Defining A Reproductive

Health Package For India:

A Proposed Framework

Saroj Pachauri

1995

POPULATION
THE
COUNCH:
New Delhi, India
DEFINING A REPRODUCTIVE HEALTH PACKAGE
FOR INDIA:
A PROPOSED FRAMEWORK

SOUTH & EAST ASIA

REGIONAL WORKING PAPERS
1995 No. 4

Saroj Pachauri
Regional Director, The Population Council
Regional Office for South & East Asia

New Delhi, India

The Population Council, a nonprofit, nongovernmental research organization esablished in
1952, seeks to improve the wellbeing and reproductive health of current and future
generations around the world and to help achieve a humane, equitable, and sustainable
balance between people and resources.

The Council analyzes population issues and trends; conducts research in the reproductive
sciences; develops new contraceptives; works with public and private agencies to improve
the quality and outreach of family planning and reproductive health services; helps
governments design and implement effective population policies; communicates the results
of research in the population field to diverse audiences; and helps strengthen professional
resources in developing countries through collaborative research and programs, technical
exchange, awards, and fellowships.

This issue of the South & East Asia Regional Working Paper Series was produced by the
Regional Office for South & East Asia, New Delhi, India.

@ Copyright 1995
The Population Council

Cover Design and Production: Media Workshop

Contents

Acknowledgements

Executive Summary

I. Reproductive Health
Concept, Framework and Ideology
Quality and Measurement
Reproductive Morbidity and Mortality
Recommended Package of Services

II, Recommended Services for Prevention, Treatment and

Management of Reproductive Health Problems
Prevention and Management of Unwanted Pregnancy
Services for Safe Abortion
Services to Promote Safe Motherhood
Services to Improve Child Survival
Services to Reduce Perinatal and Neonatal Mortality
Nutritional Services for Vulnerable Groups
Prevention and Treatment of Reproductive Tract Infections
and Sexually Transmitted Infections
Diagnosis and Treatment of Gynecological Problems
Screening and Management of Breast Cancer
Services for the Adolescent

III. Critical Factors for Effective Implementation

of Reproductive Health Services
Health, Sexuality and Gender, Information, Education and Counseling
Establishment of Effective Referral Systems

IV. Conclusion

References
List Of Tables

Table | Changes in Key Parameters 1951 to 1992

Table 2 Services for the Prevention and Management of Unwanted Pregnancy
at Different Levels of Health Service System
Table 3A Antenatal Services at Different Levels
of the Health Service System
Table 3B Delivery Services at Different Levels
of the Health Service System
Table 3C Postpartum Services at Different Levels
of the Health Service System
Table 4 Child Health Services at Different Levels
of the Health Service System
Table 5 Services for the Prevention and Treatment of RTIs and STIs
at Different Levels of the Health Service System

List Of Acronyms

AIDS Acquired Immune Deficiency Syndrome

ANM Auxiliary Nurse Midwife
CHC Community Health Center
HIV Human Immunodeficiency Virus
ICDS Integrated Child Development Services
IMR Infant Mortality Rate
IUD Intrauterine Device
MCH Maternal and Child Health
MTP Medical Termination of Pregnancy
NGO Non-government Organization
PHC Primary Health Center
RTI Reproductive Tract Infection
SRS Sample Registration System
STI Sexually Transmitted Infection
TBA Traditional Birth Attendant
UTI Urinary Tract Infection
WHO World Health Organization
 Acknowledgments

This paper is an outcome of work that I undertook as a team member of a World Bank and
Government of India Mission. My paper was one of several background papers that were used
to develop a World Bank report entitled ‘India’s Family Welfare Program: Towards a
Reproductive and Child Health Approach.’ The original paper has been substantially revised
for this publication. I gratefully acknowledge the support provided by Anthony Measham,
Advisor, Population, Health and Nutrition, the World Bank, who was the mission leader and
also for the inputs of other team members.

I would like to express my deep appreciation for the painstaking review and careful critique of
- the paper by Beverly Winikoff, Program Director, Reproductive Health, and Anrudh Jain,
Director of Programs, the Population Council, New York; Kusum Sehgal, Professor, and D.K.
Taneja, Associate Professor, Preventive & Social Medicine, Maulana Azad Medical College,
New Delhi; and Kokila Agarwal, Senior Research Scientist, the Future Group, Washington,
BAL.

Romita Ghosh deserves special acknowledgment as she undertook several important tasks
including editing and working with the publisher to prepare the cover design and print this
publication. Credits for the photographs are due to Amar Talwar and K. Srinivasan, and my
thanks to the Ford Foundation for permission to use them for this publication. And finally, I
thank H.C. Nangia for his diligence and hard work in typing numerous drafts of the manuscript.
Executive Summary

Over the past decade, there has been a clearer articulation and definition of reproductive health
as a concept and some thinking on the ways in which reproductive health problems should be
addressed. The reproductive health concept received global acknowledgment at the International
Conference of Population and Development at Cairo. The challenge now is to translate this
concept into policies and programs.

A reproductive health approach means that people have the ability to reproduce and regulate
their fertility; women are able to go through pregnancy and child birth safely; the outcome of
pregnancy is successful in terms of maternal and infant survival and well being; and couples
are able to have sexual relations free of the fear of pregnancy and of contracting disease.

This paper states that the focus of health programs should change from a population control
approach of reducing numbers to an approach that is gender-sensitive and responsive to the
reproductive health needs of clients. Reproductive health programs should aim to reduce the
burden of unplanned and unwanted child-bearing and related morbidity and mortality.

An important implication for implementing reproductive health programs is to ensure that the
quality of services is improved, particularly from the perspective of the user. There is a need
to focus on women since they are the primary users of these programs and also have the greatest
problem of access to health services. On the other hand, it is equally important to promote male
responsibility and enhance the involvement of men.

To date, the impact of family planning programs has been measured mainly in terms of their
contribution to increase contraceptive prevalence and to decrease fertility. These indicators are
inadequate for measuring the impact of reproductive health programs and, therefore, new
indicators for monitoring reproductive health services and service quality from the perspective
of the client are urgently needed. |
A framework for defining a package of reproductive health services that could be used in
particular settings in India is proposed. No single package of services can be recommended for
nationwide implementation as there is enormous diversity in India among the regions and
states as well as between rural and urban areas. The criteria used for selecting particular health
services included in the package are: levels of fertility and mortality; disease burden; cost
effectiveness; and the capacity of the health infrastructure to deliver services effectively.

The rationale for suggesting a package approach is to enable program planners to: assess the
feasibility and management implications of implementing various combinations of health
services at different levels of the health system in diverse settings; and to examine the cost,
financing and sustainability implications of implementing these health services. It is noted that
while a package of reproductive health services may be defined, for operationalizing programs
effectively fundamental changes in the health service system are needed to reflect the ethos and
ideology that is embodied within the reproductive health approach.

Providing comprehensive reproductive health services to all is a desirable goal. However, since
there is considerable variability in the organizational capacity of programs in the different
regions and states of India, the extent to which a program might expand without compromising
the quality and effectiveness of existing services must be seriously considered. There is a clear
need to prioritize and develop a phased approach with an incremental addition of health
interventions that require greater skills and resources.

Two packages of reproductive health services are discussed in the paper - a comprehensive
package which, at present, would have limited application in India, and an essential package
which is recommended for nationwide implementation. The essential package recommended
includes the following reproductive health services: the prevention and management of
unwanted pregnancy including safe abortion services; services for improving child survival
and promoting safe motherhood; the prevention and treatment of reproductive tract infections
and sexually transmitted infections; and reproductive health services for adolescents. Each of
these services incorporates a number of different health interventions. Some can be implemented
at the peripheral levels of the health service system, while others require more sophisticated
skills and facilities and can, therefore, be implemented only at higher levels or at the peripheral
level in areas with adequate facilities. Operations research should form an integral part of
program implementation and experimental projects should be undertaken to assess the
feasibility and effectiveness of implementing reproductive health services. The effective
implementation of this package of services will have major implications for strengthening
existing service capacity, especially the managerial capacity of the health system.

This paper discusses the rationale for recommending particular services in the national
program and their importance and relevance to the Indian context. Important elements that are
presently lacking but should be incorporated within the program to ensure the effective

8
implementation of reproductive health services are highlighted. Issues related to the
implementation of these services at different levels of the health delivery system are discussed,
particularly for those health interventions that are either inadequately implemented or are not
currently included in the program. The importance of managing the quality of care in
addressing clients’ reproductive needs is underscored. The importance of health, sexuality and
gender information, education and counseling together with the establishment of effective
referral systems between the community and various levels of the health service system is also
emphasized. ,

In this paper, the focus of the discussion is primarily on the role of government programs.
However, the private sector and non-government organizations also play an important role in
the provision of health care in the country. Consequently, it would be important to involve them
as partners in this effort. The establishment of referral systems could be a starting point for
developing linkages among the government health programs, non-government organizations,
the community and institutions of the Panchayati Raj to promote decentralization in the
planning and implementation of health programs. Decentralized programs accountable to the
community and designed with the participation of different constituencies would be more
effective in addressing community needs.

Currently, there are major information gaps ranging from the lack of understanding of the ethos
and the concept of reproductive health and related gender issues, to questions about the changes
necessary at the policy and program level to implement services. This lack of information deters
the implementation of reproductive health programs. In a country as large and diverse as India,
multiple constituencies must be informed and empowered before any process of social change
can be significantly affected. Therefore, advocacy is needed at the central and state levels to
engage decision-makers in policy dialogue. A range of different constituencies, including
government and non-government organizations, as well as activists and researchers should be
involved to catalyze a process of networking with a growing number of organizations so that
programs relevant to client’s needs can be designed with the active involvement and
participation of all.
10
I. Reproductive Health

Concept, Framework and Ideology

The Concept

The past decade has witnessed a significant shift in the way population and reproductive health
problems are conceptualized. There has been a clearer articulation and definition of reproductive
health as a concept as well as some thinking on ways in which reproductive health problems
should be addressed. Reproductive health terminology is now part of the rhetoric of many
constituencies as there has been a growing discourse on issues related to population and
reproductive health and more recently on sexual health. This discussion reached its pinnacle
at the International Conference on Population and Development in Cairo where reproductive
health as a concept and as an ideology received global acknowledgment. The challenge now
is to translate this concept into policies and programs at the national level.

