Maternal and Newborn Health

Maternal Mortality and Morbidity

The maternal mortality ratio has declined over the course of the 21st century, from 301 per 100,000 births in 2001–2003 to 130 by 2014–2016 (Office of the Registrar General, India, 2006, 2018). While this ratio has declined impressively throughout the country over the 21st century, it must decline much further, to 70 by 2030, if India is to meet its SDG3 commitment (Niti Aayog, 2018).

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Figure 1. Maternal mortality ratio: India, EAG*, Assam, southern states, and other states (Office of the Registrar General, India, 2006, 2011, 2013, 2018, n.d.).

Note: *Empowered Action Group (EAG), comprises eight lesser developed states (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand).

Data on causes of maternal death are unfortunately dated. Available data, from the early 2000s, suggest that common causes of maternal death are those seen in most low- and middle-income country settings (hemorrhage, sepsis, unsafe abortions, obstructed labor, and hypertensive disorders), and are largely preventable (Registrar General of India, 2006).

The real burden of maternal morbidity is poorly known, although it is accepted that for every maternal death, 20–30 others experience pregnancy-related morbidity (Firoz et al., 2013). Data on self-reported morbidity, although more unreliable than medical records, show that one in five women aged 15–49 who had delivered in the five years preceding the National Family Health Survey (NFHS)-4 had experienced massive vaginal bleeding and 15% reported the experience of very high fever within two months of their most recent delivery (IIPS & ICF, 2017). Estimates of morbidity using provider-assessed methods tend to be lower than those, such as the NFHS surveys, that rely on women’s own reports of morbidity. For example, Iyengar (2012) followed up in rural Rajasthan almost 5,000 women in their first week postpartum and measured morbidity using a structured checklist and found that 7% suffered from severe anemia, 4% with fever, and 5% from perineal conditions. Overall, 7.6% were assessed with a life-threatening condition (severe anemia, puerperal sepsis, severe hypertension, and secondary postpartum hemorrhage).

Family Planning Practices and Unmet Need

Abortion

A pioneering national study of the incidence of abortion and unintended pregnancy estimates that a total of 15.6 million abortions are performed annually, that is, an abortion rate of 47 per 1,000 women aged 15–49 (Singh et al., 2018), far in excess of previous estimates, drawn on data from small samples (6.4 million, 26 abortions per 1,000 women; Duggal & Ramachandran, 2004).

The abortion scenario in India has undergone a significant shift over the course of the 21st century with the availability of medication abortion. There has been a radical shift from surgical methods of abortion to medication abortion. Estimates from 2015 suggest that the overwhelming majority of abortions (81% or almost 13 million) are achieved using medication abortion, compared to 14% through surgical intervention, and 5% using other methods (Singh et al., 2018).

Abortion-related deaths contributed to 8% of maternal deaths according to the somewhat dated data available (Montgomery et al., 2014; Registrar General of India, 2006). Using more recent data drawn from annual health surveys conducted in EAG states (2010–2013), Yokoe et al. (2019) noted that risk factors for abortion-related deaths included abortion in adolescence, rural residence, and belonging to socially excluded scheduled tribes.

Abortion-related complication data are not widely available. Findings from the national study found that, as of 2015, the number of post-abortion complications due to induced abortion ranged from 51,000 in Assam to 1,100,000 in Uttar Pradesh, and the induced abortion complication treatment rate per 1,000 women aged 15–49 ranged from 4–7 in Assam, Gujarat, and Tamil Nadu, to 21 in Uttar Pradesh and 26 in Madhya Pradesh. That abortion has become much safer is evident from findings that the majority of women who sought care may have mistaken signals of the normal process of medication abortion, such as incomplete abortion from medication abortion or bleeding. Severe complications, many overlapping, are also estimated among treated patients: 4–16% for infection; 2–9% for physical injuries; 3–7% for sepsis; and 1–4% for shock (Singh et al., 2018).

Infertility and Surrogacy

Evidence on the prevalence of infertility in India is sparse, and in its absence, childlessness, or the percentage of women aged 40–49 who have never had a live birth is used as a proxy. According to the NFHS-4, 3% of currently married women aged 40–49 were childless (IIPS & ICF, 2017). Higher rates were observed in surveys that contained a specific module on infertility: the prevalence of current infertility was 5% (percentage who were childless and had difficulty conceiving for the first time); Patra and Unisa (2017) found it to be higher among the socially disadvantaged than among other women; and care-seeking was compromised for many. Consequences of infertility in terms of stigma, violence, and marital abandonment are often observed (Sama, 2018).

