
7
8
1 2 3 4 5 6 7
No.of children
per couple
Boys
GIRLS
Proportion of av. no. of boys&girls and family size
146
6.04 Infant Mortality Rate(IMR) :
IMR is defined as number of infants dying before reaching one year of age,
per thousand live births,in a given year.According to SRS 2009, infant mortality in
India has declined from 80 per 1,000 live births in 1990 to 68 in 2000 to 47 in 2009.
This implies an average decline of 30 points over a period of twenty years. Child
mortality also shows declining trends though at a slower rate. As per AHS 2011-12
IMR was 41 and 20 for Uttarakhand and district Almora respectively.IMR was 20 for
both males and females in the rural areas of district Almora. IMR is lowest for
district Almora in Uttarakhand. Achievents of uttarakhand and more specifically that
of Almora district are already in consonance with MDG target (42 by 2010).
6.05 Under Five Mortality Rate:
Under five mortality rate which is defined as number of children dying before
reaching age of 5 years. According to AHS 2011-12 overall Under 5 mortality rate
is 50 and 25 for Uttarakhand and district Almora respectively. For the district this
rate was 25 and 24 for males and females respectively.among females . The report
revealed that over all under 5 mortality rate was 25 for rural areas of the district.
However, Under 5 mortality rate in rural areas was 24 and 26 for boys and girls
respectively showing that the rate was 2 point higher for girls than that for boys in
rural areas.
6.06 Children’s Nutritional Status:
―In Uttarakhand forty-four percent of children under age five years are
stunted, or too short for their age,which indicates that they have been undernourished
for some time. Almost one in five(19%) are wasted, or too thin for their height, which
may result from inadequate recent food intake or a recent illness. Children in rural
areas are more likely to be undernourished but even in urban areas, more than one-
quarter (27%) of children suffer from chronic under-nutrition. Given prevailing
gender relations and attitudes and practices towards girl children, the chances are that
girls account for a larger proportion of malnourished children. Children‘s nutritional
status in Uttarakhand has improved substantially since NFHS-2Despite the
improvements over time stunting and underweight, under-nutrition is stilla major
problem in Uttarakhand.8‖
147
Anemic in children can lead to impaired cognitive performance, motor development,
and scholastic achievement. Among children between the ages of 6 and 59 months,
the great majority 61 percent are anemic. From the time of NFHS-2 the anemic level
among children under age three has declined by 8 percentage points. During the
present study data on total number of children examined by school health teams under
NRHM and children found anemic during such examination was taken from the office
of CMO Almora for the financial year 2012-13. Genderwise details are given below.
Table No.6.2: Number of anemic boys and girls
Total boys
examined
Total girls
examined
Number of boys
found anemic
Number of girls
found anemic
29496 47418 2866(9.7%) 5513 (11.6%)
The data shows that out of the students examined by school health teams during
2012-13, 9.7% school going boys and 11.6% school going girls were found anemic .
The proportion of anemic girls was higher by 1.9% in comparison with boys.To
combat anemia among children the shemes like Mid Day Meal Scheme (MDMS) and
Weekly Iron and Folic Acid Supplementation Programme(WIFS) have been
operational in the study area.
During the study the perception of respondents about the nutrional needs of male and
female children were also ascertained. The abstract of the primary data is given
below:
Table No.6.3: Perception of respondents about nutritional requirements of children
Perception of respondents about
Nutrition requirement
Frequency of responses Percentage to Total
Boys need comperatively more
nutritious food
39 13.9%
Girls need comperatively more
nutritious food
11 3.9%
Both Boys and girls need
equally nutritious food
230 82.2%
Total 280 100%
148
The primary data thus showed that majority of respondents (82.2%) did not
discriminate about the nutritional requirement of male and female child. This is
indicative of healthy social norm among the respondents. However few respondents
showed mild discrimination that in their perception things like full cream milk and
eggs etc. were more suited to boys than girls and were necessary for their proper
growth.
6.07 Education and dropout rates:
Education is a basic human right of all. It is not only a way of imparting
knowledge but also an instrument of empowering disadvantaged groups and sections
in a society. Education is a first step to begin this process. Girls continue to occupy an
unequal standing compared to boys in terms of achievements in education.A key
strategy for gender equity lies in women‘s empowerment which is achievable through
gender mainstreaming by the process of assessing the implications for women and
men of any planned action in all areas and at all levels9. One positive development in
the field of education and literacy in the past two-three decades has been the definite
change in the attitude of the hill society of Uttarakhand as a whole, whereby each
family is now sending all their children to schools at least at primary level. During
the field study in all the sample villages it was found that almost all children above
6years of age have been enrolled in nearby schools, though in most cases wherever
affordability permitted biase to send the male children to nearby private English
medium schools was evident. According to AHS 2011-12 data on Schooling status of
Children currently attending school aged 6-17Years in Almora District showed that
98.3% boys while 97.1% girls were attending school during the survey period. The
percentile for girls attending school was 97 and 99.5% in rural and urban areas
respectively.This percentile for boys was 98.4 and 97.5% in rural and urban areas
respectively. Thus there is net difference of 1.4% in the percentile of school going
girls between rural and urban areas.
One important social issue related to education of children is that of dropouts at
different level of schooling. "Several recent studies (World Bank 1996,
VimalaRamachandran 2003 and 2004) show thatchildren are more likely to drop out
and their aspirations about life are likely to remain low due to the uncertainty they
face about their ability to continue with schooling. Often dropouts are engaged in
149
some work, within the household or outside, and this work is rarely conducive to
schooling. While incentives such as free textbooks, bags and uniforms make a big
difference, recentevidence has shown that provision of a hot mid-day meal exerts a
positive influence . It is not that poor parents do not want to educatetheir children; just
that below certain threshold income levels they find it difficult to do so.‖10
According
to AHS 2011-12 the over all dropout rate among children aged (6-17Years) in Almora
District was 2.1%. Dropout rate was 1.5 and 2.7% among boys and girls
respectively.The dropout rate thus is 1.2% higher for school going girls as compared
to that for boys. The dropout rate among boys was1.5 and 2.2% in rural and urban
areas respectively .The percentile of dropout was 2.9 and 0.5% among rural and
urban school going girl child respectively. This Statistics reveals that dropout rates for
school going girl child in general and rural girls in particular are higher.Comparison
of AHS 2010-11 and 2011-12 showed some reduction in dropout rates among school
going children. This rate had reduced to 2.9 from 3.3% among school going rural
girls during this period. To reduce the drop out rates in schools among children more
focused efforts are needed to improve this situation by suitable location specific
interventions.
6.08 Mean age at marriage
An early age at marriage of women is an indicator of the low status of women
in society; at the individual level too. Too early an age at marriage can hinder healthy
and responsible family life and parenthood,however. It is recommended that marriage
and family formation be initiated after the legal age at marriage, and, preferably, after
completion of education and the attainment of economic independence. For women in
particular, an early age at marriage not only hinders the completion of education and
the acquisition of marketable professional skills, but also pushes women into
motherhood at ages when their bodies are not mature enough to safely bearchildren.
Although, in India the legal minimum age at marriage for girls and boys is 18 years
and 21 years, respectively, a sizeable proportion of women and men marry at much
younger ages11 .
As per AHS 2011-12 over all mean age at marriage in District
Almora was 27.1 Years for males and 21.8 years for girls. This was 26.8 and 21.6
years for rural males and females respectively. This shows that mean age at marriage
for rural girls was 5.2 years less than that for boys which is again indicative of gender
150
bias. Median age of marriage is 18 years in Uttarakhand, thus delaying the first birth,
particularly in cases of early marriage is highly desirable for the health of the mother
and child. Age at marriage for women should be increased through awareness creation
about the repercussions of early marriage on social ,psychological and physical
health of women and the new born child.
6.09 Marriage before legal age for Boys and Girls
As per AHS 2011-12 overall 1.2%girls in Almora district were married before
legal age of 18 years. 1.2% rural girls and 0% of urban girls were married before
legal age of 18 years.
Thus the odds of being married at early age are much higher for rural girls
compared to those in urban areas. The survey showed that 1.3% males in Almora
were married before legal age of 21years.This rate was 1.3 and 0.8% for rural and
urban males respectively. This data indicates that compared to the boys lesser
number of girls were married before legal age .
6.10Different govt.schemes for Girl child:
1.Adolescent Reproductive Andsexual Health (ARSH)
There are 225 million adolescents comprising 22% of India‘s total
population(census 2001).Females comprise almost 47% and males 53% of the
adolescent population. More than half of the currently married illiterates female are
married below legal age of marriage. Nearly 20% of the 1.5% million girls marries
under age of 15 are already mothers(Census 2001)Mortality in female adolescents of
15-19 years is higher than adolescents of 10-14 years. More than 70%girls in the age
group of 10-19 years suffer from severe or moderate anemia(DLHS-RCH 2004). Age
specific fertility rate in the age group of 15-19 years contribute to 19% of total
fertility. Amongst currently married women the unmet need for contraception is
highest in age group of 15-19 years. Nearly 27% of married female adolescents have
reported unmet need for contraception(NFHS-2). The prevalence of discrimination,
lower nutritional status, early marriage, complications during pregnancy and child
birth among adolescents contribute to female mortality (CSO2002,SRS
1999).Adolescent mothers are at higher risk of miscarriages, maternal mortality and
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give births to still babies and underweight babies. Given the above scenario,the GoI
has recognized the importance of influencing the health seeking behavior of
adolescents. The health situation of this age group will be central in determining
Indias health,mortality, morbidity and population growth scenario. Investment in
adolescent reproductive and sexual health will yield dividends in terms of delaying
age at marriage, reducing incidence of pregnancy, meeting unmet contraceptive
needs, reducing the number of maternal deaths, reducing the incidences of sexually
transmitted infections and reducing the proportion of HIV positive cases in 10-19
years age group. This will help India in realizing its demographic bonus, as healthy
adolescents are important resource for the country. ARSH is thus considered a top
development priority with far-reaching benefits across India‘s health sector.12
2. The UDAAN Model
UDAAN (Understanding, Delivering and Addressing Adolescent Needs) is
the brand name given to ARSH program in the state of Uttarakhand.UDAAN was
launched in February2009 by the Uttarakhand Health andFamily Welfare Society
(UKHFWS)and the Department of Health andFamily Welfare, Govt. of
Uttarakhand.According to UKHFWS, the main objectives of the programare to make
health care servicesmore accessible and acceptable toadolescents, to build the
capacity ofhealth care providers, to improveservice performance for the deliveryof
adolescent-friendly services,and to establish convergence ofvarious stakeholders in
providing acomprehensive package of services foradolescents based on their
needs.The project covered adolescentsaged 10 to 19 years. Tele-counseling centrewith
free helpline number 18001801200provides services from 8 AM to 8 PM. Average
call rate is 50-60 calls per day with maximum calls being received in the evening after
school hours and on school holidays.The comprehensive package of services has been
designed to respond to the diverse needs of different adolescents and includes
promotive, preventive and curative services. The package also include services which
may be beyond the purview of health per se, but are indirect determinants of the
physical, social and mental well-being of adolescents13
.Such services are enumerated
below:
Promotive Services: counseling for unmet need of contraception, information
on RTI/STI, menstruation and other sexual concerns.
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Preventive Services: nutritional counseling, supplement for nutritional anemia,
T.T. Immunization and focused antenatal care.
Curative Services: treatment for RTI/STI, Anemia, acne, cornice infection
etc.Miscellaneous Services like life skills education, career counseling and co-
curricular activities.
3. Adolescent Friendly Clinic and Counseling Centers(AFCCs)
The AFCCs are intended to provide a package of clinical and counseling
services dedicated to adolescents at existing health facilities, primary health centers
(PHCs) and community health centers (CHCs) at the block level. These services are
intended to be accessible, acceptable, appropriate and affordable to the local
community, as well as equitable, inclusive and non-discriminatory among the
beneficiaries. The AFCC provide both clinical services as well as counseling services,
and functions as a referral point. Presently in district Almora two AFCCs are
functioning in rural areas at PHC Tarikhet and Dhauladevi .OneAFCC has also been
set up in District Female hospital Almora.The clinics are organized on the bi-weekly
basis at the different timings than the regular OPD hours of the DH, the most
preferred and suitable timings for the AFCC is every Tuesday and Friday between
3:00 pm till 5:00 pm i.e. after the general working hours of the hospitals. The AFCC
provide both clinical services as well as counseling services, and function as a referral
point for the sub block services14
. The ARSH programme currently operational only
in two blocks namely Tarikhet and Dhauladevi should be extended to all the 11 blocks
of district Almora to create awareness among adolescents through peer group
educators.