A reproductive health approach means that:

@ people have the ability to reproduce and regulate their fertility;
@ women are able to go through pregnancy and child birth safely;
@ the outcome of pregnancy is successful in terms of maternal and infant survival and well
being; and
@ couples are able to have sexual relations free of the fear of pregnancy and of contracting
disease (Fathallah, 1988).

The Framework

The proponents of the reproductive health framework believe that reproductive health is
inextricably linked to the subject of reproductive rights and freedom, and to women’s status and
empowerment. Thus, the reproductive health approach extends beyond the narrow confines of
family planning to encompass all aspects of human sexuality and reproductive health needs

11
during the various stages of the life cycle. In addressing the needs of women and men, such an
approach places an emphasis on developing programs that enable clients to make informed
choices; receive screening, counseling services and education for responsible and healthy
sexuality; access services for preventing unwanted pregnancy, safe abortion, maternity care and
child survival, and for the prevention and management of reproductive morbidity. Thus,
reproductive health programs are concerned with a set of specific health problems, identifiable
clusters of client groups, and distinctive goals and strategies.

The Ideology

A paradigm shift is needed for operationalizing reproductive health programs. A change in

focus from a population control approach of reducing numbers to a client-based approach of
addressing the reproductive health needs of individuals, couples and families, is necessary.

The reproductive health concept and ideology was globally endorsed at

Cairo. The challenge now is to translate the concept into policies and
programs at the national level.

Implementing reproductive health services within the national program in India would,
therefore, require an ideological shift, which in turn would necessitate a change in the existing
culture of the program from one that focuses on achieving targets to one that aims at providing
a range of quality services. This agenda recognizes that fundamental policy changes are needed
for its implementation; one that entails a shift of program focus from societal fertility reduction
to an explicit concern for assisting individuals to meet their personal reproductive goals. At the
aggregate level, it means that instead of remaining responsible for reducing the rate of
population growth, reproductive health programs would become responsible for reducing the
burden of unplanned and unwanted child bearing and related morbidity and mortality (Jain &
Bruce, 1994). Social and economic policies must then become responsible for achieving a broad
range of demographic goals at the macro-level.

Quality and Measurement

Reproductive health programs are designed to address clients’ needs and, therefore, an
important implication for their implementation is to ensure that the quality of services is
improved, particularly from the perspective of the user. Several studies have highlighted the
wide social and cultural gap that exists between the providers and users of services. In order
to bridge this gap, more attention should be focused on the users’ perspective within the overall
framework of the service delivery system. There is a need to specially focus on women since
they constitute the major client group or users of these programs and also have the greatest

12
problem of access, both physical and social, to health services (Pachauri, 1994a).

Quality is defined in terms of the way individuals and clients are treated by the system providing
services (Jain & Bruce, 1989). Using this principle, Bruce (1990) has evolved a working
definition of quality applicable to family planning services that incorporates six elements:
choice of methods; information provided to clients; technical competence of service providers;
interpersonal relations between service providers and clients; mechanisms to encourage

Implementing reproductive health services within the national program

in India would require an ideological shift, which in turn would
necessitate a change in the existing culture of the program from one
that focuses on achieving targets to one that aims at providing a range
of good quality services. |

continuity of care; and an appropriate constellation of services to address the reproductive

health needs of the users of these services. Although developed primarily for family planning
programs, this framework is to a large extent valid for reproductive health programs also.
However, some further refinements of the framework that are specific for reproductive health
services would be needed. This framework views the individual-level outcome as a consequence
of service-giving. It is based on the idea that the clients or users of services have a right to expect
knowledge and satisfaction, and that fulfilling those expectations is the most valued aim of
managers and service providers (Jain, 1992). A basic premise of this framework is that
improvements in service quality will result in client satisfaction and will, over the long term,
translate into higher contraceptive prevalence and ultimately in fertility reduction (Jain, 1992).
However, if the broader reproductive health needs of clients can be addressed by providing good
quality services, the program will be able to achieve the objectives of not only reducing fertility
but also reducing reproductive morbidity and mortality.

India’s demographic and health profile today is radically different to the conditions of the
national family planning program when it was launched in 1951. During this period, mortality
fell by nearly two-thirds, fertility declined by about two-fifths, and life expectancy at birth
almost doubled. India’s population has more than doubled since 1961. Mortality and fertility
decline ran roughly parallel for many years, so that the population growth rate remained above
2 percent per year until 1991. By 1992, India had achieved 60 percent of its goal of replacement
fertility (2.1 births per woman), with fertility having declined from about 6 to 3.4 births per
woman (Table 1, overleaf). The contraceptive prevalence rate is 45.4 percent.

To date, the impact of the family planning program has been measured mainly in terms of its
contribution to increase contraceptive prevalence and to decrease fertility. Since these

13
indicators do not reflect the impact of the program on morbidity and mortality, they are not
adequate for measuring the impact of reproductive health services. Unless these criteria for the
program’s success or failure are modified, the program will continue to be guided by overall
goals of reducing fertility by achieving targets.

Indicators for measuring the quality of health services from the perspective of the client are
necessary. For example, if a client avoids unplanned or unwanted childbearing safely, without
negative consequences to his or her health, the program is a success. Otherwise, it is a failure
(Jain, 1992). The challenge is to find ways to synthesize this information. There is an urgent
need to develop indicators that can be used to monitor reproductive health services. Pilot
projects should be undertaken to test the feasibility, reliability and effectiveness of monitoring
and evaluation systems, especially in those areas where contraceptive targets have been
removed.

Reproductive Morbidity and Mortality

According to the World Bank, about one-third of the total disease burden in developing country

TABLE 1: CHANGES IN KEY PARAMETERS 1951 TO 1992

Crude Birth Rate 4 1.7 37.2; 28.7

(SRS 1993)

Total Fertility Rate 4. 5 3.6

(SRS 1992)

Infant mortality rate 146.0 110.0 ~

(per 1000 live births) (SES 1993)
Couple protection 10.4 | 22.8 45.4
rate (%) (1970-71)
70- (March 1994)

No. of births averted tiet4.4

(estimated in millions)
| ch

Life expectancy at birth 4 iG 50.5j

(years) (1971-81) (1986-91)

Source: World Bank, 1995

14
 women 15 to 44 years of age is linked to health problems related to pregnancy, childbirth,
abortion, human immunodeficiency virus (HIV), and reproductive tract infections (RTIs).
Among diseases for which cost-effective interventions exist, reproductive health problems
account for the majority of the disease burden in women of this age group (World Bank, 1993).
There are substantial data to show that Indian women bear a heavy burden of reproductive
morbidity (Bang et al, 1989; Bang and Bang, 1991; Pachauri & Gittlesohn, 1994; Jejeebhoy
and Rama Rao, 1992). The heavy load of reproductive morbidity among Indian women is an
outcome of their poverty, powerlessness, low social status, malnutrition, infection, high
fertility, and lack of access to health care. Thus, socio-economic and biological determinants
operate synergistically throughout the lives of poor women to undermine their health, resulting
in high levels of morbidity and mortality (Pachauri, 1994a).

The magnitude of women’s reproductive health problems is reflected in the number of deaths
related to pregnancy and childbirth, the most direct indicator of reproductive health care.
India’s maternal mortality ratio, usually estimated at 400-500 per 100,000 live births, is fifty

There is a need to specially focus on women since they constitute the

major client group or users of reproductive health programs and also
have the greatest problem of access, both physical and social, to health
services. Indicators for measuring the quality of health services from the
? perspective of the client are necessary.

times higher than that of many developed countries and six times higher than that of
neighboring Sri Lanka (Ascadi and Johnson-Ascadi, 1990). According to the National Family
Health Survey, the maternal mortality ratio in 1992-1993 was 420 per 100,000 (International
Institute of Population Studies, 1994). Expressed another way, a woman living in India runs
a 300 times greater risk of dying in pregnancy and childbirth compared to a woman in the
developed world. Mortality statistics, however, tell us only a part of the story. One small study
conducted in India showed that for every woman who dies, an estimated 16 others develop
various illness (Datta et al, 1980). Some pregnancy-related illnesses are life threatening while
others are chronic and debilitating such as vaginal fistulas and uterine prolapse which cause
terrible suffering. More research is needed to understand maternal morbidity risks as data on
maternal morbidity are grossly lacking and community-based morbidity data for developing
countries are almost non-existent.

Although there is a high burden of reproductive morbidity, cost-effective interventions are also
becoming increasingly available. The challenge is to develop cost-effective packages of good
quality services to address the needs of specific client groups in various settings and to make
these available and accessible to all, and especially to the poor and the disadvantaged. Providing

15
comprehensive reproductive health services to all is a desirable goal but, since there is
considerable variability in the organizational capacity of programs in the different regions and
states of the country, the extent to which a program might expand without compromising the
quality and effectiveness of existing services must be seriously considered. There is clearly a
need to prioritize and to develop a phased approach with an incremental addition of health
interventions that require greater skills and resources.

The discussion in this paper focuses primarily on the role of government programs. However,
the private sector and non-government organizations (NGOs) also play an important role in the
provision of health care in the country. Consequently, it would be important to involve them
as partners in this effort. In addition, social marketing programs should also be redesigned to
include products and information not only for family planning but also for RTIs including those
that are sexually transmitted.