Despite this, infertility care and management are not a public health priority, with poor infrastructure and capacity in public sector facilities well documented (Chauhan et al., 2018). At the same time, there has been an increasing trend toward the use of such options as ART and surrogacy (Malhotra et al., 2003; Nadimpally & Venkatachalam, 2016). Efforts to regulate eligibility criteria for both clients and surrogates and to ensure that the rights of surrogates are protected are underway; the Surrogacy (Regulation) Bill 2019 was introduced in the lower house of the Indian Parliament, but is yet to be passed.

Sexually Transmitted Infections, Reproductive Tract Infections, and Other Gynecological Morbidities

Self-reported prevalence of sexually transmitted infections (STIs) and symptoms such as abnormal genital discharge and genital sores or ulcers in the 12 months preceding the interview stood at 11% and 8% among sexually experienced women and men aged 15–49 years, respectively, in 2015–2016 (IIPS & ICF, 2017). A similar proportion of women (11%) but fewer men (5%) had so reported a decade earlier (IIPS & Macro International, 2007). Percentages reporting an STI, genital discharge, or a sore or ulcer ranged from a low 5% or less in Andhra Pradesh, Telangana, Sikkim, and Dadra & Nagar Haveli, to over 20% in states such as Haryana, Jammu and Kashmir, Meghalaya, and Mizoram (IIPS & ICF, 2017).

Smaller studies, using clinical or lab-detected findings rather than self-reports, also report considerable reproductive tract infections (RTIs) and STIs. Vasireddy (2017) interviewed 520 randomly selected women in the slums of Guntur and found that the prevalence of infection using the syndromic approach was 33%, with the majority reporting vaginal discharge. Clinical confirmation noted that of those reporting a symptom, almost three in five (58%) were diagnosed with bacterial vaginosis, that adolescent girls were over-represented, as were the poor, the poorly educated, and the socially excluded (Vasireddy, 2017). Ghosh, Paul, Das, Bandyopadhyay, and Chakrabarti (2018) analyzed the cases of over 5,000 women attending an STI clinic in Odisha and noted that one-third were diagnosed with Trichomoniasis and bacterial vaginosis, respectively.

A strong and consistent association between RTIs and poor menstrual hygiene management practices is documented in a study of 558 women attending two hospitals in Odisha, among whom 62% were diagnosed with at least one infection, 41% with bacterial vaginosis, and 34% with candida infection. Torondel et al. (2018) showed that, even after adjustment for potentially confounding factors, women diagnosed with these two infections were more likely than others to report poor menstrual management practices such as use of reusable absorbent material, infrequent personal washing, and unhygienic drying and storage of materials.

Cervical cancer affects large numbers of Indian women. India is estimated to account for one-quarter of the worldwide burden of cervical cancers; an estimated 1 in 53 Indian women will experience cervical cancer during their lifetime. The high burden of cervical cancer has been attributed to such risk factors as poverty, early age at marriage, multiple sexual partners, multiple pregnancies, poor genital hygiene, malnutrition, and lack of awareness. Despite this high burden, there is no countrywide state-sponsored public health policy on prevention of cervical cancer screening or Human Papilloma Virus (HPV) vaccination (Bobdey, Jignasa, Jain, & Balasubramaniam, 2016).

Care-seeking for symptoms of infection and gynecological morbidity is limited. Moreover, public sector facilities are far less likely to be sought for treatment of STI symptoms than symptoms of other health problems. For example, Mitchell et al. (2011) found that while almost all women in rural areas of two districts of Andhra Pradesh sought antenatal services from the public sector (96%), few did so for STI symptoms (16%), and just 4% had sought STI-related services from a primary health center. Gawande, Srivastaba, and Kumar (2018)’s findings in rural areas near Mumbai city corroborate: the prevalence of RTIs among ever married women was found to be 21%; yet, just 14% had sought treatment from a qualified provider. Jayapalan (2016) found that, of 85 STI-infected men and women in Kerala, 60% of men and 82% of women had sought appropriate treatment for their first point of contact, many had received inappropriate treatment at this point of contact, and many (30% of men and 37% of women) cited poor quality of care in the facility from which they had first sough care, notably the unavailability of medicine and lack of confidentiality and privacy.