4. School Health Programme
School Health program is a program launched in 2010 for school health
service under National Rural Health Mission, which has been necessitated and
launched in fulfilling the vision of NRHM to provide effective health care to
population throughout the country It also focuses on effective integration of health
concerns through decentralized management at district with determinant of health like
sanitation, hygiene, nutrition, safe drinking water, gender and social concern
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The School Health Programme was launched to address the health needs of
school going children and adolescents in the 6-18 year age groups in the Government
and Government aided schools. The programme entails biannual health screening and
early management of disease, disability and common deficiency and linkages with
secondary and tertiary health facilities as required. The School health programme is
the only public sector programme specifically focused on school age children. Its
main focus is to address the health needs of children, both physical and mental, and in
addition, it provides for nutrition interventions, yoga facilities and counseling. It
responds to an increased need, increases the efficacy of other investments in child
development, ensures good current and future health, better educational outcomes and
improves social equity and all the services are provided for in a cost effective
manner15
. Fifteen school health teams were in position during 2013-14 and were
deployed in 11 development blocks of the District Almora .Each school health team
consists of a Medical Officer,Lady Medical Officer(LMO), and Pharmacist
.According to report of CMO Almora for 2012-13 School health Teams covered
1484 schools against the target of 3694 for the district. During the period 76252
children were examined and 825 children were referred for treatment by School
Health Teams.
5. Mid Day Meal Scheme (MDMS)
MDMS focuses to improve nutritional deficiency in children and helping
the underweight and anemic.The MDM is expected to fill in the gap of rationing of
nutritious food among girls and boys. As part of this scheme, cooked meals with a
minimum content of 450 calories and 12 grams of protein are being provided to
children in school. there is evidence that the midday meal has indeed enhanced
enrolment in the schools as well as provided nutrition supplement to school going
children. Moreover in the deprived areas the MDM has been able to provide at least
one meal in the school to deprived children. To combat anemia in school going
children more awareness should be created in the villages through ASHA and other
health workers about MDMS and WIFS.
154
6. Menstrual hygiene
Menstrual hygiene is one of the important indicator of sanitation which affects
the health and hygein of the females in reproductive age. ―The Ministry of Health and
Family Welfare has introduced a scheme on pilot basis in selected districts for
promotion of menstrual hygiene among adolescent girls in the age group of 10-19
year in rural areas. Under the scheme 5 districts namely Haridwar, Tehri, Pauri,
Uttarkashi and Rudraprayag have been covered in Uttarakhand. Under the scheme
sanitary napkin packs (containing 6 pieces each) is branded as ‗Freedays‘ are
provided to the adolescent girls through central procurement with quality assurance
guidelines is through local Self Help Groups‖16
District Almora has not yet been
covered under this scheme of the govt. The use of sanitary napkin among the women
and girls has increased in the past few years across the country. During the present
study the perception of respondents about the use and utility of sanitary napkins by
their daughters was also ascertained. It was found that only 38.6% respondents were
providing sanitary napkins to their daughters and 61.4% respondents did not provide
sanitary napkins to their daughters. The main reason for not providing the napkins
was the non availability at local level, high cost of napkin and low awareness about its
utility.There is need to create awareness among the people about the utility of sanitary
napkins for health and hygein. The govt. scheme to provide sanitary napkins to the
adolescent girls should be universalized .
7. RashtriyaBalSwasthyaKaryakram (RSBK)
―The NRHM has launched a new initiative of Rashtriya Bal Swasthya
Karyakram in 2013, a Child Health Screening and Early Intervention
ServicesProgramme to provide comprehensive care to all the children in the
community. The programme aims to cover all children of 0-6 years of age group in
rural areas and urban slums, in addition to older children up to 18 years of age
enrolled in classes 1st to 12th in Government and Government aided schools.The
objective of this initiative is to improve the overall quality of life of childrenthrough
early detection of birth Defects, Diseases, Deficiencies, DevelopmentDelays and
Disability. The high burden of these childhood ill health contributessignificantly to
child mortality, morbidity and out of pocket expenditure of the poor families‖17
155
For operationalization of RBSK in District Almora, Early Intervention
Centres has been set up at Base Hospital Almora and is manned by a team of
doctors trained on Action on Birth defects(ABD),as first referral point for further
investigation, treatmentand management of early defects in children.Khushiyo Ki
Sawari(104 service) has been roped in since August 2013 for bringing children free of
cost for treatment from blocks after referral by School Health Teams to District
Early Intervention Centres and from District Early Intervention Centres to tertiary
care centre.The tertiary care centres in the state are Jolly Grant hospital
Dehradun,Max Hospital Dehradun,Fortis Hospital Dehradun andLatika foundation at
Dehradun.
During the field visits it was found that there was no awareness among
respondents about RBSK . This was due to the fact that scheme is relatively new.It is
hoped that in times to come people will benefit from this scheme after they become
aware about this with proper publicity by the health department.
8. Weekly Iron and Folic Acid Supplementation (WIFS)Programme
Anaemia, a manifestation of under-nutrition and poor dietary intake of iron is a
serious public health problem, not only among pregnant women, infants and young
children but also among adolescents. Over 55 percent of both adolescent boys and
girls in India are anaemic. Thus it is critical to address this problem which has health
implications for approximately 15 percent of Indian population and is directly linked
to new born, child and maternal morbidity and mortality. The Ministry of Health and
Family Welfare, based on empirical evidence which demonstrates that regular
consumption of Iron and Folic Acid is effective in reducing prevalence and incidence
of anaemia, has launched the Weekly Iron and Folic Acid Supplementation (WIFS)
Programme to meet the challenge of high prevalence and incidence of anaemia
amongst adolescent girls and boys. In India, prevalence of anaemia among 15-19
years is reported to be as high as 55.8 percent in girls and 30.2 percent in boys.
Adolescence is a period of transition from childhood to adulthood. It is characterised
by rapid physical, biological and hormonal changes resulting in psycho-social,
behavioural and sexual maturity in an individual. It is the second growth spurt of life
and both boys and girls undergo different experiences in this phase. During this period
156
in life there is a significant increase in nutritional requirements, especially for iron.
Anaemia, a manifestation of under-nutrition and poor dietary intake of iron is a public
health problem, not only among pregnant women, infants and young children but also
among adolescents. Anaemia in India primarily occurs due to iron deficiency and is
the most widespread nutritional deficiency disorders in the country today. The
prevalence of anaemia in girls (Hb<12 g%) and in boys (Hb< 13g%) is high as per the
reports of NFHS-3 and the National Nutrition Monitoring Bureau Survey. According
to NFHS 3 data, over 55 percent of both adolescent boys and girls are anaemic.
Adolescent girls in particular are more vulnerable to anaemia due to rapid growth of
the body and loss of blood during menstruation. According to NFHS-3 almost 56% of
adolescent girls aged 15-19 years suffer from some form of anaemia. More than 39%
adolescent girls (15-19 years) are mildly anaemic while 15% and 2% suffer from
moderate and severe anaemia respectively while during NFHS-2 the prevalence was
41%, 18% and 2% for mild, moderate and severe anaemia among 15-19 year olds
indicating that there has not been much of change in the trends. In India, the highest
prevalence of anaemia is reported between the ages 12-13 years, which also coincides
with the average age of menarche.
The major implications of Iron deficiency anaemia adversely affects transport of
oxygen to tissues and results in diminished work capacity and physical performance.
During adolescence, iron deficiency anaemia can result in impaired physical growth,
poor cognitive development, reduced physical fitness and work performance and
lower concentration on daily tasks. Iron deficiency in adolescent girls influences the
entire life cycle. Anaemic girls have lower pre-pregnancy stores of iron and
pregnancy is too short a period to build iron stores to meet the requirements of the
growing fetus. Anaemic adolescent girls have a higher risk of preterm delivery and
having babies with low birth weight. Regular consumption of iron-folic acid
supplements along with a diet rich in micronutrients is essential for prevention of iron
deficiency anaemia in adolescent girls and boys. WIFS is evidence based
programmatic response to the prevailing anaemia situation amongst adolescent girls
and boys through supervised weekly ingestion of IFA supplementation and biannual
helminth control. The long term goal is to break the inter-generational cycle of
anaemia; the short term benefits is of a nutritionally improved human capital18
.
WIFS programme has started in all the 13 Districts of Uttarakhand for all Adolescent
girls and boys going to government and Govt. aided schools through nodal teachers of
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all schools from class 6th to class 12th . Along with this all non- school adolescent
girls would also be covered under WIFS. During the study it was found that the
respondents did not know that their children were getting iron folic acid tablets under
WIFS but secondary data revealed that the school going children of respondents were
also benefited by this programme. The details of school going adolescents in
Uttarakhand and district Almora is given below.
Table No. 6.4 The Target Adolescent Boys and Girls
State/District School going
adolescent
boys
School going
adolescent
girls
Non School
going
adolescent
girls
Total
adolescents
covered under
WIFS
Uttarakhand 844159 1077878 315771 2237808
Almora 58754 74319 21969 155042
(source: UKHFWS‘s Report )
Based on the findings of the study following relevant and important
suggestions are proposed to empower the girl child :
Sensitization of both men and women is important to develop positive attitude
towards the girl child and to stop discrimination between son and daughter,
particularly in view of falling sex ratio in 0-4 years age group. Change in attitude,
to some extent, can be brought about by highlighting the govt. welfare schemes
for girl child.
Effective implementation of PNDT ACT with attitudinal changes in the society
has the potential to stabilize the population growth with gender balance. This
will result in better sex ratio at birth.
The problem of the declining child sex ratio is a recent phenomena in the study
area. It was observed during study that the girl child is discriminated at
conception stage as there was preference and desire for the son but after the girl
child was born not much discrimination was observed against the girl child as far
as her upbringing is concerned
158
A woman‗s level of education and regular media exposure increase the likelihood
of using contraception before the first birth. Imparting Knowledge and creating
awareness about family planning among school going adolescents should be
done through decentralized camps in rural areas from time to time.
Education level of women needs further impetus to empower them to move
towards gender equity. This should include vocational trainings so that their
income level also gets improved to feel empowered.
To combat anemia in school going children more awareness should be created in
the villages through ASHA and other health workers about Weekly Iron and Folic
Acid Supplementation Programme(WIFS) and Mid Day Meal scheme.
An important need is to provide effective child care support that releases girls
from the burden of sibling care, to participate effectively in elementary education.
This high lights the need for a focus on quality education and enable the
education system to be more responsive to the needs of girl children (e.g.,
separate toilets, child care support etc).
It is critical to prevent undernutrition, as early as possible, across the life cycle, to
avert irreversible cumulative growth and development deficits that compromise
maternal and child health and survival, achievement of optimal learning
outcomes in primary education and gender equality.
There is need to create awareness among the people about the menstrual hygiene
and the utility of sanitary napkins for health and hygein. The govt. scheme, to
provide sanitary napkins to the adolescent girls, presently operational in only
selected districts of the state should be universalized in Uttarakhand.
* * * * *
159
References :
1. XII five year plan, Government of India, Planning Commission
2. Devendra Kiran, in ―Empowering the Indian women”- compiled and edited by
Dr. Promilla Kapur, New Delhi. Publication Division, 2001,p33
3. Ibid.p34
4. BassiTripti, ―Women’s Development Initiatives in Education‖, IGNOU,New
Delhi.
5. ―Power, Voice and Rights‖, Asia Pacific Human Development Report,
UNDP,2010.