Recommended Package of Services

Rationale for Recommending a Package of Services

In this paper, an attempt has been made to develop a framework for defining a package of
reproductive health services for the country. The criteria used for selecting particular health
services included in the package are: cost-effectiveness; disease burden; levels of fertility and
mortality; and the capacity of the health infrastructure to deliver services effectively. The
rationale for suggesting a package approach is to enable program planners to: (1) assess the
feasibility and management implications for implementing various combinations of health
services at different levels of the health service system in diverse settings; and (2) examine the
cost, financing and sustainability implications of implementing these health services.

As there is enormous diversity in India among the regions and states as well as between rural
and urban areas, no single package of services can be recommended for nation-wide
implementation. While in underserved areas such as in the northern states of India there is a
continuing need to strengthen the health infrastructure and improve service access, in states
with the better developed programs such as Tamil Nadu and Kerala, efforts should now be made
to expand the range and quality of services provided. The availability of resources and the
capacity of the existing health infrastructure to deliver services effectively would determine the
choice of specific interventions and levels of technical complexity that can be effectively
integrated within existing programs.

In the section that follows, two packages of reproductive health services are discussed: 1) a
comprehensive package which at present would have limited application and 2) an essential
package which is recommended for nationwide implementation. Even the essential package
would require considerable managerial, technical and financial inputs for its implementation,

16
particularly in regions and states with weak infrastructural capacity (World Bank, 1995). The
proposed framework could be used to design reproductive health programs that are feasible,
affordable and effective in different contexts.

1) A Comprehensive Reproductive Health Services Package

Although a comprehensive reproductive health services package would at present have limited
application in India, it is outlined in this paper for two reasons. First, because it is important
to plan for the incremental addition of services in a phased manner particularly for the more
advanced states as well as for urban areas with better facilities; and second, because it may be
possible to implement this package of services in some selected areas. In areas where it is
implemented, it is recommended that operations research be undertaken to concurrently assess
the feasibility and effectiveness of the various health interventions included in this service |
package. The goal should be to expand the implementation of services incrementally and in a
phased manner by utilizing research results and lessons learnt from program experience. The
following services are included in a comprehensive reproductive health services package.

Prevention and management of unwanted pregnancy

Services to promote safe motherhood
Services to: promote child survival
Nutritional services for vulnerable groups
Prevention and treatment of reproductive tract infections and sexually transmitted
infections
Prevention and treatment of gynecological problems
Screening and treatment of breast cancer
Reproductive health services for adolescents
Health, sexuality and gender information, education and counseling
Establishment of effective referral systems

Clearly, this entire package of services, though desirable, would at present have limited
application. This package of services could be tried in selected urban areas where there is a
better availability of trained service providers and where it is possible to establish referral
linkages with multiple health facilities that are operating in these areas. It could also be tried
in selected districts of the more advanced states such as Kerala, Tamil Nadu and some others.

Each of the services in the recommended comprehensive package incorporates a number of

interventions. Some of these interventions can be implemented at the peripheral levels of the
health delivery system, while others require more sophisticated professional skills and facilities
and can, therefore, be implemented only at the higher level or at the peripheral level in areas
with adequate facilities. These issues are discussed in the following section. The last two
services, health, sexuality and gender information, education and counseling and the

17
establishment of effective referral systems, are not separate services but are critical for the
effective implementation of all the other reproductive health services within the service system.

It is recommended that operations research projects be undertaken in selected areas to assess

the feasibility and effectiveness of implementing interventions included in this service package
in order to document lessons learnt for improving the effectiveness of existing programs as well
as for planning new programs. Some of the research questions to be addressed are: How can
these interventions be operationalized? What are the short- and longer-range priorities? What
strategies should be designed to address the diverse needs of populations in different regions
and states? And what specific investments are needed? This package of services is recommended
for adoption, in a phased manner, in selected districts of states with a higher resource and
performance base. It should be concurrently evaluated to assess its feasibility and effectiveness.
NGOs should be encouraged to work in partnership with the government and also to develop
models of comprehensive reproductive health services. The feasibility and effectiveness of
these models should be carefully assessed. In addition, the private sector should also be an active
partner in the effort to provide high quality reproductive health services.

The effective implementation of this package of services has major implications for strengthening
existing service capacity, especially the managerial capacity of the public system. For
implementing this program effectively, there is a need to emphasize staff training and to put

Because there is tremendous diversity among regions and states as well

as between urban and rural settings, no single package of services can
be recommended. The proposed framework could be used for designing
reproductive health programs for particular settings.

in place equipment and supplies that would be necessary for providing these services. There
is an urgent need to strengthen the capacity of the delivery system at various levels to improve
the quality of services, particularly from the perspective of the user of these services and also
to ensure that there is better coordination among field level staff so that there is a convergence
of services at the user’s end. For example, services for the management of sexually transmitted
infections (STIs) and HIV/AIDS prevention programs that have been recently initiated by the
Health Department through the National AIDS Control Programme should be integrated with
services provided for the prevention and management of unwanted pregnancy and the
promotion of child survival and safe motherhood by the Department of Family Welfare as well
as with the Integrated Child Development Services (ICDS) Programme which provides food
supplements to vulnerable populations.

18
2) An Essential Reproductive Health Services Package

The following package of essential reproductive health services is recommended for nation-
wide implementation.

Prevention and management of unwanted pregnancy

Services to promote safe motherhood
Services to promote child survival
Nutritional services for vulnerable groups
Prevention and treatment of reproductive tract infections and sexually transmitted
infections
Reproductive health services for adolescents
Health, sexuality and gender information, education and counseling
Establishment of effective referral systems

All the services included in this package are presently recommended as a part of the
government’s Health & Family Welfare Programme. At present, limited reproductive health
services for married adolescents are provided through this program. In addition, food
supplementation programs are provided through the ICDS Programme. While all these
services are theoretically included in the national program and are specified in the various
policy and program documents, there have been serious problems with their implementation
at various levels of the health delivery system. There is a vast body of literature that highlights
the numerous structural and functional constraints that impede effective program implementation
and these are well understood by policy planners and program managers. These constraints
relate to access to services, program-client interactions, supervision and support, and program
financing.

For the effective implementation of the essential package of reproductive health services, these
issues must be addressed: First, the gaps in existing facilities must be filled and services
expanded to areas that are not served. Second, where reproductive health services are provided,
they must be adequately financed to ensure acceptable quality of care. The World Bank
estimates that only 17 percent incremental costs are associated with the provision of additional
services for moving the present family welfare program to a reproductive health approach. If
the entire costs are borne by the public sector, an additional amount of 8.9 percent of recurrent
costs per year in real terms would be needed for the program until the year 2000. These costs
would be minimized if some reproductive health services are also provided by NGOs and the
private sector (World Bank, 1995).

19
20
II. Recommended Services for Prevention, Treatment
and Management of Reproductive Health Problems

In the section that follows, a rationale is provided for recommending particular health
interventions in the package of essential health services and their importance and relevance in
the Indian context is discussed. An attempt is also made to delineate important elements that
are presently lacking and must be incorporated within the program to ensure the effective
implementation of the recommended services. The discussion focuses on interventions within
each service component that can be implemented at various levels of the health service system.
Health interventions that can be implemented at the community, subcenter, primary health
center (PHC) and community health center (CHC)/district/subdistrict hospital levels are
delineated in tabular form (Tables 2-5). These tables and the discussion in the text provide a
broad framework that could be used to design specific packages of reproductive health services
for particular settings.

There are significant differentials among regions and states in the staffing patterns and
facilities that are available at various levels of the health service system. In most areas at present,
subcenter facilities are reasonably well organized but cases that cannot be managed at this level
have to be referred to the subdistrict/district hospital which is usually at a considerable distance.
The PHC is the weakest link in the chain. While one PHC catered to a population of about
100,000 in the past, according to the present norms there is one PHC for a population of 20,000-
30,000 population. At present both old and the new PHCs exist. The old PHC has operation
theater facilities, the latter does not. In fact, the new PHC is often an upgraded subcenter. The
interventions recommended in the tables are feasible only at those PHCs that have an operation
theater and related facilities. CHCs are few in number and have yet to be fully organized. There
is an urgent need to upgrade PHC facilities and to develop more CHCs to improve access to
reproductive health services.

According to the government’s prescribed norms, in addition, to a voluntary worker who is paid
an honorarium, there is a provision for one male and one female multipurpose worker at each
subcenter. The female health worker is an auxiliary nurse midwife (ANM). A subcenter caters

21
to 5000 population in the plains and to 3000 population in hilly and tribal areas. The staffing
norms for the new PHC that caters to 30,000 population in the plains and 20,000 population
in tribal and hilly areas includes one medical officer, a pharmacist, a nurse midwife, a health
educator, one male and one female health assistant and one male and one female health worker.
The old PHCs have | to 3 physicians and more paramedical staff. The prescribed norms for staff
at the CHC include: five qualified or specially trained doctors — a surgeon, an obstetrician
gynecologist, a physician, a pediatrician, and a public health physician. In addition, there
should be seven nurse midwives, a dresser, a pharmacist/compounder, a laboratory technician,
and aradiographer at this facility. ACHC covers approximately 100,000 population (Government
of India, 1995). The CHC is expected to have facilities for managing obstetric emergencies.
Currently, there are very few CHCs with prescribed staff and facilities. Therefore, CHCs have
been clubbed with subdistrict and district hospitals in Tables 2-5.

In many areas staff are not in place at PHCs and CHCs according to prescribed norms. There
are particular gaps in the case of women physicians and male multipurpose workers. It is
difficult to recruit women physicians for rural facilities. The government proposes to contract
private physicians for PHCs and CHCs. The ANM is often the only staff member at the

There is a clear need to prioritize and to develop a phased approach

with an incremental addition of health interventions that require
greater skills and resources.

subcenter and, therefore, carries a heavy responsibility. Staff at the subcenter and PHC are
expected to provide outreach services to the community. However, community health workers
such as traditional birth attendants (TBAs), who are not a part of the formal health system, play
an important role in providing reproductive health services at the community level.