HIV Scenario

An estimated 2.14 million Indians were HIV+ in 2017, with overall rates declining to 0.22% from 0.31% in 2009 (NACO & ICMR-NIMS, 2018; NIMS & NACO, 2012). The NFHS found similar prevalence rates in 2015–2016, with an overall rate of 0.24%, 0.23% for women and 0.25% for men (IIPS & ICF, 2017).

India’s National AIDS Control Organization (NACO) estimates suggest that the number of new infections has declined to 87,600 in 2017 from approximately 120,000 in 2009. By 2017, almost 97% of the total population living with HIV were aged 15 or older, with females comprising 42% of this group, compared to 39% in 2009. HIV incidence per 1,000 uninfected population is estimated to have declined to 0.07 in 2017. Regional variation is considerable, and by 2017, incidence was considerably greater in northeastern states such as Mizoram, Nagaland, and Manipur (0.58–1.32) than previously high-incidence states such as Maharashtra and Tamil Nadu (0.05–0.09) and other states. The epidemic continues to be concentrated in high-risk populations, that is, sex workers, men who have sex with men, and injecting drug users (NACO & ICMR-NIMS, 2018).

Stigma and discrimination persist. The NFHS probed attitudes about an HIV+ person mixing with others in various situations (the school, the health facility, the workplace, and so on) and notes that positive attitudes on any one of seven situations were held by 60–80%, and on all attitudes by just 24% of women and 27% of men (IIPS & ICF, 2017).

Reproductive health choices have expanded for women living with HIV/AIDS. There has been a considerable increase in the coverage of HIV testing, antiretroviral therapy (ART), and prevention of parent-to-child transmission (PPTCT) services in last few years, and counseling and testing services are now available across the nation through more than 15,000 integrated counseling and testing centers and ART services are available in more than 400 centers across the country, and more than 38,000 HIV-infected women reported PPTCT services (Department of AIDS Control, 2013, 2014). Rates of mother-to-child transmission have reduced, and more women are able to fulfill their fertility desires. Despite increased coverage of antiretroviral treatment, effective reproductive health care services do not always reach HIV-infected women, resulting, for example, in a high prevalence of unwanted pregnancies and induced abortions among them, and a low level of knowledge about prevention of mother to child transmission and safe pregnancy options (Darak, Hutter, Kulkarni, Kulkarni, & Janssen, 2016).

Gender-Based Violence

Notwithstanding laws that protect women from domestic violence, gender-based violence, notably marital violence, persist. Almost one-third of ever-married women (31%) had experienced physical or sexual violence perpetrated by their husband. Many of these women experienced injuries (25%), including 4% who suffered severe burns, 6% who had suffered deep wounds, and 8% who had experienced eye injuries, sprains, dislocations, and burns (IIPS & ICF, 2017). In addition, a significant and consistent association is observed between the experience of spousal violence and symptoms of RTIs/STIs (Jejeebhoy, Santhya, & Acharya, 2013), unintended pregnancy (Raushan, 2019), pregnancy-related care, and fetal and infant mortality (Jejeebhoy, Santhya, & Acharya, 2010).

Sexual and Reproductive Health of the Young

Limited Awareness

Awareness of SRH-promoting behaviors, the need for SRH services, and women’s and men’s right to these services remain far from universal in India. Several parts of the country show low or moderate levels of awareness about best practices related to the care of women during pregnancy, delivery, the postpartum period, and of the newborns (Gupta, Shora, Verma, & Jan, 2015; Laishram, Thounaojam, Panmei, Mukhia, & Devi, 2013; Mangulikar, Howal, & Kagne, 2016; O’Neil, Naeve, & Ved, 2017; Patel et al., 2016; Santhya et al., 2017a, 2017b). For example, Santhya et al. (2017a, 2017b) showed that just 26–32% of unmarried girls, 28–32% of married girls, and 22–25% of unmarried boys, all aged 15–19 in two large states of India (Bihar and Uttar Pradesh), knew that a pregnant woman should have at least four antenatal check-ups. Awareness of danger signals is also limited (Chandhiok, Dhillon, Kambo, & Saxena, 2006; Goyal & Bhandari, 2008). Goyal and Bhandari (2008) studied delivery and postpartum morbidity in the Delhi slums and observed that, even among women experiencing excessive bleeding and high-grade fever, just 28% and 13%, respectively, recognized the condition as a severe morbidity. of 124 maternal deaths taking place across the country in 2012–2014, Subha Sri and Khanna (2014) reported that lack of awareness to seek timely care was one of the key causes.