6. XII five year plan,Government of India, Planning Commission .
7. National Family Health Survey (NFHS-3), India, 2005-06: Uttarakhand, May
2008,p 7
8. Ibid.p18
9. BassiTripti , op.cit
10. ―Ensuring Universal Access To Health and Education In India‖, New Delhi,
Published By,Wada Na Todo Abhiyan, November 2007,p22.
11. ―A Profile Of Youth In India” ,National Family Health Survey (NFHS-
3),India(2005-06), August 2009,p3
12. Implementation Guideline on ,Reproductive Child Health(RCH)- 2 Adolescent
Reproductive and Sexual Health(ARSH) Strategy,National Health Mission,
Ministry of Health and Family Welfare, Government of
India(www.nrhm.gov.in)
13. ―UDAAN (ARSH)Model,Uttarakhand Health and Family Welfare Society,
Government of Uttarakhand, Department of medical health and family
welfare(www.ukhfws.org)
14. District Health Action Plan(DHAP), District Almora, 2013-14,
15. Guidelines of the School Health Programme , Ministry of Health and Family
Welfare, Government of India(www.nrhm.gov.in)
16. Menstrual hygiene, Uttarakhand Health and Family Welfare Society,
Government of Uttarakhand, Department of medical health and family
welfare(www.ukhfws.org)
160
17. Operational Guidelines,Rashtriya Bal Swasthya Karyakram (RBSK) Child
Health Screening and Early Intervention Services under NRHM, Ministry of
Health and Family Welfare, Government of India(www.nrhm.gov.in)
18. Operational Framework of Weekly Iron And Folic Acid
Supplementation(WIFS) Programme For Adolescents, RCH-DC,
Division,Ministry of Health and Family Welfare Government of
India,(www.nrhm.gov.in)
161
Chapter 7
Conclusions and Suggestions
Discrimination against women on the basis of their gender has been prevalent
globally since the very advent of social systems and the history is replete with such
examples where women have been discriminated against through the conventions,
societal dictats, cultural marginalisation, economic dependence and the like. Global
literature also reflects this fact in its various manifestations.Though biological sex
differences are very few and would not lead to gender inequality, more often than not,
gender inequalities are socially determined and can be changed with change in
attitudes and social practices Gender discrimination affects both male and female
adversely, but women are the worse victim. Last few decades have seen a greater
awareness in this regard and issues like gender sensitization, gender equality, gender
budgeting, gender justice etc have figured as central theme at national and
international level. The principle of gender equality is enshrined in the Indian
Constitution in its Preamble, Fundamental Rights, Fundamental Duties and Directive
Principles. The Constitution not only grants equality to women, but also empowers
the State to adopt measures of positive discrimination in favour of women. Within the
framework of a democratic polity, our laws, development policies, Plans and
programmes have aimed at women‘s advancement in different spheres. Starting from
the Fifth Five Year Plan (1974-78) there has been a continuous marked shift in the
approach to women‘s issues from welfare to development to empowerment. In recent
years, the empowerment of women has been recognized as the central issue in
determining the status of women.Goals for the XII Five Year Plan include Creating
greater ‗freedom‘ and ‗choice‘ for women by generating awareness and creating
institutional mechanisms to help women question prevalent ―patriarchal‖ beliefs that
are detrimental to their empowerment and Improving health and education indicators
for women like maternal mortality, infant mortality, nutrition levels, enrolment and
retention in primary, secondary and higher education.
162
The health of Indian women is intrinsically linked to their status in society
,especially for those living in a rural area. Research into women‘s status in society has
found that the contributions Indian women make to families are often overlooked.
Instead they are often regarded as economic burdens and this view is common in rural
areas of the northern belt. There is a strong preference for sons in India because they
are expected to care for ageing parents. Indian women havelow levels of both
education and formal labor-force participation.
Sex ratio is one indicator of status of women in the society. As per the census
report 2011 the female population stands at 586.5 million out of total 1210.2
million Indian population. For Uttarakhand over all sex ratio has improved by only
one point to become 963 in 2011 as compared to 962 in 2001. Sex ratio for district
Almora as per 2011 census was 1139.District Almora and Pauri have registered
negative growth in population in the decade 2001-2011. Over all sex ratio has
marginally improved in the state but Child Sex ratio (0-6 years) has declined in hill
districts also. Champawat, Almora, Bageshwar, Pauri and Pithoragarh are such hill
districts where child sex ratio has declined as compared to 2001.Rural women of
Uttarakhand are back bone of state as they look after young and old. Also most of the
agricultural, horticultural and house hold works are carried out by the women in the
hills. Fetching drinking water and fuel wood from the forest and nearby areas are also
primarily done by the women .Thus they do multiple task. Hence their health becomes
core issue. According to Census2011,the percentage of rural population in Almora is
89.98% and only10.02% comprises the urban population.
The National Rural Health Mission (NRHM), initially mooted for 7 years
(2005-2012) has a special focus on 18 states including Uttarakhand where health
indicators were poor.Not much work has been done on the field based study of impact
of mother and child health related components of NRHM in district Almora,
particularly assessing their impact on the rural women with respect to their
educational status,the remoteness of the location of their villages,and density of
health facilities available in the development blocks. All these aspects have been
studied by the research scholar with intensive field work and interaction with the
respondents. Therefore the present study is unique, relevant and purposeful.The
findings of the study may help in formulating need based health programmes for rural
women and provide inputs for suitable changes in the sector policy to enhance and
improve the implementation strategy for the sector. It is well known that there is
163
intrinsic relation between women‘s health and their empowerment. The present
research study has attempted to examine the impact of health as a girl child, as a
mother and as a wife and also evaluate the role of health programmes in empowering
the rural women.
The study has been undertaken in district Almora, located in Kumaon division
of Uttarakhand. Census 2011 indicates that the sex ratio in the district is much above
the national average but the declining child sex ratio in 0-6 years age group is an area
of concern. The overall literacy level of Almora stood at 81.06 percent, which is
higher than the state literacy rate of 79.63 percent.
For the purpose of present study exploratory cum descriptive research design
has been used to achieve the objectives of the study. The study aims to develop an
understanding of the subject and the manner in which the selected parameters and
health schemes affect the women‘s empowerment in the rural areas of district. Based
on the density of health facilities in the 11 blocks of the district, they were grouped in
three strata.Stratified random sampling was resorted to for the random selection of
one block from each strata. The outcome of this sampling was the selection of
Hawalbagh, Tarikhet and Sult development blocks. Keeping in view the resource
constraints in terms of time and money two Gram Panchayats from each block were
selected using simple random sampling. During the field visit for collection of
primary data , the selected Gram Panchayats were visited. From within the selected
Gram Panchayats all the married women of reproductive age group 18-49 years were
interviewed.
Both primary and secondary data was be collected and used for the research
study. Interview Schedule, Meetings, Non-participant observation, Participatory Rural
appraisal (PRA) techniques were used for collection of primary data. Secondary data
was mainly collected from different organisatios which include Govt. Departments
like Panchayati Raj ,Social welfare,Economicsand statistics,Medical and Health
(CMO Almora and other offices),Block Development Officer Hawalbagh, Salt and
Tarikhet . Booklets published by department of Economics and statistics and Census
handbooks of district Almora and Uttarakhand were also referred to. Central library of
Kumaon University Nainital was also accessed from time to time.
The data collected through different tools mentioned above was scrutinized,
compiled and tabulated in the suitable formats. The data was processed and analysed
using excel and other appropriate software. Use of visual presentation aids like pie
164
charts, graphs and histograms etc. have also be done for improving the presentation of
the research findings in the study report.
Based on the analysis of primary and secondary data in the preceding chapters
the conclusions and suggestions are mentioned below:
Findings:
Ante-Natal Check-up(ANC)
Ante-natal care constitutes one of the key elements towards initiatives to
promote safe motherhood. According to AHS Data 2011-12 for district Almora, % of
women who received 3 or more ANC Check ups was 49% . There was wide gap
between the rural and urban population availing this facility which was 47% and
86.8% respectively. The analysis of the primary data collected during the present
study revealed that only 23.6% respondents had undertaken three ANC. The
percentage of respondents who received only two ANCs was 46.8%. The education
and awareness level of the respondents was found to have significant impact on the
access to the facility of Ante-Natal Check-up(ANC)by the respondents. All the
respondents with educational qualification with intermediate or higher received ANC.
Even for those with high-school education the facility of ANC was availed by 96%
women. The Percentage of rural women who did not take any ANC was highest for
illiterate at 61% .The study clearly establishes that the access to ANC facility
drastically improve with the improvement of education level of rural women. This
provides hope for better access to this facility by the rural women in future as
education level among the females is gradually improving over the years.
This health facility of Ante-Natal Check-up(ANC ) was availed thrice during
pregnancy only by 18.8% respondents in block Sult, followed by 22.2% in Tarikhet
Block and 33.3% in Hawalbagh development block. Hawalbagh andSult blocks are
respectively the nearest and farthest sample blocks from district head quarter
Almora.The inter- block situation in this regard has gradually improved with the
nearness of the places from district headquarter Almora. The access to the facility of
ANC by the respondents has thus been found to be adversely affected by the
remoteness of their villages from the district headquarter and the density of govt.
health facility in the block.
165
Institution Delivery (ID)
Institution Delivery (ID) is very important to avoid maternal and neo-netal
mortality.The analysis of primary data revealed from that the overall rate of
institutional delivery was 42.1% among the respondents. Across the caste it was
found that 46.8% of scheduled caste and 39.1% general caste respondents availed
the facility of institutional delivery in the sample villages. Adding delivery at
home conducted by ANM/Dai to the institutional deliveries 78.2% deliveries can be
termed as safe delivery rate among the respondents in the sample villages. The rate of
safe delivery was thus found to be 80.1% and 77% respectively for SC and general
caste respondents respectivelyAccording to AHS report 2011-12 the over all rate of
institutional delivery for district Almora was 45.1%. The rate of ID for rural and
urban areas of the district was 43% and 83.4% respectively indicating huge gap
between the two. If the deliveries at home conducted by skilled health personnels are
also taken into account then the overall percentage of safe delivery for the district was
63.4%. This figure was 61.7% and 94.3% for rural and urban areas respectively. This
indicates huge gap between institutional delivery percentage in rural and urban areas.
The study ,on the basis of primary data, revealed that the rate of institutional
delivery was found to be a positively correlated with the level of educational
qualification of the respondents and showed that the rate of institutional delivery was
least (12.9%) for illiterates and highest for post graduates (87.5%). It has been found
that the percentage of safe delivery is improving with the improvement in educational
qualification of respondents.
The Inference of Chi-square test performed on the primary data for 280
respondents showed the following two important conclusions:
a) the institutional delivery was found to be highly dependent on educational
qualification of the respondents. The null hypothesis that institutional delivery
is independent of educational level was rejected both at 0.01 and 0.05 level of
significance.
b) the institutional delivery was found to be independent of caste of the
respondents. The null hypothesis that institutional delivery is independent of
caste was accepted both at 0.01 and 0.05 level of significance
The study revealed that the rate of institutional delivery varied between
34.1% to 46.5% among the three sample development blocks. These figures were
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44.8%, 46.5% and 34.1% respectively for Hawalbagh, Tarikhet and Sult blocks of the
district for the sample villages. The rate of total safe deliveries was found to be
directly affected by the remoteness of the block from districthead quarter and the
density of health facility within the block. The rate of safe delivery was 92.and%,
83.8% and 55.3% respectively for Hawalbagh, Tarikhet and Sult blocks. The
proportion of safe delivery among the respondents has thus been found to be
adversely affected by the remoteness of their villages from the district headquarter
and the density of govt. health facility in the block.
On the issue of post natal check ups of mother and child in the sample
villages, overall it was found that only 47.86% respondents got post-natal checkups
done This shows low level of awareness, in general, among the respondents about the
importance of post natal checkups.
JananiSurakshaYojana (JSY)
The study revealed that only 29.6% respondentshad awareness about
JananiSurakshaYojana (JSY)in the sample villages indicating very low level of
awareness about the scheme.There was no significant difference in this regard across
the caste profile of the respondents.
The impact of education level of respondent on availing the facilities under
JSY indicated that the education level of respondent had direct bearing on the access
to benefits under the scheme as the proportion of benefitted respondents increased
with the increase in their education level.
