shodhganga.inflibnet.ac.inshodhganga.inflibnet.ac.in/bitstream/10603/114128/9/thesis.pdfHealth(ARSH)...

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

http://en.wikipedia.org/wiki/Race_%28classification_of_human_beings%29

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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24

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Women 2008/2009. Who Answers to Women? Gender and Accountability.

UNIFEM, New York. 2010.

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Empowerment as a Variable in International Development, Background,

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Assessment of the Gender Related Development Index and Gender

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Financial Requirements of Achieving Gender Equality and Women‘s

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Waafas Ofosu-Amaah, and Mirja Sjöblom. Washington, DC: The World

Bank,2008.

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2007‖ in Equality for Women: Where Do We Stand on Millennium

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Bank,2008

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/14, ,―Hope in Hard Times: Women‘s Empowerment and Human

Development‖,2010 .

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.

http://en.wikipedia.org/wiki/Kumaon_division

http://tools.wmflabs.org/geohack/geohack.php?pagename=Almora&params=29.62_N_79.67_E_

http://en.wikipedia.org/wiki/Katarmal

http://en.wikipedia.org/wiki/Kasar_Devi

http://en.wikipedia.org/wiki/Chitai

http://en.wikipedia.org/wiki/Jageshwar

http://en.wikipedia.org/wiki/Binsar

http://en.wikipedia.org/wiki/Baijnath

http://en.wikipedia.org/wiki/Rudreshwar_Mahadev_Temple

http://en.wikipedia.org/wiki/Shiva

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:

http://en.wikipedia.org/wiki/Katyuri_Kings

http://en.wikipedia.org/wiki/Dunagiri

http://en.wikipedia.org/wiki/Shakti

http://en.wikipedia.org/wiki/Dunagiri

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


Walna Walna 1376 N 29degree41.o66 minutes


Hawalbag

Kayala Kayala 1426 N 29degree39.037minutes


Udiyari Udiyari 1225 N 29degree 38.137 minutes


Sult

Barkinda Barkinda 830 N 29degree 43.937 minutes


Dadholi Dadholi 1738 N 29degree 44.746 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


Udiyari 23 27 50

2 Tarikhet

Walna 31 19 50

Uprari 20 8 28

Peepalkhand 15 6 21


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


Udiyari 115 56 59

2 Tarikhet

Walna 115 56 59

Uprari 61 31 30

Peepalkhand 50 24 26


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)

http://en.wikipedia.org/wiki/Health_care_delivery

http://en.wikipedia.org/wiki/Ministry_of_Health_and_Family_Welfare_%28India%29

http://en.wikipedia.org/wiki/Ministry_of_Health_and_Family_Welfare_%28India%29

http://en.wikipedia.org/wiki/Accredited_Social_Health_Activist

http://en.wikipedia.org/wiki/Accredited_Social_Health_Activist

http://en.wikipedia.org/wiki/Hygiene

http://en.wikipedia.org/wiki/Sanitation

http://en.wikipedia.org/wiki/Arunachal_Pradesh

http://en.wikipedia.org/wiki/Assam

http://en.wikipedia.org/wiki/Bihar

http://en.wikipedia.org/wiki/Chhattisgarh

http://en.wikipedia.org/wiki/Himachal_Pradesh

http://en.wikipedia.org/wiki/Jharkhand

http://en.wikipedia.org/wiki/Jammu_and_Kashmir

http://en.wikipedia.org/wiki/Manipur

http://en.wikipedia.org/wiki/Mizoram

http://en.wikipedia.org/wiki/Meghalaya

http://en.wikipedia.org/wiki/Madhya_Pradesh

http://en.wikipedia.org/wiki/Nagaland

http://en.wikipedia.org/wiki/Orissa

http://en.wikipedia.org/wiki/Rajasthan

http://en.wikipedia.org/wiki/Sikkim

http://en.wikipedia.org/wiki/Tripura

http://en.wikipedia.org/wiki/Uttarkhand

http://en.wikipedia.org/wiki/Uttar_Pradesh

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,

http://en.wikipedia.org/wiki/Government_of_India

http://en.wikipedia.org/wiki/Prime_Minister_of_India

http://en.wikipedia.org/wiki/Deaths

http://en.wikipedia.org/wiki/Institutional

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(%)


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 %


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%


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.


5. Reproductive and Child Health (RCH) camps,NHM,(MoHFW),Govt of India.


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

http://en.wikipedia.org/wiki/Medical_history

http://en.wikipedia.org/wiki/Blood_pressure

http://en.wikipedia.org/wiki/Blood_pressure

http://en.wikipedia.org/wiki/Pelvic_exam

http://en.wikipedia.org/wiki/Doppler_fetal_heart_rate_monitor

http://en.wikipedia.org/wiki/Doppler_fetal_heart_rate_monitor

http://en.wikipedia.org/wiki/Blood_test

http://en.wikipedia.org/wiki/Urine_test

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


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


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%


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%)

http://en.wikipedia.org/wiki/Breast_milk

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%


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.

http://www.wikipedia.com/

http://www.who.in/topics/reproductive

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


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


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%)



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

http://en.wikipedia.org/wiki/Belgium

http://en.wikipedia.org/wiki/Belgium

http://en.wikipedia.org/wiki/Adolphe_Quetelet

http://en.wikipedia.org/wiki/Units_of_measurement

http://en.wikipedia.org/wiki/Underweight

http://en.wikipedia.org/wiki/Overweight

http://en.wikipedia.org/wiki/Obesity

http://en.wikipedia.org/wiki/World_Health_Organization

http://en.wikipedia.org/wiki/Malnutrition

http://en.wikipedia.org/wiki/Eating_disorder

http://en.wikipedia.org/wiki/Obesity

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

151

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

153

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

157

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


http://www.nrhm.gov.in/

http://www.ukhfws/


http://www.ukhfws/

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.

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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.

180

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..



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.

181

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.




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.




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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92. Sapru RK,―Women and Development‖ New Delhi, S.B. Nangia,1989.

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93. Sen Geeta,‖Women’s Empowerment and Human Righst: The Challenge to

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* * * * *

200

APPENDIX

201

GLIMPSESOFFIELD STUDY

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

* * * * *

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