In the area of contraception, while awareness of at least one contraceptive method is virtually universal (99%) among currently married men and women, awareness of non-terminal is not universal. For example, just 69% and 48%, respectively, of currently married women and men were aware of IUCDs, condoms, and oral pills (IIPS & ICF, 2017). Moreover, the awareness percentage of specific methods increased only marginally over time: for example, awareness about condoms increased from 76% in 2005–2006 to 82% by 2015–2016 among currently married women. At the same time, awareness of emergency contraceptive pills increased dramatically: from 12% to 42% among currently married women, and 23% to 48% among currently married men. Furthermore, awareness of contraceptive methods tends to be superficial; among adolescents and youth, although awareness of contraceptive methods was almost universal, specific knowledge of at least one method was limited (IIPS & Population Council, 2010; Jejeebhoy et al., 2019; Santhya et al., 2017a, 2017b).

Misconceptions about HIV transmission routes and means of protection against HIV are evident. A comparison of the levels of comprehensive awareness of HIV, that is, common misperceptions about transmission were rejected and the importance of consistent condom use and single-partner relations as means of avoiding infection were known, in 2005–2006 and 2015–2016 shows almost no change (17% to 21% among women and 33% to 32% among men; IIPS and ICF, 2017; IIPS and Macro International, 2007).

Limited awareness permeates the domain of rights and entitlements too. Women and the wider community lack awareness of women’s rights and the programs to which they are entitled. For example, they are poorly informed about the full range of services to which they are entitled under JSY (Santhya et al., 2011). Moreover, many women remain poorly informed about the legality of abortion and their rights under the Medical Termination of Pregnancy Act (Banerjee et al., 2013; Jejeebhoy et al., 2011a, 2011b). For example, a community-based study found that while three quarters of rural women were aware that abortion is legal in at least one situation, about half believed that it is illegal in the case of unmarried women or contraceptive failure, and almost all women believed that women seeking abortion must obtain their husband’s consent (Jejeebhoy, Zavier & Kalyanwala, 2010). The perception that abortion is illegal in India has been partly fuelled by conflicting messages about the illegality of abortion following prenatal sex detection and the legality of abortions for other reasons (Nidadavolu & Bracken, 2006).

Limited Female Agency, Compromised Exercise of Reproductive Rights, and Wide Gender Power Imbalances

Within the age and gender-stratified family systems prevailing in India, women’s agency is hugely constrained. There is considerable evidence of the extent to which limited agency — in terms of decision-making, freedom of movement, control over economic resources, and experience of violence—has compromised health promoting behaviors and timely care-seeking (Bloom, Wypij, & Gupta 2001; Jejeebhoy & Santhya, 2014; Leon, Lundgren, Sinai, Sinha, & Jennings, 2014). Although women’s participation in decisions relating to their own health care has increased over time (62% in 2005–2006 to 75% in 2015–2016), women’s freedom to visit a health facility unescorted has remained unchanged (48% to 50%; IIPS & ICF, 2017; IIPS & Macro International, 2007). Likewise, while the proportion of women who have a savings account that they themselves use has tripled since 2005–2006 (15% to 53%), the proportion of women who have money that they can decide how to use had remained unchanged (45% to 42%).

Women’s limited agency is manifested in compromised exercise of reproductive rights too. A sub-national study of youth in India observed that 51% of young women expressed a desire to have postponed first pregnancy, but of those with demand, only 10% had practiced contraception (Jejeebhoy, Santhya, & Zavier, 2014). Also reflecting young women’s compromised exercise of reproductive rights were their reported reasons for not using a contraceptive despite a desire to postpone the first birth, as revealed in the recent stat-representative studies in Bihar, Uttar Pradesh, and Jharkhand: the leading reason, expressed by 18% of girls in Jharkhand, 20% of girls in Bihar, and 33% of girls in Uttar Pradesh was their husband’s objection to doing so, and 11–16% to other family members’ objections to doing so (Jejeebhoy et al., 2019; Santhya et al., 2017a, 2017b). Similarly, about a fifth of women aged 15–49 who had a live birth in the five years preceding the survey who did not go for an institutional delivery cited objections from husband and other family members for doing so nationally (IIPS & ICF, 2017).