Other than low level of awareness, one of the reasons for low level of benefits
availed by respondents under the scheme could be that deliveries of many respondent
women were conducted before the beginning of JSY, which was launched in 2005.
Efforts to improve awareness among the people about JSY is expected to facilitate
higher access to the benefits of the scheme.
Village Health and Nutrition Day (VHND)
The regular and proper organization of the Village Health and Nutrition Day
(VHND) is the most crucial component of NRHM for guaranteeing service provision
at the village level. The study revealed that overall awareness level about VHND was
only 37.14% which is dismally low.The awareness level was found to be directly
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corelated to the educational qualification of the respondents and was inversely
proportional to the remoteness of the sample village from district head quarters and
density of health facilities in them.
The awareness level for VHND was found to be 4.14% higher among SC
than general caste respondents.
Reproductive and Child Health (RCH) programme
RCH Programme is one of the important intervention under NRHM, which
was launched in 2005 by GoI. Major Elements of RCH Programme includes
Interventions to Promote Safe Motherhood. It was found, during the present study
that the overall level of awareness about RCH camps among the respondents was
dismally low at 11.4%.
The study found no definite pattern of correlation between awareness about
RCH and education upto highschool level in general but the awareness level was
comparatively higher among the respondents who had educational qualification as
intermediate or higher. The awareness level among women with different educational
level ranged between 3.8% and 37.5%. It was lowest among women with primary
education and highest among women who were post graduates.
Breast-feeding
Breast-feeding of child immediately after birth with colostrum(mothers highly
nutritious first milk) is important as it contains antibodies that provide immunity to
the child .The analysis of primary data collected during the present study for sample
villages revealed that overall 75.4% children were breastfed within an hour of their
birth. These figures were at 74.0%, 63.7% and 90.5% for Hawalbagh, Tarikhet and
Sult blocks respectively, indicating towards very healthy trend for this parameter in
the interior areas like Sult.
It was found during the study that across caste 77.5% general caste children
were breastfed within an hour of birth whereas this figure was 72.1% for Scheduled
caste.
The significant finding of the study was that overall by second day of birth
89.3% and by third day 98.6% children were breast fed.
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It can thus be concluded that the awareness level about breast feeding the
children in the study area was very high irrespective of caste, education and location
of the sample villages. Good old social traditions in this respect also appear to have
played significantly vital role to pass on this healthy habit from generation to
generation and is still continuing well.
According to AHS report 2011-12, the overall ratio of children breastfed
within one hour of birth in Uttarakhand was 63.7% which was higher in rural areas at
66.6% compared to urban areas at only 55.6% . The ratio of children breastfed within
an hour of birth for district Almora was 80.9%, 81.4% and 70.6% for the district, rural
and urban areas respectively.
Immunization
Immunization of a women during pregnancy is important as it immunes her
against deadly infection like Tetanus Toxoids Immunization of child is vitally
important to reduce neo natal mortality rate. Universal Immunization Programme
(UIP) vaccines for six vaccine-preventable diseases (tuberculosis, diphtheria, pertussis
(whooping cough), tetanus, poliomyelitis, and measles) are available for free of cost
to all.
The study based on primary data showed that overall 87.9% respondents
gotimmunised themselves and their children at appropriate time. This rate was 91%
and 85.8% for SC and general caste women respectively.
The rate of immunisation was 96.9% and 94.9% for Hawalbagh and Tarikhet
blocks respectively. However this rate was abysmally low at 69.4% for Sult block,
which is the remotest of three sample blocks.
Rate of immunization coverage among the respondents was found to be
directly correlated with education level of the mother. Immunization coverage was
64.5% for illiterates and more than 90% for educated women. This underlines the
huge awareness gap which requires to be filled up speedily for ensuring primary
health care.
Across the sample villages it was found that ,out of the immunised
respondents,more than 90% women had accessed the facility of immunisation at the
nearest subcentre (SC)/PHC .
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AHS report 2011-12 indicates that the rate of children aged 12-23 months who
were fully immunised was 77.9% and 83.1% for Uttarakhand and district Almora
respectively. This rate of full immunisation was in general found to be higher for
urban population compared to the rural and the gap between the two was 6.5% for
district Almora. Overall rate of women in rural areas who received at least one TT
injection was 87.5% as against the desired rate of 100%.
JananiShishuSurakshaKaryakram (JSSK)
JSSK is a flagship programme of government that was launched in June
2011,for health care of mother and child. Under JSSK various entitlements like Free
drugs and consumables, free essential diagnostics (blood, urine tests and ultra
Sonography etc.),Free diet during stay in the govt. hospital (up to 3 days for normal
delivery and 7 days for caesarian section, Free provision of blood, Free transport from
Home to Health Institutions, between facilities in case of referral and drop back from
institutions to home are provided for. Exemption from all kinds of user charges is
provided to pregnant women. JSSK has been launched in district Almora since 2011.
The study, on the basis of primary data, showed that overall awareness level
about the services under the scheme was found to be very low among the respondents
and varied between 8.21% to 12.14% for different services. Among the sample
blocks awareness level was lowest in Sult at 1.18% and was highest in Hawalbagh at
14.58%. The scheme having been relatively recently launched, it is expected to
improve in times to come with increase in awareness level by appropriate means.
Family planning
Family planning allows individuals and couples to anticipate and attain their
desired number of children and the spacing and timing of their births. It is achieved
through use of contraceptive methods. A woman‘s ability to space and limit her
pregnancies has a direct impact on her health and well-being as well as on the
outcome of each pregnancy.Women‘s control on pregnancy is an important indicator
of women empowerment.
During the study it was found that perception of respondents about family
planning varied among them and the major findings are as follows :
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i) According to majority(55%) of respondents Family Planning is limiting
number of children up to two .
ii) 14.64% respondents were of the opinion that family planning is keeping
age gap between children.
iii) Only 30.36% respondentsperceived family planning correctly as both
limiting number of children up to two and keeping age gap between
them.
iv) Across various education level of respondents it was found that proper
understanding of family planning as limiting family up to two children
and keeping age gap between them improved with improvement in
education level among the respondent women.
v) The knowledge about permanent methods of family planning likeMale
and Female Sterilization was known to majority of respondents though the
knowledge and awareness about temporary methods of family planning
was comparatively low.
vi) The study proved conclusively that the level of awareness about both the
permanent and temporary methods of family planning is directly correlated
with education level of respondents, further establishing the fact that
education of women is a very powerful and effective tool to control
fertility rate and family size.
vii) Female education has played a very important role in promotion, adoption
and use of contraceptives. Total fertility rate (TFR) in district Almora is
1.9 against the national target of 2. This shows positive social change and
could be due to higher level of education among women in Almora. The
literacy rate among women in AlmoraDistrict is76.7%. This demonstrates
positive correlation between education level and fertility rate.
viii) The study revealed that the contraception prevalence rate was
67.85%among the respondents.
ix) Among temporary methods of family planning condoms are most widely
used, whereas Female Sterilization is most widely adopted permanent
method of Family Planning.
x) Female Sterilization is most commonly used family planning method used
by 39.29% married women, followed by use of condoms(11.07%),Oral
pills(9.29%),Male Sterilization(6.07%) and Cu-T(1.79%).
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xi) The rate for Male Sterilization among respondent couples was higher
among Schedule Caste (9.91%) in comparison to General Caste
(3.55%).This shows that the males of Schedule Caste respondents shared
comparatively higher responsibility of Family planning. However female
sterilization is higher among General respondents (41.42%) than Schedule
Caste respondents (36.04).This indicates that husbands of General Caste
respondents perceived that contraception was primarily women‘s
responsibility.
xii) Prevalence of condom use was found to be more than thrice among general
caste couples as compared to SC couples. This rate was 15.38% and 4.5%
for general caste couples and SC couples respectively.
xiii) Over all 27.81% General Caste and 13.51% Schedule Caste couples use
different temporary methods of Family Planning such as oral pills,
Copper-T, Condoms.
xiv) Awareness level about Cu-T/IUD was maximum at 65.63% among
respondents in block Hawalbagh, followed by block Tarikhet at63.64%
and was least in Sult block at 24.71%. This shows inverse relationship
between awareness level of respondents about temporary family planning
methods with remoteness of area from district headquarter.
xv) Comparatively higher proportion of illiterate respondents had adopted
Female Sterilization (62.90%). With increase in educational level, The
rate of adopting temporary methods of family planning like Oral pills,
IUD/Cu-T or Condoms was found to be higher among educated
respondents as compared to those with no education.
xvi) Across age groups it was found that the permanent methods of family
planning, particularly female sterilization is more common among older
women and temporary methods among young women (18-28 yrs).
According to AHS report 2011-12,overall ratio of women with 2 children
wanting no more children in Uttarakhand is 80.2% which is higher in urban areas at
85.8% compared to 76.5% in rural area. The ratio of womenwith 2 children wanting
no more children for district Almora is 56.2%.This figure was 55.2%and 68% for
rural and urban areas respectively
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Perception about health
Health is defined not only by the absence of disease or illness, but by physical,
mental and social well being. The analysis of primary data on the perception of
respondents about health revealed that overall46.07% respondents perceived health
as not falling ill. Only 20% respondents perceived health as being physically,
mentally and socially healthy.
Majority of illiterate women (75.81%) consider health as not falling ill, while
only 6.45% illiterate consider health as being physically, mentally and socially
healthy.
There was considerable difference of perception about health as being
physically, mentally and socially healthy across the caste profile of respondents. The
data showed that 24.26% General Caste respondents perceived health as being
physically, mentally and socially healthy, whereas this percentage was 13.5% for
Schedule Caste respondents.
Even among educated respondents, no definite pattern was observed on the
understanding about health .The perception about health being physically mentally
and socially healthy varied between 10.39% to 55% among them.
About the frequency of health check-up it was found that 91.79% women get
their health examined only when they fall ill and only 6.07% women get their health
checked-up twice a year. No significant variation was found across the caste or
education level of respondents in this respect.
On treatment of ailments at the appropriate time the study revealed that overall
only 43.57% respondentsseeked treatment on being highly ill, whereas 31.43%
women seeked treatment in beginning of illness and about 25% did so in middle of
their sickness. This is indicative of lower level of awareness among respondents about
their health.
The study revealed that among the respondents with qualification level of high
school and above there was direct relationship between education level of women
and importance given by them to timely diagnosis and treatment of illness in time.
This shows that the critical level of education to trigger awareness in this regard was
found to be high school for the respondent rural women.
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The Inference of Chi-square test performed on the primary data from 280
respondents on as to what stage of illness the respondents got them checked up for
treatment showed the following two important conclusions:
a) The stage of illness at which the respondents got themselves checked up for
treatment was found to be highly dependent on the educational qualification of the
respondents. The null hypothesis that the stage of illness at which the respondents
got themselves checked up for treatment was independent of educational level was
rejected both at 0.01 and 0.05 level of significance.
b) The stage of illness at which the respondents got themselves checked up for
treatment was found to be independent of the caste of the respondents. The null
hypothesis that the stage of illness at which the respondents got themselves
checked up for treatment was independent of their caste was accepted 0.05 level
of significance.
Access to Health Care facilities
It was found during the study that 48.9% respondents usually sought health
care services from their nearest Sub-Centres(SCs), 19.6 % from Primary Health
Centre(PHC)and (3.6%) from Community Health Centre(CHC) and rest 27.9% from
private hospitals in the sample villages
In the absence of government health facility or lack of availability of doctors
and other medical professionals in the govt. hospitals in nearby area of the sample
villages private hospitals catered health services to more than 70% rural women in
sample villages of block Tarikhet. However services of private hospitals were
available only by 5.2% women in block Hawalbaghand 1.2% block Sult.This
indicates that SC/PHC/CHC in vicinity of the villages can provide primary health
services to the local people if professional personnel‘s are manning the facilities.
Sub-Centres were found to be most frequently visited by the respondents for
primary health care facilities. It was found that usually with increase in education
level the respondents seeking health care services from private hospitals also
increased
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Access of rural women to Health Care)
The study revealed that the nearest govt. Health facility was within 1 km
distance for 46.79% respondents, whereas 25.36% respondents had to cover more
than 3 km for accessing primary health facilities from nearest govt. health facility.