It is not possible to reflect the true ‘reality’ in India because of the enormous variations, not only
between states but also within states. Tables 2-5 show services that are available and those that
should be included within the rural health system. No systematic attempt has been made in this
paper to discuss how reproductive health services should be implemented in urban areas. Urban
health in India has been neglected even though the urban poor are growing in numbers and are
increasingly exposed to serious health risks.

Because there is tremendous diversity among regions and states and even within states as well
as between urban and rural settings, no single package of services can be recommended. The
proposed framework could be used for designing reproductive health service programs for
particular settings in India. Interventions that are not presently implemented in most parts of
the country have been highlighted in the tables. It should be noted, however, that latter are, in

22
fact, implemented in some areas but not in most parts of the country. These tables should be
re-formatted for specific areas to design reproductive health programs and to highlight those
interventions that require special attention. This framework could, perhaps, also be adapted for
designing reproductive health services in some other developing countries.

Prevention and Management of Unwanted Pregnancy

The program currently relies heavily on female sterilization which is by far the most dominant
method. However, there is a growing consensus among policy planners in India that the
overriding emphasis on female sterilization in the present program is not likely to achieve the
desired demographic goal of replacement fertility. A ‘basket of services’ is recommended to

For ensuring contraceptive safety the program must focus greater

attention on all clinical procedures, especially on aseptic techniques
and on screening clients for contraindications and pre-existing health
problems. Developing effective outreach programs should be a high
priority if counseling and follow-up services are to be provided,
especially in rural areas.

enhance choice for women. A greater emphasis should, therefore, be placed on increasing
method choice by including reversible contraceptive methods. Reversible methods are more
likely to affect birth rates and also to improve maternal and infant health. These methods,
however, require complementary attention to improving the quality of services and addressing
clients’ reproductive health needs.

Table 2 (overleaf) lists interventions for the prevention and management of unwanted
pregnancy that are recommended for implementation at different levels of the health service
system. Since there has been a particular emphasis in the program on providing family services,
several interventions are already in place. However, to improve access and quality of services,
there is a need to strengthen sexuality and gender information, education and counseling,
expand method choice and develop effective referral systems. Essential elements that must be
incorporated within a service delivery system that is designed to include reversible methods are
discussed below.

Method Mix and Informed Choice

Since contraceptive needs and preferences of clients are different and change over time, a broad
selection of reversible and irreversible methods should be available through a variety of service

23
 TABLE 2: SERVICES FOR THE PREVENTION AND MANAGEMENT
OF UNWANTED PREGNANCY AT DIFFERENT LEVELS OF
THE HEALTH SERVICE SYSTEM

Community Subcenter Level Primary Health Community Health

Level Center Level Center/District/Subdistrict
Hospital Level

Sexuality and Sexuality and gender Sexuality and gender Sexuality and gender
gender information, information, information, education and
information, education and education and counseling
education and counseling counseling
Expansion of contraceptive
_ counseling Expansion of Expansion of choice
Community contraceptive choice contraceptive choice
Provision of oral
mobilization Provision of oral contraceptives and condoms
Provision of oral
and education
contraceptives and contraceptives and
for adolescents, Insertion of IUDs after
condoms condoms
youth, men screening for contraindications
and women Insertion of IUDs after Insertion of IUDs after
Conducting sterilization
screening for screening for
Community- procedures
contraindications contraindications
based Provision of first and second
distribution of Counseling, Conducting vasectomy
trimester medical termination
contraceptives management and procedures
of pregnancy
referral for side-
Social marketing Performing first
effects, method- Counseling and
of contraceptives trimester medical
related problems, management of cases
termination of
Establishment and change of referred for side-effects,
pregnancy (upto 10
of effective method where method-related problems,
weeks)
referral indicated and change of method
systems — Counseling and where indicated
Motivation and
management of cases
referral for sterilization Establishment of effective
referred for side-
referral systems
Counseling and effects, method-
referral for medical related problems, and Management of referred
termination of change of method cases and feedback to
pregnancy where indicated referral source

Establishment of Motivation and referral

effective referral for tubal ligation
systems
Counseling and
Management of referral for second
referred cases and trimester pregnancy
feedback to referral termination
source
Establishment of
effective referral
systems

Management of
referred cases and
feedback to referral
source

Note: Health interventions that are not a part of the present program are highlighted.
delivering points including commercial outlets. The recent National Family Health Survey
shows that there is a large unmet demand for reversible methods (International Institute of
Population Studies, 1994). Condoms and oral contraceptives can be provided through social
marketing programs at the community level and should also be made available at subcenters.

Other methods, including permanent methods, should be available at PHCs and CHCs. The
addition of injectables, progestin-only pills (for women who are breast feeding), barrier
methods and spermicides should be considered in order to expand contraceptive choice and to
meet the needs of younger, lower parity couples (Table 2). The threat of HIV/AIDS and the
growing demand from women’s groups for barrier methods make a strong case for including
these methods in the basket of contraceptive services. Research shows that each new method
added attracts new users and improves continuation rates. Analysis of data from seventy-two
developing countries has shown that access to arange of methods greatly improved contraceptive
prevalence (Freedman and Berelson, 1976).

For ensuring contraceptive safety, the program must focus on all

clinical procedures especially aseptic techniques and on screening
clients for contraindications and preexisting health problems.
Developing effective out reach programs should be a high priority if
counseling and follow-up services are to be provided, especially
in rural areas.

With the availability of a real cafeteria of services, informed choice must form an important
element of the program. Service providers should help clients make decisions for selecting
contraceptive methods that are most appropriate for them. Clients should, therefore, receive
information on the contraindications as well as on the advantages and disadvantages of
contraceptive methods that are offered to them. Information should also be provided on what
clients can expect from service providers with regard to advice, support, supply, treatment,
referral and related services.

Contraceptive Safety

The objective of the program should be to provide people with the means to achieve their
reproductive goals in a healthful manner (Jain & Bruce, 1994). Contraceptive safety is an
essential requirement; the program must ensure that contraceptive services are delivered safely.
At the very least, those reproductive health problems that are directly related to the provision
of contraceptive services must be addressed by the program. For example, infections should not
be caused or exacerbated by the provision of contraceptive methods. Ensuring service quality

25
and safety is specially important for all surgical procedures. Special care must also be taken for
inserting intrauterine devices (IUDs), particularly in areas where RTIs and STIs are widely
prevalent and when the client’s RTI status is not known. Auxiliary nurse midwives (ANMs)
should be trained to provide informed choice of methods, counseling and follow-up care. If the
ANM is expected to insert IUDs at the subcenter as it is the case in several states, then subcenters
must be provided with equipment to enable her to effectively perform this procedure and special
training programs must be organized to ensure that she can develop the skills for inserting [UDs
safely.

A woman must be free of contraindications to the [UD which must be inserted under aseptic
conditions to prevent infection. Follow-up of acceptors must be regular and continuous as these
women are at greater risk of infection because RTIs can be exacerbated by the presence of IUDs.
IUDs can lead to increased menstrual bleeding, the increase being greater for women with
anemia, thus aggravating this condition (Zurayk, et al, 1994). For ensuring safety therefore,
the program must focus greater attention on all clinical procedures, especially on aseptic
techniques and on screening clients for contraindications and pre-existing health problems.

Counseling and Follow-up

Supportive counseling and follow-up services are essential elements of a program designed to
provide quality care, particularly for reversible methods. After the clients have made or
reconfirmed their choice of the method, counseling should concentrate mainly on the services
which they would receive on the proper use of the method. Follow-up services are especially
important in the initial period for providing advice and managing side-effects. Clients should
have access to service providers if they experience method-related problems and should have
the freedom to switch methods for which supportive counseling should be provided.

It is necessary to plan convenient follow-up contacts with clients and encourage them to
approach service providers at any time when they need to discuss their fears or problems. Follow
up visits are a good opportunity for continuing counseling and education and for discussing
related reproductive health issues that were not dealt with in the first visit. These visits also
provide an opportunity to discuss alternative choices if the client is not satisfied with the method
which is being used. Developing effective outreach should be a high program priority if
counseling and follow-up services are to be provided, especially in rural areas.

Male Participation and Responsibility

Special efforts should be made to encourage men to take responsibility for family planning.
Vasectomy is a simpler and safer procedure than tubectomy but the latter is, by far, the most
dominant method in the national program. Health providers should be pro-active by making
special efforts to reintroduce vasectomy into the program and should encourage men to accept

26
responsibility for family planning, reproduction and child care. Their fears and anxieties
regarding vasectomy should be allayed through counseling. In addition, the condom should be
promoted as a method to provide dual protection against both pregnancy and infection. For
those at risk of STIs, condoms should be advised even if the client or partner has been sterilized
or is using another family planning method such as the IUD or oral contraceptives.

Given that gender inequalities favor men in most societies in India and that sexual and
reproductive health decisions are made by men, there is a growing realization that unless men
are reached, program efforts would have limited impact. Research on sexuality, especially in
the field of HIV/AIDS, has highlighted the inadequacy of strategies that target only women who
are usually subordinate to men and, therefore, cannot effectively negotiate changes in sexual
behavior. Research on sexual negotiation has dramatically underscored the need for involving
men in programs that aim at bringing about changes in sexual behavior for the prevention of
infection.

However, such behavioral change is relevant not only for the prevention of infection but also

Given that gender inequalities favor men in most societies in India and
that sexual and reproductive health decisions are made by men, there is
a growing realization that unless men are reached, program efforts
would have limited impact.

for addressing other reproductive health problems. Other areas that should be examined
include working with men on concepts of masculinity and sexuality; opening up health care,
education and social welfare programs to increase the influence and acceptance of men;
working with communication systems to change images of the role of men as husbands and
fathers; and legal and political reforms.