Gender power imbalances are evident in the persistence of marital violence. Women’s inability to refuse marital sex, even if they suspect their husband has engaged in extra-marital relations, and gendered attitudes that condone pre- and extra-marital sex for men but not women also have the potential to compromise women’s health. Several studies have noted that, as a result, many women, including the newly married, are at risk of acquiring infections from their husbands (Santhya & Jejeebhoy, 2007).

Limited Male Involvement and Traditional Notions of Masculinity

Men’s attitudes and behaviors influence not only their own SRH outcomes but also those of their wife or partner. Just 6% of couples practicing contraception were using a male method, even as recently as 2015–2016. Condom use among men reporting high-risk behaviors has also been found to be limited: 41% of men who had engaged in high-risk sexual behaviors in the year preceding the interview used a condom at last high-risk sex and 48% of men who had engaged in paid sex in the year preceding the interview used a condom during their last paid sexual intercourse (IIPS & ICF, 2017). Furthermore, the percentage of men who perceive that contraception is women’s business rather than a man’s concern has increased from 22% to 37% and that women who use contraception may become promiscuous from 16% to 20% over the period 2005–2006 to 2015–2016.

Male involvement in their wife’s pregnancy-related care has increased only marginally over time: of the men whose youngest living child was less than three years old at the time of the survey, and whose wife had received antenatal care, 79% had accompanied their wife for an antenatal check-up in 2015–2016 (increased from 74% in 2005–2006). Moreover, the leading reason provided by men whose wife did not receive antenatal care was the husband’s own objections, although the percentage so citing had declined over the decade (to 26% from 40%; IIPS & ICF, 2017; IIPS & Macro International, 2007).

Limited Spousal Communication

Spousal communication about sexual and reproductive matters is limited. Mishra and Ramanathan (2002) found that 45% of the husbands whose pregnant wives attended an antenatal clinic in Delhi reported that they had discussed family planning with their wives. Char, Saavala, and Kulmala (2009) observed that one-third of men in Madhya Pradesh who responded to a survey questionnaire and most of those participating in focus group discussions reported themselves to be the sole decision-makers about reproductive health. Limited communication is also evident among the young: the Youth Study found, for example, that just one-third (34%) of married men aged under 30 and half (54%) of married young women aged 15–24 had ever discussed contraception with their spouse (IIPS & Population Council, 2010). Where communication occurs, moreover, it is selective: a study of young men and women in Guntur district (Andhra Pradesh), and Dhar and Guna districts (Madhya Pradesh) found that topics discussed frequently included antenatal care-seeking but rarely included contraception (Santhya, Jejeebhoy, & Ghosh, 2008).

Spousal communication on reproductive illnesses, especially STIs, is also limited. Santhya and Dasvarma, (2002) showed that, in rural Tamil Nadu, only 37% and 20%, respectively, of married women and men with symptoms of possible RTIs had informed their spouse about their illness experience. Marfatia et al. (2000) also found that only 18% of married and unmarried men attending clinics in Gujarat had informed their wife or partner about their illness, while Mishra and Ramanathan (2002) highlighted that the same occurred for less than one-third of husbands of women attending antenatal clinics in Delhi, and Sahasrabuddhe et al. (2002) mentioned two-fifths of married males at a clinic in Maharashtra.

Infrastructure and Human Resources

Limitations with regard to infrastructure and human resources play a key role in compromising access to and the quality of health services in general, including reproductive health services.

As far as infrastructure is concerned, as of March 2018, there were a total of 158,417 sub-centers, 257,43 primary health centers (PHCs), and 5,624 community health centers (CHCs) in rural areas, and an estimated shortfall of 32,900 sub-centers, 6,430 PHCs, and 2,1185 CHCs in the country (MOHFW, 2018a). Of those currently functional, just 7%, 12%, and 13%, respectively, of sub-centers, PHCs, and CHCs are functioning as per the Indian Public Health Standards.