Other than the distance of health facility from the villages of respondents ,it was
found that one major issue was that of non availability of female health service
provider higher than Auxiliary Nurse Midwife (ANM) . Non-availability of qualified
health professional at govt. health facility in rural areas was a major problem
frequented by women to access health services from govt. health facilities. ANMs
help was obviously confined to provide help and advice on maternity issues alone.
The frequent transfer without replacement of the specialized doctors for
providing services like male sterilization,female sterilization,and Skilled birth
attended(SBA) training has hampered effective implementation of rural health
programmes under NRHM.Most of the times this situation is taking place because of
doctors opting out for higher studies (MD,MS) and child care leave(CCL) in case of
female doctors. Satisfaction level of respondents about the infrastructure and health
services was also assessed. Majority of the respondents (79.3%) were not satisfied
with the services provided by govt. health facilities. The main reason for this was the
lack of doctors and health workers in the centres.
Affordability of primary health services
On the issue of availability of primary health care facilities to the respondents,
it was found that proportion of respondents who viewed that these services were
available to them free of cost,at affordable cost, and at higher cost from their norms
was 22.5%,57.86% and 19.64% respectively.
Study across three blocks revealed that free of cost primary health services
were available to 22.92%, 5.05% and42.35% respondents inHawalbagh,
TarikhetandSult block respectively. This large variation within different blocks is
primarily due to the distance of Sub-Centre/Primary Health Center /Community
health Center from the sample villages as well as lack of doctors and medical
professionals in govt. health facilities
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These findings highlight the need for further improving the density of govt.
health facilities in the rural area to provide quality health services to larger population
including the rural women at affordable cost.
The Body Mass Index (BMI), is a measure for human body shape based on an
individual's mass and height. It was found during the study that over all 60.71%
respondents were with normal BMI and about a quarter of sample (25.71%
respondents) had less than normal weight and 13.57% respondents were found to be
over weight or obese.
Poor economic condition, lack of adequate purchasing power, gender
discrimination and ignorance were found to be the major reasons why many rural
women were not getting proper dietry intake in the sample villages. There is also
need to sensitize their husband and other family members about the repercussions of
being underweight.
During the study it was found that there was still a strong preference for sons
in the study area.About one in five women and one in seven men in Uttarakhand want
more sons than daughters. The desire for more children is strongly affected by
number of male children in the family.
Dominant Patriarchy system is primarily responsible for gender inequality but
with increase in education level among women and exposure to audio-visual means
have set-in social change and the society is now more aware about women‘s status
which is gradually improving, though the pace is low.
Comparison of AHS 2010-11 and AHS 2011-12 revealed that there is slight
improvement of 4 points in the sex ratio in 0-4 years age group for district Almora
which improved to 900 from earlier figure of 896 .AHS 2011-12 showed that the sex
ratio in 0-4 years is 903 in rural areas and 849 in urban areas of district. This is
indicative of slightly better situation in rural areas as compared to the urban areas.
One important finding of the study is that the family size of respondents was
determined by number of sons and the sequence of their birth in the family. Later the
birth of male child in the sequence of children‘s birth in family,larger is the family
size and more are the number of girls in the family. This indicates strong preference
for the male child in the study area.
The average number of children per couple was 2.6 among respondents.
Some major shortcomings in the effective implementation of thePNDT act
which were identified during the study include lack of regular meetings, non-
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submission of report in form-F by the diagnostic centres. In the absence of regular
reports in form-F, no meaningful and effective monitoring and resulting action was
possible. PCPNDT Act had limited impact.
The study also revealed the following:
Total fertility rate (TFR) in district Almora is 1.9 against the national target of 2.
CDR for Uttarakhand and Almora was 6.4 and 5.9 respectively. CDR was
lowest for Almora in Uttarakhand.
MMR for Uttarakhand and Almora was 10 and 11 respectively.
IMR was 41 and 20 for Uttarakhand and district Almora respectively.IMR was 20
for both males and females in the rural areas of district Almora. IMR is lowest for
district Almora in Uttarakhand. Achievements of Uttarakhand and more
specifically that of Almora district are already in consonance with MDG target
(42 by 2010).
Under 5 mortality rate was 50 and 25 for Uttarakhand and district Almora
respectively. For the district this rate was 25 and24 for males and females
respectively.
The over all under 5 mortality rate was 25 for rural areas of the district.
Under 5 mortality rate in rural areas was 24and 26 for boys and girls respectively
showing that the rate was 2 point higher for girls than that for boys in rural areas.
9.7% school going boys and 11.6% school going girls were found aby school
health teams during 2012-13.
According to AHS 2011-12 data on Schooling status of Children currently
attending school aged 6-17Years in Almora District showed that 98.3% boys
while 97.1% girls were attending school during the survey period.
The percentile for girls attending school was 97 and 99.5% in rural and urban
areas respectively.This percentile for boys was 98.4 and 97.5% in rural and
urban areas respectively.
One important social issue related to education of children is that of dropouts at
different level of schooling.
Over all dropout rate among children aged (6-17Years) in Almora District was
2.1%.
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Dropout rate was 1.5 and 2.7% among boys and girls respectively.The dropout
rate thus is 1.2% higher for school going girls as compared to that for boys.
The dropout rate among boys was 1.5 and 2.2% in rural and urban areas
respectively .
The percentile of dropout was 2.9 and 0.5% among rural and urban school going
girl child respectively.
This Statistics reveals that dropout rates for school going girl child in general and
rural girls in particular are higher .
Comparison of AHS 2010-11 and 2011-12 showed some reduction in dropout
rates among school going children. This rate had reduced to 2.9 from 3.3%
among school going rural girls during this period.
Over all mean age at marriage in District Almora was 27.1 Years for males and
21.8 years for girls. This was 26.8 and 21.6 years for rural males and females
respectively. This shows that mean age at marriage for rural girls was 5.2 years
less than that for boys which is again indicative of gender bias.
The study showed that the family size is determined by number of sons and the
sequence of their birth in the family. Later the birth of male child in the sequence
of children‘s birth in family,larger is the family size and more are the number of
girls in the family. This indicates strong preference for the male child in the study
area.
The attitude of respondents about the preference for son was also studied in the
field. Based on the primary data the perception of respondents showed that 83.9%
respondents had preference for male child and who wanted at least one son among
their children. The reasons for this attitude was strong belief among them that son
is necessary for continuity of lineage, old age care of parents and performance of
last rights and rituals.
The primary data thus showed that majority of respondents (82.2%) did not
discriminate about the nutritional requirement of male and female child.
Menstrual hygiene is one of the important indicator of sanitation which affects the
health and hygein of the females in reproductive age. During the present study the
perception of respondents about the use and utility of sanitary napkins by their
daughters was also ascertained. It was found that only 38.6% respondents were
providing sanitary napkins to their daughters and 61.4% respondents did not
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provide sanitary napkins to their daughters. The main reason for not providing the
napkins was the non availability at local level, high cost of napkin and low
awareness about its utility.
The values of composite Health Empowerment Index (HEI) is indicator of the
women‘s health empowerment. The calculated values of HEI, based on six
parameters like education, understanding of health, availability of primary health
services, status of institutional delivery, decision making authority on matters of
family planning and body mass index for respondents show that it had highest
value for Tarikhet block followed by Hawalbagh . The value of HEI was least
(0.575) for Sult block which is the remotest of three slected blocks. HEI values
for Tarikhet and Hawalbagh blocks was found to be 0.668 and 0.643
respectively.Over all value for all 280 respondents was 0.631 in the scale of 0-1.
Other health related issues
About 70.36% respondents were always eager, curious and interested to know
and discuss health related issues but are not always able to do so due to lack of
accessibility to the services of professional health workers. Around 9.64%
respondents were not eager to discuss their health related issues.
On the issue of actual discussions of rural women with ANM/ASHA it was
found that overall about 26.43% respondents discussed health related problems with
ANMs on every possible opportunity whereas proportion of respondents
occasionally discussing health related issues was 31.79% .
Data also revealed that 16.43% respondent women shied away from
discussing their health related problems and 18.93% did it only on falling ill.
The perception of respondents about the necessity of the female doctors and
others for treatment of their gynecological problems in the society was also studied in
the sample villages. Over all 82.86% respondents perceived that female doctor was
necessary for consultation/treatment of women health related issues whereas 11.43%
felt that this could be done by any qualified doctor. No significant variation in this
regard was found across castes or education level of respondents in the sample
villages.
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It was found during the study that overall 61.79% respondents showed their
main faith in modern system of medicine for primary health care, followed by
27.86% and 10.35% respondents who had faith in traditional treatment through
home remedies and natural therapy respectivey. It was also found that ,in general,
improvement in the education level resulted in higher proportion of respondents with
faith in modern medicine system.
The study revealed that the two major sources of information dissemination
on health related issues and services were Television /Newspapers and Health
department and other government agencies which covered 41.47% and 28.6%
respondents respectively. 5.6% respondents did not get information about health
related issues and services through any medium.
Most of the respondents who had no or negligible information on health
related issues and services were also both uneducated and remotely located with
negligible interaction with any agency involved in information dissemination related
activities. Women with no education, were thus in a disadvantageous position.The
primary data underlines that better educated respondents had comparatively higher
degree of awareness and better level of relevant information about health related
issuesand services.
Even though nuclear family is primarily considered to be an outcome of
urbanization but this social trend of nuclear family was found to be marginally on
rise among the respondents in the rural areas also.
Recommendations
Based on the findings of the study the following main recommendations are
put forth for improvement in the planning and implementation of health schemes
affecting the rural women of district Almora:
Education level of women is vital factor which influences the access to different
health schemes and empowerment of women. Present efforts to provide
education to all needs to be sustained in future also.
There is need to increase awareness among the rural women about the govt.
health schemes and their benefits available to them through wide publicity.
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TVandnews papers and health dept./govt. agencies have been found to be major
means of communication with respondents for dissemination of information
related to health services, these should be utilised more to create awareness and
disseminaterelevant information on health related issues of women in rural
areas.
Theme based advocacy materials for maternal health and safe motherhood
should be developed and used in rural areas to create awareness . Such material
can include posters, folklore and plays at the community level, radio and
television messages etc..
The health facilities in rural areas are few and far in between. For providing
quality health care, existence of appropriate health care infrastructure is a
precondition Availability of basic health facility infrastructure with adequately
trained medical staff, doctors especially female doctors and equipments etc.,
are important and crucial factors that influence delivery of and access to health
services. Lack of doctors in PHC and CHC has hampered the implementation
of rural health programmes.There is need to start special drive to improve
health service infrastructure and put in place adequate medical professional
including female doctors in the rural areas. This could be started by providing
adequate and appropriate incentives to the doctors and other medical staff to
compensate for serving in rural areas. Extrs monetary incentives should be
given to medical personnels who are serving in remote areas. More female
doctors should be put in place in health care centres so that rural women can
discuss about their health related issues freely and fearlessly with them.
Even after more than 8 years since the launch of JSY ,the awareness among
the respondents about the scheme is low and this is one of the main reasons
for lower rate of institutional deliveries. Creating awareness about the benefits
of Institutional Delivery for maternal health can lead to better implementation
of the scheme.
Presently TV and radio are widely in use by health department for enhancing
the publicity and creating awareness about the benefits of Janani Shishu
Suraksha Karyakram(JSSK) and Janani SurakshaYojna (JSY) . Similar efforts
should be made for wider publicity of VHND and other lesser known health
programmes.
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Theme based advocacy materials for maternal health and safe motherhood
should be developed and used during VHNDs and meetings of Gram
Panchaysts in rural areas to create awareness regarding different aspects of
safe motherhood incuding at least 3 ANC check Ups ,institutional delivery and
timely immunization of pregnant mother and child. Such material can include
posters, folklore and plays at the community level, radio and television
messages etc.
