Abstract: Kerala has an impressive record in the area of reproductive and child health when compared to the rest of India. The fertility rate is said to be well below what is needed for replacement and its mortality rates are extremely low. It enjoys low infant mortality rates and also low adult mortality rates. Epidemiological transition is well under way and even if the infectious diseases have not been completely eradicated, chronic diseases do contribute significantly to the total morbidity within the state. The usual parameters of reproductive health like maternal mortality ratio, maternal morbidity, unmet need for family planning, abortion, HIV prevalence, low birth weight babies, and the nutritional status of mothers and children warrant a discussion in the present context.
Keywords: reproductive health, low birth weight, female sterilisation, infant mortality rates, maternal mortality ratio, abortion
The Reproductive Health Situation
The usual parameters of reproductive health like maternal mortality ratio, maternal morbidity, unmet need for family planning, abortion, HIV-prevalence, low birth weight babies, and the nutritional status of mothers and children, warrant a discussion in the present context.
The fertility levels in Kerala had declined from 3.74 children per women in the early seventies, to 1.73 per women during the early 90s (SRS various volumes). Accompanied with the given fertility transition, Kerala state has attained significant improvement in the mortality situation also. Currently, it depicts a developed country scenario of low mortality combined with high morbidity (Panickar and Soman, 1984; KSSP, 1991; NSS 28 Round). This is an issue subject to controversy that is still ongoing, but yet this situation is also indicative of the state being ahead in the epidemiological transition.
The maternal Health
The maternal mortality ratio in Kerala varied between 87 to 132 per 100,000 live births as against the same for India being 453-572 in 1993 (Navaneetham, 1999). While it is relatively better when compared with the other states of India, it is reasonably high when compared with the developed country situations. This ratio has actually shown a steady decline from 247 in 1982-86, to 125 in 1993-94. This remarkable decline of 50 per cent in a decade may be partly attributed to decline in fertility. But, even now, hypertensive disorders and haemorrhage account for about forty per cent of the maternal deaths (Sekharan, 1999). The other causes and also maternal factors need to be identified, and some of these are discussed later on in this paper.
With respect to gynaecological morbidity, slightly above 40 per cent of the women were reported to experience any gynaecological morbidity on clinical examination (Shenoy, et. al., 1997). On the family planning front, the state is considered to be a model to be replicated elsewhere with a contraceptive prevalence rate of about 63 per cent, of which 47 per cent is accounted for by sterilisation (PRC, Thiruvananthapuram and IIPS, 1995). But this feature of predominance of sterilisation is not different from other south Indian states. However, follow-up services at home/outside home from health workers after sterilisation, seems to be the poorest in Kerala when compared to other south Indian states (PRC, Thiruvananthapuram and IIPS, 1995). The dominant use of sterilisation in the state could be the reason for the higher unmet need for spacing (7.2 per cent) when compared to that for limiting future births (4.5 per cent). Yet, we can, in general say that the unmet need is not high at all, but it is possible that women have a very limited choice of contraception.
The incidence of abortion is higher among adolescent and young women in the ages 15-19 and 20-24. This indicates that there is a need for other methods of contraception among younger women who resort to abortion to avoid unwanted
We already know that the existing reported measures of abortion are underestimates, and that since other temporary methods are less frequently used, it is possible that women take recourse to induced abortions to control unwanted or ill-timed births and in Kerala, women have declared slightly more than one fifth of the pregnancies to be unwanted or ill-timed (IIPS, 1995).
Kerala enjoys the positive effects of near universal use of ante-natal care and institutional deliveries, which result in low maternal mortality rates and infant mortality rates. But, at times the Government run ante-natal services have been used as a mechanism to bring the women closer to the family planning services (Mishra, Roy and Irudayarajan, 1998).
Kerala is the only state in India where about 95 per cent of the deliveries are institutional. There are, however, variations in this by districts and in Malapuram, Wyanad and Palakkad, this percentage was found to be about 75 per cent. Ante-natal care was also found to be near universal, but the quality of this care needs to be examined.
Kerala has reported a higher prevalence of Caesarean deliveries when compared to the other major states of India (13.94 per cent) with only Goa having a higher prevalence. A C-section rate of about 14 per cent can be considered relatively high, especially in the context of the association with private institutional deliveries in the state (Mishra and Ramanathan, 1999).
The effective reproductive span in Kerala was found to be about five years (Mishra and Irudayarajan, 1997). What does this mean? This means that women complete their reproductive role within this short span leaving very little room for spacing births. The use of temporary methods is quite low and women seem to prefer female sterilisation, with the average age of sterilisation at about 27 years. This has two important implications for reproductive health of women. One is that when sterilisation has become the norm in a society, then women adopt it with very little thought or counselling. This could give rise to future regret of the decision to be sterilised and Kerala did indeed report the highest levels of regret among the south Indian states (Ramanathan and Mishra, 1999) and the major reasons were, the desire for an additional child followed by the issue of after-effects of the surgery that caused regret. This, in a state which experiences one of the lowest levels of infant and child mortality, is reason to pause and think about the implications of promoting female sterilisation, and an easy and one-step procedure to demographic ‘Nirvana’.
It is definitely true that women accept sterilisation voluntarily and would prefer it to the problems of having another child. Yet, it is important, from a quality of service perspective, to ensure that women are well informed about the various choices available, and their relative advantages and disadvantages and then asked to select. However, in the public health services in Kerala, this is not often done (Ramanathan, 1996). Even a request for an abortion, which is legally available, is turned into an opportunity to canvass for concurrent sterilisation without regard for the client’s needs, and in this the service providers are often not guided by the concern for the client’s well-being. By insisting on acceptance of sterilisation, the public service delivery system pushes women towards the more expensive, but anonymous private sector for such services. But, this approach fails to realise that women do not have control over their sexuality or their reproductive capacity, and further disempowers them.