Lack of human resources poses as severe a constraint to health service delivery as does the poor infrastructure. As of 2017, there were 7.8 doctors and 21 nursing and midwifery personnel per 10,000 population in India (WHO, 2018). As of March 2018, there was a shortage of 6% of auxiliary nurse midwives (ANMs) at sub-centers and PHCs, 14% of doctors at PHCs, and 82% of specialists at CHCs (MOHFW, 2018a). Moreover, not all sanctioned posts have been filled—13% of posts of ANMs at sub-centers and PHCs, 25% of posts of doctors at PHCs, and 74% of posts of specialists at CHCs sanctioned were vacant.

These shortages in human resources are attributed to a number of factors, including difficulties in recruiting and retaining doctors and nurses in rural areas, especially in the high focus states, delays in sanctioning posts, and limited investment in building a cadre of midwives (MOHFW, 2011a; Prakasamma, 2009). While the inclusion of contractual staff has significantly improved the availability of staff at health center level, contractual employment is fraught with problems, including delayed renewal of contracts, poor service conditions, high turnover, and disparities between contractual and permanent staff including in terms of salary (MOHFW, 2011a).

Provider Capacity and Training

Significant measures have been taken, under the NRHM, to strengthen provider capacity. However, the reach of provider training has been variable, and provider awareness remains of concern. For example, awareness of health promoting behaviors was limited among many accredited social health activists (ASHAs) (MOHFW, 2011b; Santhya, Jejeebhoy, & Zavier, 2011); an eight-state evaluation found that just 26% of ASHAs recognized foul-smelling vaginal discharge as a danger signal during the postpartum period and 34% knew that a newborn should not be bathed immediately (MOHFW, 2011c). Medical officers at PHCs in selected districts of Maharashtra and Rajasthan were ill-informed about abortion-related issues: just half were aware that the consent of the husband or guardian is not required in order for an adult woman to undergo abortion (Jejeebhoy et al., 2011a, 2011b).

Training does not always translate into enhanced knowledge or the practice of new skills. A study of some 96 ANMs in two districts in Rajasthan reports that 36% had conducted deliveries in the last three months; of those who had conducted deliveries, just 6% had always used the partograph while conducting the deliveries, and just 22% gave oxytocin injections always or sometimes during the third stage of labor (Santhya & Jejeebhoy, 2012).

Inequitable Reach of Services and Failure to Reach the Most Vulnerable

Findings from national level surveys have noted that despite some narrowing, there remain huge geographic and socio-demographic inequities in reproductive health indicators (e.g., infant mortality, child marriage, and early childbearing) and access to services (e.g., institutional delivery, contraception), by geography and socio-demographic characteristics. Figures 2 and 3 illustrate the change over time (2005–2006 and 2015–2016) in selected indicators between the most and the least disadvantaged across several socio-demographic characteristics. Findings underscore the country’s failure to reach the most marginalized, although improvement over time is seen.

As Figure 2 shows, neonatal mortality rates were considerably higher among adolescents (54/1,000, and 39/1,000, respectively, in 2005–2006 and 2015–2016) than among those aged 20–39 (34/1,000 and 27/1,000, respectively). Differences by education and household economic status were pronounced, but by religion and caste were relatively narrow by 2015–2016 (IIPS & ICF, 2017). Findings suggest that while levels of perinatal and neonatal mortality rates have declined among the least and the most disadvantaged, disparities have not narrowed or have narrowed marginally over the decade with respect to most indicators except educational attainment.

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Figure 2. Neonatal mortality by socio-demographic characteristics, 2005–2006 and 2015–2016 (IIPS & ICF, 2017; IIPS & Macro International, 2007).

Note. ● = Most advantaged group; → = Most disadvantaged group.

The Constitution of India recognises and makes provision for special reservations for individuals belonging to socially disadvantaged castes and tribes in India, and classifies them as belonging to scheduled castes (SC) and scheduled tribes (ST).

Figure 3 shows corresponding patterns with regard to modern contraceptive use. There has been little change in either levels or patterns of modern contraceptive use. Disparities between the more and the less advantaged remain, for the most part, as wide in 2015–2016 as they were in 2005–2006. However, the rural–urban disparity narrowed from 11 to 5 percentage points, and the disparity across household wealth quintiles narrowed from 23 to 17 percentage points.