Services for Safe Abortion

The Medical Termination of Pregnancy (MTP) Act was passed by the Indian Parliament in
1971 but what was thought to be a landmark in social legislation, has failed to translate into
reality for the majority of Indian women, particularly in rural areas. Today, there are more
illegal abortions in India than there were prior to the MTP Act with about 15,000-20,000
abortion-related deaths occurring annually, mainly among married, multiparous women.
(Chhabra and Nuna, 1994). These figures show that there is a vast unmet need for contraception
and safe abortion. Table 2 indicates that counseling and referral services for MTP should be
organized at the peripheral levels of the health care system. Services for first trimester abortion
should be made available at PHCs and facilities for second trimester abortions at CHCs.

27
Unsafe abortion is an important cause for maternal mortality and results in high levels of
maternal morbidity in India. In large part, this is due to the failure of the program to integrate
MTP services with family planning services. About 11-12 percent of maternal deaths in rural
India are due to septic abortion (Government of India, 1990). Septic abortions account for upto
25 percent of all maternal deaths in hospital studies in India (Bansal and Sharma, 1985; Mathur
and Rohatgi, 1981; Kamalajayaram et al, 1988). Community-based data, which would provide
more accurate estimates, are not available. Although unsafe induced abortion is the greatest
single cause of mortality for women, it is also the most preventable. Women need not die or
suffer medical consequences from abortions because abortions do not kill women; it is, rather,
unsafely performed abortions which kill (Maine 1991).

Expanding family planning services is an important strategy for decreasing pregnancy related
mortality and morbidity. The infant mortality rate could be significantly reduced by decreasing
the number of pregnancies, by spacing births and by delaying the age at first pregnancy.
Estimates show that if all women who state that they want no more children were able to avoid
future pregnancies, there would be a substantial decline in maternal mortality (Maine et al,
1987). However, even with vigorous family planning programs, there will always be some
unwanted pregnancies, and therefore, a demand for abortion. High levels of maternal mortality
associated with clandestine, unsafe abortions can be prevented by enhancing women’s access
to safe abortion services. The conceptual link between family planning and abortion is
fundamental. Effective contraception is an important means of preventing an unwanted

Unsafe abortion is an important cause of maternal mortality and results

in high levels of maternal morbidity in India. While public sector
programs should be strengthened to provide safe abortion services, there
is an urgent need to improve the quality of services provided by the
private sector as private practitioners are by far the most important
providers of abortion services in the country.

pregnancy and pre-empting the need for abortion, but in the absence of safe abortion back-up,
women will continue to be forced to employ unsafe means for terminating unwanted
pregnancies with attendant high maternal mortality and morbidity (Pachauri, 1993).

A recent report on abortion shows that poor women in India, particularly in rural areas, do not
have access to safe abortion services. Some of the important programmatic constraints that have
limited access are: rigid bureaucratic control; an inflexible approach; inadequate funding; lack
of training of health care providers; and poor monitoring of MTP services. The following
recommendations have been made for improving access to safe abortion services:

28
@ Equitable, need-based services should be organized country-wide.
@ The process of recognition of physicians and institutions to provide MTP services should
be decentralized to the district level.
@ The presently elaborate confidential recording and reporting procedures should be
simplified.
@ Women should be ensured the right to emergency care in life-threatening circumstances.
@ First trimester abortion services should be made widely and easily available and there
should be a clear differentiation between first and second trimester abortions for the
registration and organization of facilities.
@ The net of service providers who can be trained to deliver MTP services in the early first
trimester should be widened.
@ The MTP Act should be reexamined and reframed to remove legal, bureaucratic and
medical constraints. (Chhabra and Nuna, 1994).

While public sector programs should be strengthened to provide safe abortion services, there
is an urgent need to examine the quality of services provided by the private sector and to
organize training programs for private practitioners, as they are by far the most important
providers of abortion services in the country.

Services to Promote Safe Motherhood

Although maternal and child health (MCH) services form an integral part of the Family
Welfare Programme, the program has focused primarily on efforts to improve child survival.
Maternal health has suffered from relative neglect in this program. There is, therefore, an
urgent need to strengthen maternity care services. Tables 3A, B & C list interventions that
should be implemented at various levels of the health service system to promote safe
motherhood.

Maternity Health Services

Services for maternity care should be designed to ensure timely detection, management and
referral of complications during pregnancy, delivery and the postpartum period. Because of
their impact on the health of the mother and the child, maternity services are highly cost-
effective. Providing antenatal, delivery and postpartum services costs less than $2000 per death
averted (World Bank 1993). Virtually all interventions to improve women’s health in
pregnancy, labor and delivery have positive impacts on pregnancy outcome and child health
but the reverse is not the case. Maternity services have received minimal attention in the
National Family Welfare Programme. In recent years there has been an effort to remedy this neglect
with the implementation of the safe motherhood initiative. This program must now receive priority
within the family welfare strategy. The following services need immediate attention:

29
ANTENATAL SERVICES

In Table 3A interventions that should be implemented at the community and subcenter level
are highlighted since many women do not have access to higher level facilities. In addition, the
need for strengthening two-way referral systems, especially for complicated pregnancies and
interventions for the management of STIs and RTIs, (especially, screening for syphilis during
the antenatal period, to prevent maternal and neonatal morbidity and mortality) are highlighted
in this Table since these services are not being implemented in the program at present.

Antenatal services should be organized to detect and manage complications related to

pregnancy such as anemia, infection, pre-eclampsia, malpresentation and obstructed labor.
Women should be educated about the danger signs of pregnancy and provided information on
where to seek help. Antenatal visits should provide an opportunity to offer advice and
counseling on hygiene, breastfeeding, nutrition, family planning and immunization as well as
to treat pre-existing conditions such as diabetes and infections such as malaria and tuberculosis
that are commonly prevalent, may be aggravated by pregnancy, and may complicate pregnancy
(World Bank, 1994).

There is no universal protocol for the content and timing of antenatal care. However, an
essential minimal package of antenatal services must be implemented. [WHO is currently
undertaking a large research project which should shed some light on this issue within the next
few years.] There should be at least 3-4 antenatal examinations by a health care provider. The
first visit should take place as soon as pregnancy is detected, preferably before 10 weeks to
confirm the pregnancy; provide nutritional advice and supplements; and provide the first dose
of tetanus toxoid immunization. A second visit is recommended at 20-24 weeks to detect and
treat abnormalities; to identify and refer cases with complications; and to provide the second
tetanus toxoid injection. A visit at 28-32 weeks would enable the service provider to detect
malpresentation and to diagnose and treat maternal illnesses. An antenatal visit should be
made at 36-38 weeks to confirm the position of the fetus; to make an assessment of
cephalopelvic disproportion; and to manage maternal illnesses.

The number and content of antenatal visits should be expanded in accordance with the
availability of trained staff and facilities at PHCs and CHCs. Equipment and supplies should
be made available at all these health facilities, including at the subcenter. To manage antenatal
cases effectively, the ANM must have essential equipment and supplies. The subcenter must
be equipped for examining hemoglobin, blood pressure, urine albumin and sugar, and for
checking body weight and height.

Outreach services should be strengthened to ensure that all women are registered as early in
pregnancy as possible and antenatal care initiated. In addition, PHC’s must also be upgraded
to manage some complications and provide facilities for delivery.

30
 TABLE 3A: ANTENATAL SERVICES AT DIFFERENT LEVELS
OF THE HEALTH SERVICE SYSTEM

Community Subcenter Level Primary Health Community Health

Level Center Level Center/District/Subdistrict
Hospital Level

Counseling and Counseling and Counseling and Counseling and education for
education for education for education for breastfeeding, nutrition, family
breastfeeding, breastfeeding, breastfeeding, nutrition, planning, rest, exercise, etc.
nutrition, nutrition, family family planning, rest,
Immunization for tetanus
family planning, rest, exercise, etc.
prevention
planning, rest, exercise, etc.
Immunization for tetanus
exercise, etc. Birth planning
Immunization for prevention
Detection and tetanus prevention Provision of antenatal
Detection and referral of
referral of services at clinics (at least 4
Treatment of malaria cases with complicated
cases with visits)
pregnancies
complicated Birth planning
Management of cases with
pregnancies Birth planning
Provision of complications
Immunization antenatal services at Treatment of malaria
Treatment of malaria
for tetanus clinics and through Treatment of
outreach (at least 4 Treatment of tuberculosis
prevention tuberculosis
visits) Routine testing for syphilis
Birth planning Provision of antenatal
Detection and Diagnosis and treatment of
services at clinics and
referral for RTIs and STIs
through outreach (at
complications, e.g.,
least 4 visits) Management of referred
hypertension,
Detection and cases and feedback to
preecclemphxia,
management of referral source
eccalmpsia, severe
anemia, malaria, complications, e.g.,
tuberculosis, hypertension,
diabetes, antepartum preecclemphxia,
hemorrhage and malaria, tuberculosis
cephalopelvic and diabetes
disproportion Referral for hospital
Detection and delivery in cases with
referral of women complications
with RTIs and STIs Routine testing for
syphilis
Diagnosis and
treatment of selected
RTIs and STIs, and
referral for others
Management of
referred cases and
feedback to referral
source

Note: Health interventions that are not a part of the present program are highlighted.
 SAFE DELIVERY SERVICES

All deliveries must be managed by trained birth attendants. Normal deliveries can be managed
at home or at an institution but in all cases infection must be prevented by ensuring clean
delivery practices. Because complications can develop without warning, it is critical to put in
place effective systems to ensure timely referral and management of emergency complications.
Death from hemorrhage, for example, can occur within two hours of the onset of bleeding.
Establishing effective referral systems for life-threatening complications is, therefore, critical
for saving women’s lives. Communities should be involved in organizing timely transportation
for women needing care to the referral facilities.