Presently all the sub centres located in rural areas are not providing the
services of institutional delivery for variety of reasons.To increase the
proportion of institutional delivery, all the existing Sub Centers in the rural
areas should be equipped with necessary facilities and trained man power to
make them functional. The process of training of ANMs and Staff Nurses for
Skilled Birth attendant(SBA) should be carried in time bound manner.SBA
training is prerequisite for safe delivery.
The presence of ANM in Sub-Centre (SC) on 24x7 basis must be ensured by
medical department so that women can access their services freely at ease.
Monetary incentives should be given to medical personnel‘s who are serving
in remote areas to provide health facilities.
For development andup gradationmaintenance of health services infrastructure
sufficient resources are available under NRHM,but the condition of all
SC,PHCs,andCHCs are not satisfactory in the rural areas. One hand,the
conditions of buildings, wards,toilets,operation theatre,labour rooms,lenin
etc.in these centres are mostly in pathetic condition and on the other hand
budget for the same under NRHM is not utilized fully.There is need to put in
place a system which should ensure timely implementation of planned
activities for the up gradationand maintenance of health facilities and full
utilisation of NRHM funds for strengthening the health
infrastructure.Effective periodic monitoring of the implementation of the plan
prepared and approved by Rogi Kalian Samitis(RKS) in the time bound
manner is the need of the hour.Medical department should start administrative
reform in this regard which will promote transparency and accountability in
this regard.
During the study it was found that an amount of Rs.10000 as untied fund is
available with the ANMs of the Sub-Centers for fulfilling need based
182
requirements to provide health services, but this decentralised power was not
utilised fully by many AMNs.There is need for capacity building of ANMs to
facilitate and speed up the process of utilizing this untied fund.
Many Sub-Centers are running in rented buildings. There were quite a few
existing Sub Centre buildings in the study area which were not being utilised
to provide the services of institutional delivery because of the lack of facilities
like labour rooms and basic facilities like water and electricity. Up-gradation
of such SCs was under way.Construction and development of infrastructure,
particularly buildings is carried out by the construction agency .There is lack
of coordination between construction agency and the medical department with
regard to progress of works and more often in handing over the building which
often results in inordinate delay. A committee headed by DM at district level
and SDM at tehsil level may facilitate and speed up this process.
One of the major activities of VHND is also to create awareness among the
women about family planning and importance of safe delivery. Both of these
along with timely immunization of mother and child have direct and positive
relationship with the mother and child health. The low level of awareness
about VHND and other health programmes can be improved by publicity with
appropriate means. Like JananiShishuSurakshaKaryakram(JSSK) and
JananiSurakshaYojna(JSY) the use of television and radio for wider publicity
should be started and encouraged for VHND and other lesser known health
programmes.
Lack of adequate knowledge about contraceptives adversely affect the health
of women in many ways including unwanted pregnancies, closely spaced
births, and abortions. Awareness and information are thus key areas to be
focussed upon for good woman health.
Gone are the days when children were considered as Gods gift. This myth is
now blasted and women know that fertility rate can be controlled by adopting
suitable method of family planning and they can control their family size.The
efforts should be made to provide temporary methods of family planning
easily available in rural areas also so that women can exercise their choice of
family planning method as per their need and preference.
Access to family planning methods should be improved in rural areas to
provide optimum choices to the rural women. The health facilities in rural
183
areas are few and far in between. For providing quality health care, existence
of appropriate health care infrastructure is a precondition.
Female education has played a very important role in promotion, adoption and
use of contraceptives. Education and awareness about use and adoption of
contraceptives should be improved with better publicity in the rural areas.
Higher rate of female sterilisation as family planning method in the sample
villages shows the attitude in the society that most of the males still consider
that contraception is women‘s primary responsibility. There is strong felt need
to bring about change in this attitude and both men and women should share
the responsibility to control fertility rate.
Dominant Patriarchy system is primarily responsible for gender inequality but
with increase in education level among women and exposure to audio-visual
means have set-in social change and the society is now more aware about
women‘s status which is gradually improving, though the pace is low. There is
need to devise innovative means to continue this effort on sustained basis.
There is still a strong preference for sons in the study area.About one in five
women and one in seven men in Uttarakhand want more sons than daughters.
The desire for more children is strongly affected by number of male children
in the family.Existing govt. schemes targeted at welfare and support of girl
child should be made universally available to all girls without riders attached
to them.This is expected to improve the social attitude towards the girl child
and achieving gender equity. Attitudinal change in society is precursor to
social and gender equity.
The effective implementation of PNDT act along with attitudinal changes in
the society has the potential to stabilise the population growth with gender
balance. Effective communication campaign at block and district level can
serve as an effective tool to make service providers and the general
population aware of PNDT Act. Periodic review of Implementation of PNDT
,strict enforcement of act by regular monitoring and inspection of all
ultrasound clinics along with sensitization of officials of enforcing agencies
and educational institutions can play an important role in achieving the
objectives of the Act.
Sensitization of both men and women is important to develop positive attitude
towards the girl child and to stop discrimination between son and daughter,
184
particularly in view of falling sex ratio in 0-4 years age group. Change in
attitude, to some extent, can be brought about by highlighting the govt.
welfare schemes for girl child.
Effective implementation of PNDT ACT with attitudinal changes in the
society has the potential to stabilize the population growth with gender
balance. This will result in better sex ratio at birth.
The BMI of about a quarter respondents was found below normal. Weight of
such respondents must be monitored on regular basis by ICDS and Health
department. ICDS should provide such women with fortified food and
IronFolicAcid tablets.The local health department professionals and para-
medical staff should monitor their iron level regularly and advise them from
time to time. The families of such women who are under weight or over
weight have greater responsibility to pay more attention to the diet taken by
such women.
The professional health workers usually focus only on the lactating mother
and child health care, where as there is felt need to focus on entire women
health issues of the women of varying age profile.
There is need for adopting bottom up approach to identify the specific health
related issues of rural women and fine tune existing programmes accordingly.
Greater sense of ownership needs to be developed in the community about the
govt. health schemes by more frequent and effective interaction between the
health workers and the women. This is expected to improve the understanding
and confidence of the women to have better access to the facilities provided
by the govt.
Median age of marriage is 18 years in Uttarakhand, thus delaying the first
birth, particularly in cases of early marriage is highly desirable for the health
of the mother and child. Age at marriage for women should be increased
through awareness creation about the repercussions of early marriage on
social,psychological and physical health of women and the new born child.
A woman‗s level of education and regular media exposure increase the
likelihood of using contraception before the first birth. Imparting Knowledge
and creating awareness about family planning among school going adolescents
should be done through decentralized camps in rural areas from time to time.
185
To reduce the drop out rates in schools among children more focused efforts
are needed to improve this situation by suitable location specific
interventions.
Education level of women needs further impetus to empower them to move
towards gender equity. This should include vocational trainings so that their
income level also gets improved to feel empowered.
The ARSH programme currently operational only in two blocks namely
Tarikhet and Dhauladevi should be extended to all the 11 blocks of district
Almora to create awareness among adolescents through peer group educators.
To combat anemia in school going children more awareness should be created
in the villages through ASHA and other health workers about Weekly Iron and
Folic Acid Supplementation Programme(WIFS) and Mid Day Meal scheme.
Participatory monitoring of the health programmes at villge level by the
members of the community in the presence of field health workers at regular
intervals will improve the implementation of the programmes.
Availability of basic health facility infrastructure with adequately trained
medical staff, doctor's especially female doctors and equipments etc., are
important and crucial factors that influence delivery of and access to health
services.
Majority of illiterates (55.56%) sought health check up only on being highly
ill. There is need to improve the education level of the rural women for better
health awareness and empowerment. Creating environment for healthy living
in the family and society is very important.
The rural women empowerment will come only with improvement in
education and change in social attitudes
There is strong need to create continuous awareness in the society about
gender equality and importance of girl child as an asset who contributes to the
social and economic well being of the family and society.There is further need
to increase awareness among the people about the govt. schemes which are
targeted to improve the social and economic status of females and their
benefits available to them through more and more decentralized camps in the
rural areas after wide publicity through appropriate means. All awareness
programmes should also be in local dialect to increase the participation of the
local community. Sensitization of both men and women to develop positive
186
attitude towards the girl child and to stop discrimination between son and
daughter.
For better implementation of rural health programmes results based
monitoring of indicators at gram Panchayat, block, district level by public
representatives on periodic basis is necessary. Bahuuddeshiya camps
organized by district administration can provide an effective platform for
participatory monitoring of the implementation of rural health schemes.
Decentralized planning should be encouraged and Village Health Nutrition
and Sanitation Committee (VHNSC) should be encouraged to be proactive
and provide timely inputs to the medical department for timely action to
control any out break of disease at village level.
Wider consultations with public at large should be done in formulating block
level action plan for health related activities.The gram panchayats should be
actively involved in this process.
Continuous efforts should be made for better coordination among the
activities of different departments like health, education and ICDS in
implementation of programmes like school health programme, weekly iron
and folic acid supplement programmes and providing fortified food to
lactating mothers and extremely mal-nutritioned children.
Education level of women needs further impetus to empower them to move
towards gender equity. This should include vocational trainings so that their
income level also gets improved to feel empowered.
An important need is to provide effective child care support that releases girls
from the burden of sibling care, to participate effectively in elementary
education. This highlights the need for a focus on quality education and enable
the education system to be more responsive to the needs of girl children (e.g.,
separate toilets, child care support etc).
It is critical to prevent undernutrition, as early as possible, across the life
cycle, to avert irreversible cumulative growth and development deficits that
compromise maternal and child health and survival, achievement of optimal
learning outcomes in primary education and gender equality.
Many health problems of rural women are due to high levels of fertility.
Closely spaced births, unwanted pregnancies, abortions negatively affect the
health of women. Reducing fertility through use of contraceptives in an
187
important element through which health condition of rural women can be
improved.
Through this approach, at least one ASHA would get positioned in each
AaganwadiCenter(AWC); and at least one Auxiliary Nurse Midwife (ANM) /
Health Worker (Female) would beavailable for a cluster of Aaganwadi
Centers(AWCs) within every panchayat. Both could be brought under the
oversight of thepanchayat level health, nutrition and sanitation committee
recently notified by the Ministry of Healthand Family Welfare
Support staff should be made available at PHC and CHC level for
administrative works so that the doctors are free to devote adequate time to the
patients.
There is need to create awareness among the people about the menstrual
hygiene and the utility of sanitary napkins for health and hygein. The govt.
scheme, to provide sanitary napkins to the adolescent girls, presently
operational in only selected districts of the state should be universalized in
Uttarakhand.
As the present study has limited scope in terms of detailed nutritional
status of rural women and girls, a comperative study of urban,rural societies on this
aspect can be done. Social customs affecting the status of girl child can also be
studied.
* * * * *
188
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104. Srivastava Shushma, ―Women empowerment‖, New Delhi, Commonwealth
Publishers, 2008.
198
105. Stein Jane, ―Empowerement and Womens Health‖New Jersy,Zed Books
Ltd,1997.
106. Suguna B. and G. Sandhya Rani ―Health status of women‖, New Delhi,
Century Publications and Printers, 2008.
107. Swain Gyanarranjan, ―Analysing structures of Patriarchy‖ , New Delhi,
Viva Books Pvt.ltd, 2006.
108. Thrope Edgar and Thrope Showick, ―Pearson General Studies manual‖,
Delhi Pearson education,2008
109. “Towards Universal Access: Scaling up priority HIV/AIDS interventions in
the Health Sector. Progress Report”,WHO, Geneva, 2009.
110. XII Five Year Plan on National Mission for Empowerment of Women.
111. Twelfth Five Year Plan(2012-17), Government of India Planning
Commission, October, 2011.
112. XII Five Year Plan Report of the Working Group on Women’s Agency and
Empowerment, Ministry of Women and Child Development Government of
India,2011.
113. Uttarakhand Health and Family Welfare Society, Government of
Uttarakhand, Department of medical health and family
welfare(www.ukhfws.org)
114. United Nations Human Development Report, 1995
115. “Women’s Economic Empowerment”,Paper for the Partnership Event on
―MDG3 – Gender Equality and Empowerment of Women – A Prerequiste
for Achieving All MDGs by 2015‖. UNDP, New York,September 25,
2008:
116. World Bank India: “Primary Education: Achievement and
Challenges”,1996.