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Figure 3. Modern contraceptive method use at the time of interview by socio-demographic characteristics, 2005–2006 and 2015–2016 (IIPS & ICF, 2017; IIPS & Macro International, 2007).

Note. ● = Most disadvantaged group; → = Most advantaged group.

The Constitution of India recognises and makes provision for special reservations for individuals belonging to socially disadvantaged castes and tribes in India, and classifies them as belonging to scheduled castes (SC) and scheduled tribes (ST).

The reach of frontline workers also remains limited and inequitable: contact with a health worker (ANM, AWW, ASHA, MPW, and other) in the three months prior to the NFHS-4 interview was reported by just 24% of women. Unmarried women were about one-third as likely as currently married women (11% and 28%, respectively) to report a contact with a health worker (IIPS & ICF, 2017).

Poor Quality of Services

The poor quality of SRH services in the public sector has been widely observed, and such issues as lack of cleanliness, long waiting times, shortages of drugs, lack of visual and auditory privacy, demands for unauthorized payments, and absence of respectful treatment documented. For example, the most commonly reported reason for not using government health facilities is the poor quality of care (reported by 48% of households that do not generally use government facilities). Likewise, information provided tended to be skewed: the leading topic discussed was immunization, and even among pregnant women, such topics as delivery preparedness, complication readiness, and postpartum care were discussed with seven percent or less (IIPS & ICF, 2017).

The Ministry of Health and Family Welfare (2010a, 2011a), the Planning Commission (2011), Santhya et al. (2011), and the United Nations Population Fund (2009) have also pointed to lacunae affecting the quality of services: a lack of supplies, skewed prioritization of responsibilities, delays in payments, and inadequate mentoring or supervision, for example.

The quality of services is also hampered by the uneven use of best practices. For example, the active management of the third stage of labor was practiced infrequently; instead, unmonitored intrapartum oxytocin has been observed even in hospital deliveries (Iyengar, Iyengar, Suhalka, & Dashora, 2009a; Iyengar, Suhalka, & Agarwal, 2009b; Sharan, Strobino, & Ahmed, 2005). Relatively few women in Rajasthan (29%) reported that all essential examinations had been performed at the time of hospital delivery (Santhya et al., 2011).

Concerns about the quality of care characterize HIV/AIDS/STI/RTI services as well. Health care providers are not always adept at communicating messages linking HIV and reproductive health: for example, about the prevention of sexually transmitted infections, unintended pregnancy and vertical transmission of HIV, promotion of a healthy sexual life, and relationships free from stigma and discrimination. They are also not necessarily well informed about HIV and sexual and reproductive health and rights, or have the skills to provide good quality care (Bharat & Mahendra, 2007).

Continued Unmet Need for Family Planning

A number of factors may be responsible for the program’s inability to satisfy the demand for family planning. Although the program is said to provide a cafeteria of contraceptive methods, choices offered are, in practice, limited. In fact, only seven methods are offered in the program: tubal ligation, vasectomy, oral contraceptives, IUCDs, condoms, injectable contraceptives, and emergency contraceptive pills (MOHFW, 2018b). Methods that have aroused controversy, such as implants, are not available to women from the public health system.

Finally, although efforts to involve women in the selection of contraceptive methods or provide them information that could help them arrive at a decision for themselves have improved, client choice continues to be constrained. For example, in 2015–2006, of women using modern contraceptives at the time of the interview and who had initiated use in the previous five years, 54% (an increase of 26 percentage points during the 2005–2006 to 2015–2016 decade) were informed about more than one method of contraception (IIPS & ICF, 2017). Also, far from universal was the experience of contraceptive counseling with regard to how the method works, what likely side effects are, and how side effects can be managed. Of women who were practicing contraception and had adopted a method in the previous five years, just 47% (an increase of 15 percentage points from 2005–2006) were informed about side effects or problems relating to the method they had adopted, and just 39% (an increase of 13 percentage points) were told what to do if they experienced side effects (IIPS & ICF, 2017).