As a part of the safe motherhood initiative, first-level referral units (FRUs) with specialists and
equipment are now being established to treat complicated pregnancies and obstetric emergencies
in selected states and districts. Innovative approaches are needed to attract specialists to work
at these rural units and to expand their reach so that peripheral level institutions can be
upgraded to provide specialist care.

However, the vast majority of births in India take place at home. The National Family Health
Survey shows that in 1992-93 only 25.6 percent of all births and 16.1 percent of all rural births
were conducted in institutions and as many as 65 percent were delivered by traditional birth
attendants (International Institute of Population Studies, 1994). An immediate priority
therefore, is to ensure safe home delivery by trained birth attendants. Traditional birth
attendants must be trained to recognize danger signs and ensure timely referral to FRUs.
Programs should, therefore, be organized to ensure that all pregnant women are registered in
the first trimester of pregnancy; are provided antenatal services; and those with complications
are referred for specialized services to FRUs. Guidelines for operationalizing FRUs have been
developed by the Department of Welfare (Government of India, 1993). In Table 3B several
interventions to be implemented at the community and subcenter levels are highlighted because
- most deliveries are conducted at home. The need for conducting clean home deliveries using
safe delivery kits and the importance of recognizing danger signals for emergency obstetric care
are highlighted in the table.

POSTPARTUM SERVICES

To date, postpartum programs in India have focused primarily on providing family planning
services. These programs have had limited success because they have not been designed to
address women’s reproductive health needs. Postpartum programs should include services for
the early detection and management of infection and hemorrhage; support for breastfeeding for
at least six months; nutrition counseling; and family planning services. Educating women,
their families, birth attendants, and community health workers to recognize early signs of
complications and seeking care for hemorrhage and infection, for example, may be lifesaving.

32
 TABLE 3B: DELIVERY SERVICES AT DIFFERENT LEVELS
OF THE HEALTH SERVICE SYSTEM
Community Subcenter Level Primary Health Community Health Center/
Level Center Level District/Subdistrict Hospital
Level

Detection of Detection of Detection of Provision of institutional

pregnancy pregnancy complications and delivery services
complications complications and referral for hospital
Treatment of pregnancy
and referral for referral for hospital delivery
complications
hospital delivery delivery
_ Cleanhome
Management of obstetrical
Clean home Clean home deliveries * deliveries
emergencies
deliveries with with delivery kits
Supervision of a
delivery kits Routine prophylaxis for
Recognition of home deliveries by
gonococcal infection in the
Recognition of danger signals ANMs
newborn
danger signals (rupture of
Treatment of
(rupture of membranes of more Arrangement of transport
infection
membranes of than 12 hours for obstetrical emergencies
more than 12 duration, prolapse Routine
Management of referred
hours duration, of the cord, prophylaxis for
cases and feedback to
prolapse of the hemorrhage) and gonococcal
referral source
_ cord, referral infection in the
hemorrhage) and newborn
Supervision of home
referral Arrangement of
deliveries by ANMs
Routine transport for
Routine prophylaxis
prophylaxis for referral
for gonococcal
gonococcal Management of
infection in the
infection in the referred cases and
newborn
newborn feedback to
Treatment of
Arrangement of referral source
infection
transport for
referral Arrangement of
transport for
referral

Note: Health interventions that are nota part of the present program are highlighted.
Antibiotic treatment is sufficient to cure infection in more than 80 percent of cases if taken
within four days of the onset of fever (Winikoff et al, 1991). ANMs must, therefore, be trained
to treat and to refer cases.

If postpartum programs are designed to respond to women’s needs and preferences, they will
be better utilized. In addition to providing follow-up and counseling services immediately after

33
birth, these programs should be organized to provide health services and information for the
mother and the infant up to the fortieth day after birth which is culturally considered to mark
the end of the postpartum period. In most communities, special social events are organized to
celebrate the birth of a child. Postpartum services may be better accepted if they are linked with
such religious and cultural activities. In Téble 3C, a number of interventions that should be
implemented through outreach care and are required for the detection and referral of
complications in women as well as for the management of the newborn with complications, are
highlighted.

All deliveries must be managed by trained birth attendants and

postpartum programs should be designed to respond to women’s needs
and preferences. Because complications can develop without warning,
it is important to put in place effective systems to ensure timely referral
and management of emergency complications.

With a few exceptions, maternity benefits schemes have not been provided for women in the
non-formal sector in India. However, the government now proposes to launch a national
scheme to provide maternity benefits to all women for their first and second births.

Services to Improve Child Survival

Services to improve child survival are included in the reproductive health package because
several interventions for improving child survival, particularly those designed to reduce
perinatal and neonatal mortality, are related to maternal health and thus to improving women’s
reproductive health.

The child survival program in India has received considerable attention during the past decade
and there have been significant declines in infant mortality. The infant mortality rate (IMR),
however, varies significantly between urban and rural areas and between regions and states.
There are considerable variations even within states. Therefore, efforts to extend program
coverage must be continued with particular emphasis on states with higher IMR. In areas where
significant mortality reduction has been achieved, however, further declines in IMR will only
occur if additional reproductive health interventions are implemented. The focus of the child
survival program in India has, so far, been on controlling immunizable and diarrheal diseases,
and more recently, on managing acute respiratory infections. Thus, efforts have primarily been
_ directed at reducing post-neonatal mortality. The program should now begin to focus its efforts
also on reducing perinatal and neonatal mortality, particularly in those states where there have
been significant mortality reductions. These interventions are linked to maternal health status

34
 TABLE 3C: POSTPARTUM SERVICES AT DIFFERENT LEVELS OF
THE HEALTH SERVICE SYSTEM

Community Subcenter Level Primary Health Community Health

Level Center Level Center/District/Subdistrict
Hospital Level

Provision of Provision of Provision of Provision of postnatal

postnatal care postnatal care postnatal care care through four
through four through four through four postpartum visits (less
postpartum visits postpartum visits postpartum visits than 24 hours, 7-10 days,
(less than 24 hours, (less than 24 hours, (less than 24 hours, 3-4 weeks and 5-6 weeks)
7-10 days, 3-4 weeks 7-10 days, 3-4 weeks 7-10 days, 3-4 weeks
Provision of breastfeeding
and 5-6 weeks) and 5-6 weeks) and 5-6 weeks)
support
Provision of Provision of Provision of
Provision of family
breastfeeding support breastfeeding support breastfeeding support
planning, counseling and
Provision of family Provision of family Provision of family services
planning, counseling planning, counseling planning, counseling
Provision of nutrition
and services and services and services
education and supplements
Provision of nutrition Provision of nutrition Provision of nutrition
Treatment of puerperal
education and education and education and
scepsis
supplements supplements supplements
Manual removal of retained
Management of mild Treatment of Management of
placenta
and moderate puerperal scepsis women referred with
asphyxia of the complications Resuscitation for asphyxia
Management of mild of the newborn
newborn
and moderate Treatment of
Management of asphyxia of the puerperal scepsis Management of neonatal
neonatal newborn hypothermia
Resuscitation for
hypothermia Management of asphyxia of the Management of referred
Outreach care within neonatal newborn cases and feedback to

24 hours of delivery hypothermia referral source

Management of
by subcenter or PHC neonatal
Treatment for some
staff hypothermia
and referral for
Management of low other complications Referral for
birth weight (2000- complications
2500 grams) infants
by feeding, Management of
temperature control referred cases and
and infection feedback to referral
prevention measures source

Detection and
referral for
complications

Note: Health interventions that are not a part of the present program are highlighted.
and are, therefore, a part of the reproductive health services package. Table 4 lists interventions
that should be implemented at different levels of the health service system for improving child
survival.

Services to Reduce Perinatal and Neonatal Mortality

Perinatal and neonatal mortality constitutes a significant proportion, 50-60 percent of all infant
mortality. Prematurity and growth retardation, important causes of death in the first month of
life (the neonatal period), are inextricably related to the health of the mother. Therefore,
interventions for improving maternal health must be implemented in order to reduce neonatal
and perinatal deaths. Maternal malnutrition and infection which have a synergistic impact on
pregnancy outcome are important risk factors. Other causes of neonatal death are asphyxia,
birth injuries, infection of the newborn and congenital defects.

Maternal Nutrition

The effect of pre-pregnancy weight and weight gain during pregnancy on birth weight and
pregnancy outcome has been well documented (Pachauri and Marwah, 1971). Studies show
that continued heavy work during pregnancy coupled with low dietary intake may adversely
affect maternal nutrition and the course and outcome of pregnancy because of the energy deficit
due to the gap between energy intake and energy expenditure (Gopalan, 1962).

The association between anemia and low birth weight, prematurity, perinatal mortality and
maternal mortality has been extensively documented in India. In hospital studies, high
mortality has been reported for pregnant women who have anemia (Rao, 1975; Sen Gupta and
Gode, 1987). Indian studies show that a fall in maternal hemoglobin below 11 gms/dl is
associated with a significant rise in the perinatal mortality rate. There is usually a two to three-
fold increase in perinatal mortality when maternal hemoglobin levels fall below 8 gms/dl and
an eight to ten-fold increase when maternal hemoglobin levels fall below 5 gms/dl. Maternal
mortality rates show a steep rise when maternal hemoglobin levels fall below 5 gms/dl (Prema,
et al 1981). The prevention of anemia is clearly a priority but strategies implemented in the past
have not demonstrated impact. Evaluation of the anemia prophylaxis program shows that the
prevalence of anemia during pregnancy has remained essentially unaltered over the past three
decades (Indian Council of Medical Research, Beate Therefore, the strategies used for this
intervention should be re-evaluated.

Anemia antedates pregnancy, gets aggravated during pregnancy, and the repeated succession
of rapid pregnancies and lactation perpetuate the problem. Serious problems of reaching
pregnant women with supplements as well as of compliance has raised some questions on
whether pregnancy is the best time for offering interventions to prevent anemia in women.
Studies show that women continually bear an enormous burden of anemia. In a World Health

36
Organization (WHO) study for instance, the mean hemoglobin level reported for all ages and
parity groups in India was 7.5 gms/dl or less (Omran and Stanley, 1976).