199
117. United Nations Development Fund for ―Women,Progress of the World’s
Women 2008/2009”,“Who Answers to Women? Gender and
Accountability”,UNIFEM, New York,2010.
118. United Nations Population Fund,―State of the World’s
Population”(UNFPA), New York, 2005.
119. Venkateswaran, Sandhya ―Environment, development and the gender
gap‖,New Delhi, Sage Publications,1995.
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121. World Bank, 2001; ―Engendering Development: Through Gender Equality
in Rights, Resources, and Voice‖., New York, Oxford University
Press,2001
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Tomorrow’sAgenda.WHO, Geneva, 2009.
* * * * *
200
APPENDIX
201
GLIMPSESOFFIELD STUDY
202
203
mÙkjnkrk dk uke-----------------------------------------------------mez-------------fyax&efgyk-----------------xkao dk uke-------------------------
xzkelHkk------------------------------------------------------------------------fodkl[k.M dk uke--------------------------------------------------------------------------------
-------------------
Js.kh& lkekU; vuqlwfpr tkfr vuq-tutkfr fiNM+k oxZ
ifjokj& la;qDr ,dy
ifjokj esa cPpksa dk fooj.k& dqy la[;k yM+ds yM+fd;ka
ftys dk uke----------------------------------------------------------------------------------------------------------
'kSf{kd ;ksX;rk& lk{kjrk fuj{kj lk{kj
izkbZejh vkaBoh nloha ckjgoha
Lukrd LukrdksÙkj vU;
ifjokj esa lnL;& efgykvksa dh la[;k iq:"kksa dh la[;k cPpksa dh la[;k
;ksx
iz'u 1& ifjokj dh vkfFkZd fLFkfr
1&chih,y
2&,ih,y
iz'u&2 ifjokj dh ekfld vk; fdruh gSA
1& 5000 ls de
2& 5000 ls 10000
3& 10000 ls 15000
4& 15000 ls 20000
5& 20000 ls vf/kd
iz'u 3& vkids lcls NksVs cPps dh orZeku mez D;k gS \
iz'u 4&vkids vuqlkj LokLF; D;k gS \
1& chekjh uk gksuk]
2& 'kjhfjd :i ls LoLF; gksuk
3& ekufld 'kkjhfjd :i ls LoLF; gksuk]
4& ekufld 'kkjhfjd ,oa lkekftd :i ls vPNk@LoLF; jguk
iz'u 5& vius LokLF; dk ijh{k.k vki dc djkrh gSa\
1& izfr N% ekg esa]
2& izR;sd ,d o"kZ esa]
204
3& izR;sd nks o"kZ esa]
4& dsoy chekj gksus ij
iz'u 6& vkids }kjk LokLF; laca/kh ijs'kkfu;ksa dk fuLrkj.k fdu&fdu voLFkkvksa esa gksrk gS \
1& jksx dh izkjfEHkd voLFkk esa]
2& e/; esa]
3& vfr gkfudkjd gksus dh fLFkfr esa
iz'u 7& LokLF; laca/kh tkudkfj;ska dks izkIr@tkuus esa vki mRlqd jgrh gSa \
1&gkW]
2&ugha]
3&dHkh&dHkh
iz'u 8& D;k vkids {ks= esa ,-,u-,e-@vk'kk vkrh gS fd ugha \
1&gkW]
2&ugha]
3& vU; fooj.k
iz'u 9& D;k vki vk'kk dk;Zd=h@ANM vkfn ls viuh LokLF; laca/kh leL;kvksa dh ppkZ djrh gSa \
gkW] ugha
;fn gkW rks
1& volj feyus ij ges'kk]
2& dHkh&dHkh]
3& dsoy dksbZ LokLF; laca/kh leL;k gksus ij
4& gekjs {ks= esa ,-,u-,e-@vk'kk ls laidZ u gks ikus ds dkj.k ppkZ ugha gks ikrh
iz'u 10& izkFkfed LokLF; mipkjksa ds fy, vki fdl ij fuHkZj djrh gSa \
1&izkd`frd mipkj ij]
2& ijEijkxr rkSj rjhds ls gksus okyk ?kjsyw mipkj ij]
3& vk/kqfud mipkj iz.kkyh@fpfdRld ij
iz'u 11& LokLF; laca/kh lwpukvksa vkSj lsokvksa ds ckjs esa vkidks fdl rjg tkudkjh feyrh gS \
1& Vsyhfotu@U;wt isij]
2& fe=ksa ,oa ifjokj }kjk]
205
3& ,u-th-vks- }kjk
4& ljdkjh ra=@LokLF; foHkkx ls
5& vU; ek/;e
6& tkudkjh feyrh gh ugha gS
iz'u 12& efgyk LokLF; lEcU/kh ijs'kkfu;ksa ds ijke'kZ@mipkj gsrq fdl izdkj ds fpfdRld dk gksuk
vko';d gS \
1&efgyk fpfdRld]
2&iq:"k fpfdRld]
3&uhe gdhe]
4&,0,u0,e0@vk'kk
5&QkeZflLV
6& dksbZ Hkh ;ksX; fpfdRld
iz'u 13& D;k vkidks ^^tuuh f'k'kq lqj{kk dk;ZØe** (JSSK) ds ckjs esa tkudkjh gS \
1& gk¡]
2& ugha
iz'u 14& xHkkZoLFkk ds nkSjku vkids }kjk fdruh izlo iwoZ fdruh tkWpsa djkbZ xbZ Fkh\
1&,d
2&nks
3&rhu
4&dksbZ ugha
iz'u 15& vkidk Last izlo fdl rjg lEiUu gqvk \
1&?kj ij izlo ,-,u-,e-@nkbZ ds }kjk]
2&?kj ij izlo fcuk ,-,u-,e-@nkbZ ds
3&laLFkkxr izlo
iz'u 16& D;k vkidk tPpk&cPpk dkMZ cuk;k x;k \
1&gk¡]
2& ugha
;fn gkW rks mldk fdl izdkj mi;ksx fd;k x;k\
206
1&lHkh lsok;sa fu;r frfFk ij yh]
2&dHkh&dHkh lsokvksa dk mi;ksx fd;k
3&dsoy dkMZ cukrs le; lsok dk mi;ksx fy;k
iz'u 17 v& D;k vki }kjk izlo mijkUr ekW vkSj cPps dh tkWp djk;h x;h\
1- gka 2- ugha
c& ;fn gka rks fdruh ckj \
1& ,d ckj
2&nks ckj
3&rhu ;k T;knk ckj
iz'u 18& D;k vki ^^tuuh f'k'kq lqj{kk dk;ZØe** (JSSK) ds varZxr fuEufyf[kr lqfo/kkvksa ds ckjs esa
tkurh gSa \
lqfo/kk dh tkudkjh@ykHk tuuh f'k'kq lqj{kk
dk;ZØe ¼twu 2011½ ls
iwoZ
tuuh f'k'kq lqj{kk
dk;ZØe ¼twu 2011½
ds i'pkr
1& izlo ds ckn] ?kj NksM+us dh lqfo/kk esa]
2& izlo ds ckn] fu'kqYd Hkkstu
3& izlo ds ,d ekg ckn tPpk@cPpk dks
eq¶r lqfo/kk nsus ds ckjs esa
4&eq¶r C-Section]
5- fu'kqYd nokbZ;ka] [kwu dh tkWp] ySc VSLV]
[kwu p<+kuk
JSSK ds izkjEHk gksus ls igys izlo gks pqdk FkkA
iz'u 19& izlo ds fy, tuuh lqj{kk ;kstuk (JSY) ds vUrxZr /kujkf'k izkIr gqbZ \
1&gk¡]
2&ugha
;fn gkW rks fdruh /kujkf'k izkIr gqbZ & #0---------------
iz'u 20& mDr :i ls izkIr /kujkf'k dk mi;ksx fdl dk;Z gsrq fd;k tk; lEcU/kh fu.kZ; fdlus fy;k \
1&Lo;a vki }kjk]
2&vkids ifr }kjk
3&vU; }kjk
207
mDr /kujkf'k dk mi;ksx fdl dk;Z gsrq fd;k x;k dk fooj.k ----------------------------------
iz'u 21& D;k vki xzkeh.k LokLF; ,oa iks"k.k fnol (VHND) ds ckjs esa tkurh gSa \
1& gk¡]
2& ugha
iz'u 22& vkaxuckM+h dsUnz esa vk;ksftr xzkeh.k LokLF; ,oa iks"k.k fnol (VHND) dh lqfo/kkvksa dk ykHk
vkius fy;k \
1& gk¡]
2& ugha
iz'u 23& D;k vki xzkeh.k LokLF; ,oa iks"k.k fnol (VHND) esa nh tkuh lqfo/kkvksa ds ckjs esa tkurh
gSgk¡] ugha \ ;fn gkW rks D;k \
iz'u 24& vkius xzkeh.k LokLF; ,oa iks"k.k fnol (VHND) esa fdu lqfo/kkvksa dk ykHk fy;k gS\
lqfo/kk dh tkudkjh@ykHk xzkeh.k LokLF; ,oa iks"k.k
fnol ;kstuk ¼2005½ ls
iwoZ
xzkeh.k LokLF; ,oa
iks"k.k fnol ;kstuk
¼2005½ ds i'pkr
1& izlo iwoZ tkap
2& CyM izslj dh tkap
3& otu uiok;k
4& Vh-Vh- dk Vhdk yxok;k
5& vkbZ-,Q-,- dh xksfy;ka yh]
6& ifjokj fu;sktu dh tkudkjh
7& cPpksa dk Vhdkdj.k
8& vU;
iz'u25& D;k vki RCH f'kfoj ds ckjs esa tkurh gSa \
1& gk¡]
2& ugha
;fn gkW rks D;k \
iz'u26&vkids {ks= esa fiNys 1 o"kZ esa fdrus RCH f'kfoj yx pqds gS \
208
iz'u27&vkius RCH f'kfoj ds vUrxZr fdu&fdu lqfo/kkvksa dk ykHk mBk;k gS\
lqfo/kk dh tkudkjh@ykHk xzkeh.k LokLF; ,oa iks"k.k
fnol ;kstuk ¼2005½ ls
iwoZ
xzkeh.k LokLF; ,oa
iks"k.k fnol ;kstuk
¼2005½ ds i'pkr
1& izlo iwoZ tkap
2& Vh-Vh- dk Vhdk yxok;k
3& vkbZ-,Q-,-@vk;ju dh xksfy;ka yh]
4& ifjokj fu;sktu dh tkudkjh
5& cPpksa dk Vhdkdj.k
6& xHkZ fujks/kd xksyh ys x;h
7& xHkkZoLFkk dk iathdj.k djok;k
8& esfMdy Vjehus'ku vkWQ izsxusUlh
¼MTP½ djok;h
9&dkWij&Vh yxok;h
vkbZ0,Q0,0@vk;ju dh xksfy;kW vki }kjk fdruh ckj yh x;hA
iz'u 28& vki ifjokj fu;kstu ls D;k le>rh gSaA
1& 2 cPpksa rd ifjokj lhfer j[kuk]
2 cPpksa ds chp mez dk vUrj j[kuk
3& mDr nksuksa]
4& vU;
iz'u 29& vkids lEcU/k esa ifjokj fu;sktu lEcU/kh fu.kZ; ysus esa eq[; izHkko fdldk gS \
1& vkidk]
2& vkids ifr dk
3-vkids ifr o vkidk feydj]
4& vU;] dk
209
iz'u 30& vki ifjokj fu;kstu ds dkSu ls mik; viukrh gSa \