Limitations in Meeting Women’s Need for Abortion Services

The NRHM Operational Guidelines stipulate that MVA and MA should be provided at PHC level for women up to eight and seven weeks of gestation, respectively, and these, along with second trimester abortion and management of post-abortion complications should be available at all facilities from the CHC level (those identified as first referral units) upward (MOHFW, 2010b). These guidelines have not been realized, and abortion services are typically unavailable and inadequate in the public health system at levels below the District Hospital in most states. A recent sub-national study found that, among abortions provided in facilities, the public sector accounts for only one-quarter of facility-based abortion provision, largely because many public facilities do not offer abortion services. At the same time, also reflecting poor-quality services, relatively few abortions overall—fewer than one in four—are provided in health facilities, and almost three-quarters of all abortions are achieved using medication abortion drugs obtained directly from chemists and other unregistered persons, many without a prescription, rather than from health facilities (Moore et al., 2019; Singh et al., 2018). Among surgical abortions taking place in public sector facilities, moreover, between one-quarter and two-fifths continue to be performed using dilation and curettage or dilation and evacuation, indicating that these facilities are using methods that are outdated, and more likely to place women at risk of complications than other available methods (Singh et al., 2018). Notably, most PHCs and even some CHCs lacked trained staff, necessary certification, and/or the required equipment and supplies for providing safe abortions (Kalyanwala, Zavier, & Jejeebhoy, 2010). Finally, although medical abortion should be free in all public facilities, in several states, just 12–42% offered free medical abortion services, and 28–53% offered free first trimester surgical abortion (Moore et al., 2019).

Violations of women’s right are also evident. Inadequate provision of information to women about the law, including where and till which gestational age abortion is provided, poor quality of care, lack of confidentiality, and the frequent insistence by providers on concurrent family planning deter women from seeking abortion in public sector facilities (Stillman et al., 2014). Providers in almost all the facilities in the district-level study in Maharashtra and Rajasthan required the husband’s written consent, and many refused abortion to minors and the unmarried. Quality of care reported by women who had undergone abortion was indifferent, with relatively few women counseled about post-abortion contraception (Jejeebhoy et al., 2011a; 2011b; Jejeebhoy, Zavier, & Kalyanwala, 2010). Finally, the government of India’s strict measures to enforce the Pre-Conception and Pre-Natal Diagnostics Techniques (PCPNDT) Act of 2003, which prohibits the misuse of prenatal diagnostic tests for the purpose of sex determination often denies women the right to access legal abortion. Many women themselves misperceive that abortion for any reason as illegal. And a number of qualified providers are reluctant to offer abortion services because they fear reprisals from authorities imposing restrictions on sex-selective abortions.

Limited Emphasis on Engaging Men in Reproductive Health

Health system biases persist against involving men in reproductive health. There has been, effectively, a bifurcation of services for men and women, with HIV/AIDS-related activities focused on men, and sexual and reproductive health services focused on women. The ASHA program and other periphery-level services overwhelmingly cater to women. Although efforts to engage men in the antenatal care of their wife have improved, substantial proportions of men are still not reached out. Of men whose youngest living child was aged under three years, only 37–51% reported that they had ever been informed by a health care worker about such specific signs of pregnancy complication as vaginal bleeding, convulsions, prolonged labor, severe abdominal pain, and high blood pressure (increased from 21–25% in 2005–2006), and 47% (increased from 37%) had been told what to do in case of complications (IIPS & ICF, 2017). Family planning services are also more focused on women than men, and couple counseling is rarely reported. Finally, efforts to include men in programs intended to change traditional notions of masculinity and build greater respect for women have been limited.

Gaps in the Implementation of Policies and Laws

India has a host of strong laws, policies, and programs that are intended to promote SRH and protect the rights of women, men, and young people to access appropriate services. Unfortunately, implementation of these laws and policies has been lax on several fronts. For example, child marriage persists and prosecution of violators is rare, despite a forward-thinking law prohibiting the practice. Abortions remain inaccessible despite a law that guarantees women’s right to access it. Unmet need for contraception is considerable, despite program commitments to ensure contraceptive choice is fulfilled. Efforts to raise awareness about rights under these laws, policies, and programs are limited, and people’s awareness of their sexual and reproductive rights is therefore compromised (see, for example, Jejeebhoy et al., 2011a, 2011b; Santhya, 2019).