The second issue, is one of the time spent by women during post sterilisation, wherein women are likely to experience the morbidity that is related to the sterilisation procedure itself. A study has indicated that sterilisation is associated with higher chances of menstrual problems with odds ratio of 4 for women who had undergone sterilisation, against women who were non-users of any contraceptive methods (Sowmini, and Sarma, 1999). With women undergoing sterilisation much earlier, the period of exposure to the risk of menstrual problems following the procedure get prolonged. It is possible that the morbidity experienced is a consequence of the relatively low quality of sterilisation services in the state (Ramanathan, Dilip, and Padmadas, 1995; Ramanathan, Mishra and Dilip, 1999).
Child Health and Nutrition
Kerala enjoys one of the lowest infant (IMR) and child mortality rates (CMR) experienced in the country. It is reported to be about 16 per 1000 live births, for the year 1991, when the figure for India was 80 per 1000 live births. By 1997, the IMR had further declined to 13 in Kerala. CMR in Kerala is also low. However, the causes for infant and childhood mortality are not clearly known, but it is expected that deaths due to vaccine preventable diseases, except measles, would be low (Navaneetham and Thankappan, 1999).
Kerala lags behind countries like Sri Lanka and Costa Rica, with which it is compared to usually in the area of low birth weight for babies. A study indicated that in 1996, 13.3 percent of the babies born in rural Kerala were Low Birth Weight (LBW) babies (Kunhikannan and Aravindan, 1999). In comparison, China and Costa Rica, have 6 and 7 per cent LBW babies.
The per capita calorie intake in Kerala was found to be 9 per cent below the standard in 1998-99, and the per capita protein intake was found to be 12 per cent below the standard. Using the weight for age criteria, 29 per cent of children were undernourished and 6 per cent were severely so. Using the weight for height measures, 12 per cent of the children below 4 years of age were considered as under nourished and this indicates the prevalence of acute under-nutrition (IIPS, 1995).
Childhood immunisation is quite high, with a coverage evaluation study in 1993 reporting that DPT, Polio, BCG and TT for mothers was over 90 per cent but for measles it was lower, around 75 per cent. Yet, compared to other states in India, the situation is Kerala is one among the best.
Kerala’s relative lower nutrition status for the child is well known and has been documented. However, because of methodological issues and data problems, this has not been resolved conclusively. What is needed is detailed nutrition intake studies to monitor prospectively the nutritional intake of children in Kerala, so as to be able to develop programmes that contribute enhancing this status, should it be necessary.
Is the lower nutritional status reflective of the disadvantage that the infant has during birth in terms of lower birth weight (Kurup, 1997)? The women of Kerala have the lowest effective reproductive span in the country. Combine this with the high age at marriage and we have a picture of potential for short birth intervals (Mishra and Irudayarajan, 1997). This could also independently contribute to low birth weights and the consequent infant disadvantage.
While Kerala enjoys one of the highest levels of immunisation coverage, an analysis of the 1992-93, National Family Health Surveys indicates that there are gender disparities in immunisation coverage, with female infants less likely to have received all the immunisation that is necessary when compared to male children (Elamon, 1998). It becomes important to address this issue of disparities in order to bring about increases in coverage.
What is visible in terms of low Infant Mortality Rates, fertility rates, longevity are reflections of the averages, and there could be wide disparities within the state. It is the outcome of the development process in terms of low fertility and mortality rates, and other similar rates that are taken note of and even celebrated. When such a process has indeed taken place, i.e., mortality and fertility have declined, and when the declines in fertility have been over a short period of thirty years starting from the sixties, the society’s ability to cope with this transition is also brought into question. These are issues related to the transition process itself, and its consequences bear researching especially in the light of their impact on the well being of the population. The concomitant issues of nuclearisation of families, rapid ageing of the population and need for old age care facilities and other issues, fall beyond the scope of this discussion, even though, these are also part of the consequences of the rapid transition that has occurred. These issues are relevant as they form the wider context for this discussion.
Clearly, not all the segments of the population have benefited equally from this development process. The state is doubly burdened in the sense that while it has not done away entirely with infectious diseases, it is faced with a high chronic disease morbidity, especially among the adult population. In addition, we have to account for diseases that are re-emerging in newer and more virulent forms perhaps, like Malaria in the coastal belt, Japanese encephalitis in Allepey, and more recently Typhoid in Ernakulam.
Future priority areas
The child related issues that need to be prioritised are:
1. Malnutrition of children, especially because the proportions of severe malnutrition are very low, but that of moderate levels are relevant.
2. Gender differences in immunisation, even though this is not reflected in the chances of child survival
3. Low birth weights of infants – the possible causes.
The maternal issues that need to be prioritised are:
1. The higher levels of c-section deliveries in the state – are they justified?
2. The possibility of use of abortion as a means of contraception?
3. The high reliance on sterilisation and the possibility of regret, indicates the need for promotion of other methods, especially male-based methods of contraception.
4. The potential for reproductive morbidity associated with sterilisation calls for prioritising quality of services in the RCH programme.
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MALA RAMANATHAN. Faculty, Achutha Menon Centre for Health Science Studies and the Sree Chitra Tirunal Institute of Medical Science and Technology, Thiruvananthapuram. Obtained her M Sc in Statistics from the Madras University and M.A in Medical Anthropology from the University of Amsterdam. Her M Phil was on Population Studies. Her PhD on Population Studies was from the International Institute for Population Sciences, Mumbai.