1& xHkZ fujks/kd xksyh]
2& ulcUnh ¼iq:"k@efgyk½]
3& fujks/k]
4& dkij&Vh]
5& dqN ugha
iz'u 31 v & vki ifjokj fu;kstu ds ckjs esa vius ifjokj ls [kqydj ppkZ dj ikrh gSaA
1& gka]
2& ugha
c& ;fn gkW rks ppkZ fdlds lkFk gksrh gS \
1-dsoy efgykvksa ds lkFk
2-LokLF; dk;ZdfrZ;ksa ds lkFk
3-vU;
l&;fn ppkZ ugha gksrh gS rks dkj.k&
1-'keZ ds dkj.k]
2-Hk; gksus ds dkj.k]
3-le>@tkudkjh u gksus ds dkj.k
4-lkekftd :i ls vlgt gksus ds dkj.k
iz'u32& vki }kjk ifjokj fu;kstu lEcU/kh lsok ysus esa vkids lkFk dkSu vk;k Fkk \
1&vk'kk]
2&ifr]
3&lkl]
4&dksbZ ugha Lo;a
iz'u 33& D;k vki bu mik;ksa ls larq"V gSa \
1& gka]
2&ugha
210
iz'u 34& D;k vki lksprh gSa fd bu mik;ksa ds ckjs esa T;knk foLrkj ls tkudkjh izkIr djuh pkfg,\
1&gka]
2&ugha
iz'u 35 v& D;k vkius ;k vkids ifr us ulcUnh djok;h gS \
1&gka]
2&ugha
c& ;fn gkW rks ulcUnh fdlus djokbZ\
1& vkius]
2&vkids ifr us
iz'u 36& ;fn ulcUnh djkbZ xbZ rks ulcUnh djkus ls igys D;k vkidks fdlh vU; mik;ska ds ckjs esa
crk;k x;k tks vki bLrseky dj ldrs Fks \
1&gka]
2&ugha
iz'u 37& ulcUnh djkus ls iwoZ vkidks D;k laHkkfor lkbM bQSDV~l ds ckjs esa crk;k x;k FkkA
1&gka]
2&ugha
iz'u 38& D;k vkidks ulcUnh ds fy, LokLF; foHkkx us dksbZ Hkqxrku fd;k\
1&gka]
2&ugha
;fn gka rks fdruk #0 -------------------------
iz'u 39& D;k vkidks crk;k x;k Fkk fd vxj mik;k ds bLrseky esa vxj vkidks dksbZ leL;k gks rks
D;k djuk gSA
1&gka]
2&ugha
iz'u 40& D;k vkidks ?kj ij ;k LokLF; lqfo/kk ij ulcUnh djkus ds ckn dksbZ QkWyksvi ns[kHkky izkIr
gqbZ FkhA
1&flQZ ?kj ij]
2&flQZ LokLF;lqfo/kk esa]
3&nksuksa]
211
4&nksuksa esa ls dksbZ ugha
iz'u 41& D;k lsok;sa izkIr djrs gq, vLirky esa xksiuh;rk dk;e j[kh x;h Fkh \
1& gka]
2& ugha
iz'u42& vkidks ifjokj fu;sktu ds fdl lk/ku ds ckjs esa lykg nh xb \
1& daMkse]
2& xksfy;kW]
3& vkbZ ;w Mh@dkWij&Vh]
4& efgyk ulcanh]
5& iq:"k ulcanh ¼,u ,l oh½
6& vU; ¼Li"V djsa½
iz'u 43&D;k vki tkurs gSa fd ifjokj fu;sktu ds fdu&fdu lk/kuksa dk ykHk mBk;k tk ldrk gS \
1& gka]
2& ugha
;fn gkW rks tkudkjh dk Lrj&
1& vkbZ ;w Mh@dkWij&Vh]
2& efgyk ulcanh]
3& iq:"k ulcanh ¼,u ,l oh½]
4& daMkse
5& xksfy;kW]
iz'u 44& bLrseky u djus dk D;k dkj.k Fkk \
1&ugha tkurs fd dgka tk,a]
2&tkudkjh dh deh]
3&xksiuh;rk ugha]
4&vU; ¼Li"V djsa½
212
iz'u 45& fuEu esa ls vkidks dkSu&dkSu lh lqfo/kk,a miyC/k gSa \
1&ihus dk LoPN ty]
2&ikSf"Vd vkgkj]
3&fpfdRlk lqfo/kk]
4&'kkSpky; lqfo/kk
iz'u 46& vkidks LokLF; laca/kh lsok,a vius fuokl ls fdrus fdyksehVj nwjh ij miyC/k gSaA
1& 0&1 fdeh-]
2& 1&2 fdeh-]
3& 2&3 fdeh-]
4& 3 fdeh ls vf/kd nwjh ij
iz'u 47& vkidks lkekU; LokLF; laca/kh lsok,a fdl izdkj ls miyC/k gSa \
1& LokLF; midsUnz]
2& izkFkfed LokLF; dsUnz]
3& lkeqnkf;d LokLF; dsUnz]
4& futh fpfdRld
iz'u 48&D;k vki ljdkj }kjk pyk;h xbZ 108 lsok lqfo/kk ds ckjs esa tkurh gSA
1&gkW
2&ugha
3&vU; fooj.k
iz'u 49& izk;% vkidks LokLF; lsok,a fdl ykxr esa miyC/k gksrh gSa \
1& fu%'kqYd]
2& vkids vuqlkj okftc nke ij]
3& egaxs nkeksa ij
iz'u 50&vki jktdh; vLirkyksa esa LokLFk; dsUnzksa ds }kjk miyC/k lqfo/kkvksa ls larq"V gSA
1&gkW
2&ugha
;fn gkW rks D;ksa \
213
iz'u 51& vkids xkao dh xHkZorh efgykvksa ds laca/k esa fofHkUu LokLF; laca/kh tkap dh fLFkfr %
gkW gsrq rFkk uk gsrq x yxk;saA
lqfo/kk dh tkudkjh@ykHk 2005 ls iwoZ 2005 ds i'pkr fVIi.kh
ckjackjrk
(Frequency)
ckjackjrk
(Frequency)
otu ukiuk]
2& Å¡pkbZ ukiuk]
3& gheksXyksfcu]
4& CyM izS'kj]
5& CyM lqxj
6& is'kkc dh tkap
7& Vh Vh- batsD'ku]
vkbZ,Q, VscysV
8& vYVªklkm.M
9+& vU;
iz'u 52& LokLF; lqfo/kk izkIr djus ds LFkku rd vkidh igqWp fdl izdkj dh gSA
1&[kjkc]
2&vkSlr]
3&lqxe@vPNk
iz'u 53& D;k izlo iwoZ tkWp lqfo/kk,a bLrseky djrs gq, vkius dksbZ [kpZ fd;k Fkk \
1&gk¡]
2&ugha
;fn gkW rks fdlesa &
1&vkus tkus esa]
2&nokbZ;ksa esa]
3&lsokvksa esa ¼tkWp lesr½]
4&vU; ¼Li"V djsa½]
214
iz'u 54& vki vLirky @fpfdRlk laLFkku ls izlo ds ckn ?kj dSals x;h \
1&viuk okgu]
2&fdjk;s dk okgu]
3&lkoZtfud okgu]
4&108 ,acwysal]
5&vU;
iz'u 55& vLirky@fpfdRlk laLFkku esa izlo djkus gsrq vkus&tkus ds fy, O;;@fdjk;k fdlus fn;k \
1&Lo;a]
2&ifr]
3&lkl]
4&ifjokj ds vU; lnL;]
5&vU;
iz'u 56& vLirky@fpfdRlk laLFkku esa vkidk izlo fdlus djk;k \
1&MkWDVj]
2&izf'kf{kr ulZ@,-,u-,e-]
3&vU;
iz'u 57& v& cPps ds tUe ds ckn vki fdrus le; rd vLirky esa jgha FkhA
1& 24 ?kaVs ls de]
2& 1 fnu
3& 2 fnu]
4& 3&4 fnu]
5& 5 fnu ls T;knk
c& vLirky ls fMLpktZ vkidh bPNk ls gqvk Fkk \
1& gka]
2& ugha]
iz'u 58& D;k tUe ij vkids cPps dk otu fy;k x;k Fkk \
1&gka]
2&ugha]
3&irk ugha]
4&cPpk ejk gqvk iSnk gqvk
215
iz'u 59& D;k vkids uotkr f'k'kq dks cPps ds MkW- us Lo;a ns[kk o tkWpk Fkk \
1& gka]
2& ugha]
3& irk ugha
iz'u 60& vkius vius uotkr cPps dks igyh ckj viuk nw/k fiyk;k Fkk \
1& rqjUr@ 1 ?kaVs ds vanj]
2& 1&5 ?kaVs ds vUnj]
3& igys fnu esa]
4& nwljs fnu esa
5& rhljs fnu]
6& rhljs fnu ds ckn
iz'u 61&D;k uotkr f'k'kq dks iSnk gksrs le; dksbZ LokLF; lacU/kh leL;k Fkh \
1&gkW
2&ugha
;fn gkW rks D;k leL;k Fkh
iz'u 62&;fn uotkr f'k'kq ds iSnk gksrs le; dksbZ LokLF; lacU/kh leL;k Fkh rks mldk fujkdj.k dSls
fd;k x;k \
1&izlo djkus okys fpfdRlk dsUnz ij
2&jSQjy mijkUr vU; fpfdRlky; ij
3&leL;k dk fujkdj.k ugha gks ik;k
iz'u 63& D;k vkidh jk; esa ifjokj esa iq= dk tUe gksuk vko';d gS \
1&gkW
2&ugha
;fn gka] rks D;ksa \
1& ifjokj dh fujUrjrk dks cuk;s j[kus ds fy;s
2& cq<+kis esa lkgkjs ,oa ns[kHkky ds fy;s
3& vafre laLdkj ds fy;s
4& mi;qZDr lHkh
216
iz'u 64&tc vkidks izlo mijkUr vLirky ls fMLpktZ fd;k x;k Fkk rks vkidks laLFkkxr izlo lEiUu
djkus gsrq izksRlkgu /kujkf'k feyh Fkh \
1&gkW
2&ugha
;fn gkW rks dc o fdruh S\
iz'u 65& ifjokj esa yM+ds] yM+fd;ksa dh vkgkj@Hkkstu vko;'drk ds fo"k; esa vkidh jk; \
1& yM+dksa dks vf/kd ikSf"Vd Hkkstu dh vko';drk gS
2& yM+fd;ksa dks vf/kd ikSf"Vd Hkkstu dh vko';drk gS
3& nksuksa dks viuh mEkz ds vuqlkj lkekU; ikSf"Vd Hkkstu dh vko';drk gS
iz'u 66&efgyk LokLF; lacU/kh l'kfDrdj.k gsrq vki fdu igyqvksa dks fdruk egRoiw.kZ ekurh gSA 0&10
dsLdsy esa voxr djk;sa \
1&f'k{kk dk Lrj
2&LokLF; dh le>
3&LokLF; lsokvksa dh mfpr njksa ij miyC/krk
4&laLFkkxr izlo
5&ifjokj fu;kstu lacU/kh fu.kZ; ysus dk vf/kdkj
6&ch0,e0vkbZ0
iz'u 67& Lo;a o cPpksa dk izfrjks/kd Vhdkdj.k djkrs gSa \
1&gka]
2& ugha
;fn gkW rks dgkW ij lqfo/kk dk mi;ksx fd;k x;k \
1& utnhdh LokLF; dsUnz@midsUnz ij
2& xzkeh.k LokLF; ,oa iks"k.k fnol ij vkaxuokM+h eas]
3& ,0,u0,e0 }kjk vkids ?kj ij
217
iz'u68& D;k vki ekfld /keZ ds nkSjku viuh iq=h dks lsusVjh iSM miyC/k djokrh gS \ gkW ugha
1&;fn gka] rks D;ksa \
1& lqfo/kktud gS
2& lkQ&lqFkjk gS
3& vU; dkj.k
;fn ugha rks D;ksa \
1& iSM LFkkuh; :i ls vklkuh ls miyC/k ugha]
2& iSM dk ewY; T;knk gksus ds dkj.k
3& vU; dkj.k
iz'u 69& mÙkjnkrk efgyk dk otu---------fdxzk esa]
Å¡pkbZ-------------lseh esaa
iz'u 70& xzkeh.k efgykvksa dks vf/kd vPNh LokLF; lsok;sa izkIr gks ldsa& blds fy, lq>koA
fnukad ---------------- mÙkjnkrk ds gLrk{kj
* * * * *