Waiting to treat anemia until pregnancy, when hemoglobin drops physiologically, ensures that
more women will have more severe anemia. The anemia prophylaxis program in India has
targeted women only during pregnancy. Anemia continues to be widely prevalent because
nothing is done to improve the nutrition of the young girl, the growing adolescent, the married
woman before her first pregnancy, between pregnancies and after pregnancy (Winikoff, 1988).
It is, therefore, recommended that programs for nutrition education and micronutrient
supplements such as iron and folic acid, should be targeted to all women in the reproductive
age group and also to adolescent girls. For improving nutritional status, there should be a
greater emphasis on nutrition education programs and on reaching and targeting pregnant and
lactating women as well as adolescent girls for food supplementation programs.

Perinatal and neonatal mortality constitutes a significant proportion,

50-60 percent of all infant mortality. Prematurity and growth
retardation, important causes of death in the first month of life, are
affected by the health status of the mother. Because of their impact on
the health of the mother and the child, maternal health services are
highly cost-effective. :

Maternal Infection

Maternal immune depression and increase in morbidity due to infections have been reported
in women with hemoglobin levels below 8 gms/dl (Prema, et al, 1982). Immune depression due
to anemia and the consequent increased morbidity due to infection, especially urinary tract
infections (UTIs) and RTIs, are factors responsible for low birth weight in anemic women.
Screening for, and effectively treating infections in anemic women should, therefore, result in
improved pregnancy outcome. As almost every RTI has been associated with prematurity and/
or growth retardation (Wasserheit, 1989), services for the diagnosis and treatment of RTIs may
present a relatively cost-effective intervention for reducing neonatal mortality particularly in
areas with high levels of RTIs.

Services for the Newborn

Services for the newborn have received scant attention in the national program although
recommendations for organizing essential neonatal services were made more than a decade
ago. A task force, set up by the Ministry of Health and Family Welfare, made recommendations

37
for providing minimum perinatal care in 1982 (Government of India, 1982). This task force
recommended strategies for strengthening perinatal care through a three-tier system. It
recommended that level I care should be available to all and should comprise four antenatal
examinations at 20, 30, 34 and 38 weeks of gestation when the mother should receive
immunization against tetanus, nutritional advice and supplements, and should be assisted to
plan for her delivery. Neonatal services should be provided to ensure adequate cardio-
respiratory effort, control of temperature, asepsis, cord care, weight record and physical
examination to identify cases with complications including congenital defects. The ANM and
the traditional birth attendant (TBA) should be trained to provide minimal, first level care at
home or at the subcenter level and to refer cases with complications.

Level II care should be provided at CHCs or upgraded PHCs with better facilities and skilled
manpower. Regional perinatal centers with trained neonatologists, laboratory facilities and
intensive care units should provide level III care. Only a few selected regional centers can be
recommended for level III care because of the high cost and sophistication of facilities that are
needed for providing tertiary care. However, low-cost neonatal care facilities have been
successfully organized at the district and subdistrict hospitals on a pilot basis in Tamil Nadu
(Rajan, 1995). The feasibility and effectiveness of such pilot projects for reducing perinatal and
neonatal mortality should be assessed in other states. Table 4 lists child survival interventions
to be implemented at various levels of the health service system and highlights the importance
of detection and referral of newborns with complications to prevent mortality. In addition
routine prophylaxis for gonococcal infection is recommended for the prevention of eye
infections. The cost-effectiveness of this intervention is discussed in the section on prevention
and treatment of RTIs and STIs.

Nutritional Services for Vulnerable Groups

Food supplementation programs for pregnant and lactating women are organized at the village
level through the Integrated Child Development Services (ICDS) Programme which presently
covers about 40 percent of the community development blocks in the country. Closer linkages
should be developed between health workers and ICDS workers to ensure that women receive
food supplements at least in areas where the ICDS Programme is implemented. Nutrition
education programs and iron and folic acid supplements are provided through the MCH
program nationwide. A detailed discussion on nutritional services for reducing maternal and
infant mortality and morbidity is provided in earlier sections. The scope of these programs
should be expanded to include not only pregnant and lactating women but all women. In
addition, nutritional interventions should also be organized for adolescent girls. Improving the
nutritional status of the girl child would clearly have an important health impact.

In some states such as Tamil Nadu, mid-day meal programs are implemented for school
children. Plans are underway to implement the National Programme of Nutrition Support for

38
 TABLE 4: CHILD HEALTH SERVICES AT DIFFERENT LEVELS OF
THE HEALTH SERVICE SYSTEM

Community Subcenter Level Primary Health Community Health

Level Center Level Center/District/Subdistrict
Hospital Level

Health education for Health education for Health education for Health education for breast-
breast-feeding, breast-feeding, breast-feeding, feeding, nutrition,
nutrition, nutrition, nutrition, immunization, etc.
immunization, etc. immunization, etc. immunization, etc.
Provision of immunization
Provision of Provision of Provision of
Supplementation of Vitamin A
immunization immunization immunization
Treatment of diarrhea
Supplementation of Supplementation of Supplementation of
Vitamin A Vitamin A Vitamin A Treatment of acute respiratory
infections
Treatment of diarrhea Treatment of diarrhea Treatment of diarrhea
without dehydration with mild/moderate Treatment of infection
Treatment of acute
dehydration Provision of first aid for
Treatment of some respiratory infections
upper respiratory Provision of first aid injuries, etc.
Provision of first aid
infections for injuries, etc. Treatment of infants referred
for injuries, etc.
Management of Treatment of some with low birth weight, asphyxia,
Treatment of infection
mild and moderate upper respiratory infections, severe dehydration,
asphyxia and low infections Management of acute respiratory infections, etc.
birth weight infants referred cases
Treatment of mild Provision of routine
(2000-2500 grams) Referral of infants with prophylaxis for gonococcal
and moderate
Provision of routine asphyxia and complications infection
prophylaxis for management of low Treatment of Management of referred
gonococcal infection birth weight infants asphyxia and cases and feedback to
(2000-2500 grams) management of low referral source
Referral of infants
with complications Provision of routine birth weight infants
prophylaxis for (2000-2500 grams)
gonococcal infection Provision of routine
Referral of infants prophylaxis for
with complications gonococcal infection
Management of
referred cases and
feedback to referral
source

Note: Health interventions that are not a part of the present program are highlighted.

39
Primary Education nation-wide. Improving the nutritional status of the child would clearly
have an important health impact. Such programs would also provide an incentive for parents
to send their children to school and to reduce the school drop-out rates, especially for girls. The
links between women’s education and reproductive health, especially with fertility and child
mortality are well established. These programs should, therefore, have important positive
consequences.

Prevention and Treatment of Reproductive Tract Infections and Sexuality

Transmitted Infections

Services for the prevention and treatment of RTIs and STIs are not currently implemented.
However, early efforts are underway to develop these services. Because experience with these
services is, at present, limited, a more detailed discussion is provided on the rationale for
including these services as well as on strategies to integrate these services within existing
programs. The linkages between services for the prevention and treatment of RTIs and STIs
and family planning and MCH services are also discussed.

Recent years have witnessed a growing concern for RTIs, especially those that are sexually
transmitted. The serious threat of the acquired immune deficiency syndrome (AIDS) has drawn
attention to the importance of STIs. RTIs and their sequelae are inextricably intertwined with
key health programs, such as those concerned with family planning, child survival, women’s
health, safe motherhood, and HIV prevention. RTI syndromes have profound implications for
the success of each of these initiatives and conversely, these initiatives provide a critical
opportunity for the prevention and control of RTIs. From the program and policy perspective,
therefore, RTIs could offer a strategically important common element for reproductive health
programs. However, substantial political will and commitment, profound changes in scientific
approaches, sexual behavior, and gender power relations are necessary to achieve these
program goals (Germain et al, 1992).

Strong programmatic and epidemiological reasons have been put forward for considering
family planning and MCH services as an appropriate focal point for the prevention and control
of RTIs and STIs: First, these services require access to the same client groups - sexually active
populations.

Second, providers of these services require similar skills for addressing the needs of their
clients. Third, both aim at modifying sexual behavior. Fourth, condoms and other barrier
methods and spermicides are common technologies presently available for the prevention of
STIs and unwanted pregnancies. And finally, since these infections can seriously affect the
health of the mother and the newborn child, their diagnosis and management during pregnancy
is particularly important. These infections can result in infertility, chronic pelvic inflammatory
disease, ectopic pregnancy and can adversely affect child survival by causing pre-term delivery

40
of low birth weight, immature infants. The special risk of HIV in women, particularly during
pregnancy, the increasing number of HIV infections resulting from mother-to-child transmission,
the rising numbers of children affected by AIDS, and the fact that HIV can be transmitted
through breast milk, are problems that have serious implications for maternal health and child
survival (Pachauri, 1993b).

Reproductive Tract Infections and Family Planning

There are many areas of strategic interdependence between initiatives concerned with RTI
morbidity and family planning programs. RTIs may decrease acceptance and continuation of
contraceptive methods either directly when the client believes that the symptoms of infection
are a contraceptive side-effect or indirectly, by creating a fear of limiting or delaying fertility
because of frequent complications of RTIs, which prevent healthy childbearing (Germain, et
al, 1992). Several researchers have discussed the effect of infertility on contraceptive

RTIs, STIs and their sequelae are inextricably intertwined with key
health programs, such as those concerned with family planning, child
survival, safe motherhood, and HIV prevention.

acceptance (Caldwell et al, 1989; Rosenberg et al, 1986). Such effect is more evident in
communities with high levels of infertility where studies show that women are most likely to
attribute RTI symptoms to their contraceptive method (Bhatia, 1982; Hopcraft et al, 1973).
These findings indicate that programs for the diagnosis and treatment of RTIs may be essential
to the success of family planning programs.

By compromising fertility, pregnancy outcome and child survival, RTIs may decrease the
demand for contraception. If symptoms of RTIs are perceived as side-effects of contraceptive
methods, there is likely to be high discontinuation of these methods. Real or perceived
association between RTIs and contraceptive methods, particularly in settings where women
suffer from high levels of RTI morbidity and where family planning programs do not have the
facilities for RTI screening and treatment, can seriously jeopardize the use of methods such as
the IUD. While screening of potential IUD acceptors for RTIs is recommended for all programs
and is routinely carried out in developed countries, it is not a part of family planning services
provided in resource-poor settings where the risks are high and where such screening is most
needed. Several studies have shown that women in India bear the symptoms of RTIs silently
without seeking any health care. While some of this reflects a lack of an awareness and a
fatalistic approach that this is a ‘woman’s lot in life,’ it also reflects the reality that there are
no facilities where women can seek treatment. (Pachauri, 1994a).

The prevalence and consequences of RTIs also form an important dimension in an expanded

41
concept of unmet need. In a recent essay, Ruth Dixon-Mueller and Adrienne Germain define
a broader scope of unmet need. They argue that the concept of unmet need should include
recognizing the need among non-users at risk of unwanted pregnancy for any method of
contraception, as well as the need among some users for a more effective, satisfactory, or safer
method; the need among both users and non-users for treatment of contraceptive failure (or
non-use) through safe and accessible abortion services; and the need for related reproductive
health services such as the prevention and treatment of RTIs (Germain and Dixon-Mueller,
1992).

Reproductive Tract Infections, Maternal Health, and Child Survival

A working group convened by the WHO to examine cost-effective interventions for reducing
maternal and infant infectious morbidity concluded that five cost-effective interventions are
available, of which the first four concern infectious morbidity related to RTIs. These are
prophylaxis against gonococcal ophthalmia neonatorum (eye infections in the newborn),
prenatal screening and treatment for maternal syphilis, training of traditional birth attendants,
hepatitis B immunization of infants, and immunization of mothers with tetanus toxoid to
prevent neonatal tetanus (WHO, 1992).

Schultz and co-workers compared the seriousness of problems caused by RTIs in developing
countries with that of infectious diseases currently addressed by donor agencies, and surmised
that not only are the problems caused by RTIs at least as serious as those caused by the
immunizable diseases currently addressed, but several RTI interventions are also more cost-
effective. The cost per child for full immunization in developing countries was estimated to vary

Strong programmatic and epidemiological reasons have been put

forward for considering family planning and MCH services as an
appropriate focal point for the prevention and control of RTIs and STIs.

between US $5 and $15 (EPI, 1985). The cost effectiveness estimates for immunizable diseases
ranged from $40 to $150 per adverse outcome averted. By comparison, in many locations in
the Third World, $1.40 would avert one case of gonococcal neonatorum and $12 would avert
an adverse outcome associated with syphilis during pregnancy. While women’s health benefits
were not computed in these cost-effectiveness analyses, synergistic effects to the woman in
many instances would enhance the attractiveness of the interventions proposed (Schultz et al,
1997);

Sexually Transmitted Infections and HIV/AIDS

The AIDS pandemic has emphasized the urgent need for increased support for policy, research

42
and education for the prevention and control of STIs. It has highlighted the importance of
sexual transmission in the spread of infection as well as the lack of control programs for STIs
in many parts of the world (Piot et al, 1992). In their search for a possible explanation of the
ravaging AIDS pandemic, professionals have begun to unravel several linkages between HIV
and STIs. During the last decade, research on the relationship between HIV and other STIs has
revealed several important findings. Research studies show that the sexual transmission of HIV
may be facilitated by the presence of other STIs, which perhaps partly explains the differing
rates of spread of HIV around the world (Piot et al, 1992). On the other hand, the natural history
of STIs and their response to treatment may be altered by HIV (Laga, 1992).

Based on a number of baseline surveys and a review of the available scientific literature, the
annual incidence of STIs in India is estimated at 5 percent, which indicates that approximately
40 million new infections occur every year. The brunt of the burden of direct and long-term
morbidity related to STIs is borne by women. Women suffer more complications, and in much
larger numbers than men, women suffer asymptomatic or mildly symptomatic infections. As
many as 50 percent of women with gonococcal infection are asymptomatic, and for infections
with chlamydia this number is even higher (van Dam, 1994).

Although limited research data are available on STIs in India, studies have shown that the range
of positive syphilis serology among women attending antenatal clinics ranged from 1.1 to 4.8
percent in different cities. In a study in Jaipur, 13.6 percent antenatal clinic cases had
candidiasis, 13.2 percent had trichomoniasis, 1.6 percent had gonorrhea, and 1.6 percent had
syphilis (van Dam, 1995). There was generally a relatively low awareness of reproductive and
sexual health among women, and their access to non-stigmatizing health services was severely
restricted. It is recommended that initially STI services should be provided to symptomatic
women, but depending on the availability of simple diagnostic tools, these services should
subsequently be extended to asymptomatic women as well (van Dam, 1994).

The essential elements of a control program for sexually transmitted infections are:
@ information, education and communication for the promotion of safer sexual behavior,
including consistent condom use; and the promotion of appropriate health care seeking
behavior especially for individuals with STI related symptoms, and those at increased risk
of infection;
@ provision of clinical services for the diagnosis and treatment of symptomatic and
asymptomatic patients and their partners; and
@ provision of condoms of good quality at affordable prices (van Dam, 1994).

In the past, because of the complexity of diagnosis and the expense of treatment, RTI and STI
interventions have appeared to be beyond reach. However, recently proposed alternatives that
simplify case management of STIs such as using a syndromic approach for diagnosis and
algorithms for treatment (WHO, 1991) could make selected interventions feasible and

43
affordable at the primary health care level, particularly if the cost of early diagnosis and
treatment is compared with that of treating complications and sequelae of STIs (Piot & Rowley,
1992). Over and Piot concluded that a program of STI treatment could be highly cost-effective
if it was targeted at high-prevalence groups. They recommended that outside such groups, case
management strategies should focus on improved case finding in order to reduce the cost per
case identified. Women who attend family planning and MCH clinics or who are seen at
primary health care facilities would be a prime target group for such case finding programs
(Over and Piot, 1993).

Recommendations for Management of RTIs and STIs

RTIs and STIs are currently treated at several health centers in urban areas as well as at the
district and subdistrict hospitals and at CHCs in rural areas. In most cases, these diseases are
treated symptomatically by physicians in government and private clinics. With the serious
threat of AIDS, the government has more recently begun to strengthen programs for the
prevention and management of STIs. Since strategies for the management of RTIs and STIs
are very similar, it is recommended that the latter also be included in government programs.
What is needed now is to organize these services more systematically; upgrade laboratory
diagnosis and treatment facilities; and establish effective referral linkages. The objective is to
interrupt the transmission of infection and prevent the occurrence and consequences of STIs.
Strategies for control include health education; counseling; disease detection through screening;
case-finding and diagnosis by clinical and laboratory procedures; treatment of cases; and the
management of sexual contacts. Table 5 lists interventions that can be implemented for the
management of RTIs and STIs at different levels of the health service system. Since services
for the prevention and treatment of these infections have been neglected in the past and not
currently implemented, many of the interventions in the table are highlighted.

The training of health functionaries at various levels of the health delivery system is an essential
requirement for the successful implementation of these services. Therefore, training needs
should be assessed and programs designed to train health care providers. Health workers at all
levels should be trained to recognize symptoms of RTIs and STIs and to use appropriate
treatment and referral protocols. Health workers should also be trained to counsel clients on
condom use; identify sexual contacts; and assist in the notification of partners. The National
AIDS Control Organization has developed training modules for service providers and has
recently initiated training programs. The effectiveness
of these training programs should be
systematically assessed and programs expanded.

The skills required by various service providers would necessarily differ at different level
facilities. For example, an ANM at the subcenter could be trained to effectively screen clients.
for various family planning methods; recognize contraindications; refer clients for the
diagnosis and management of specific problems; and provide counseling and follow-up

44
services. While an ANM would not be able to diagnose specific RTIs and STIs, she could be
trained to suspect the presence of an infection from the client’s history and clinical examination
(such as the presence of a vaginal discharge) and refer suspected cases for diagnosis and
treatment. There are some examples of NGO programs where ANMs and even TBAs have been
successfully trained to treat RTIs by symptoms (Bang, 1994). Pilot projects should also be

TABLE 5: SERVICES FOR THE PREVENTION AND TREATMENT OF RTIS

AND STIS AT DIFFERENT LEVELS OF THE HEALTH SERVICE SYSTEM

Community Subcenter Level Primary Health Community Health

Level Center Level Center/District/Subdistrict
Hospital Level

Sexuality and Sexuality and gender Sexuality and gender Sexuality and gender
gender information, information, information, information, education and
education and education and education and counseling for adolescents,
counseling for counseling for counseling for youth, men and women
adolescents, youth, adolescents, youth, adolescents, youth,
Provision of condoms
men and women men and women men and women
Laboratory diagnosis and
Community-based Provision of condoms Provision of condoms
treatment
condom distribution
Pilot testing of the Pilot testing of the
Pilot testing of the syndromic
Social marketing of syndromic approach syndromic approach
approach
condoms
Referral of women Diagnosis and
Partner notification and
Routine prophylaxis with vaginal treatment of some
treatment
for gonococcal © discharge, lower infections and
infections of the abdominal pain and referral of others Routine syphilis testing in
newborn genital ulcers, and antenatal women
Partner notification, ©
men with urethral Routine prophylaxis for
treatment and
discharge, genital gonococcal infections of the
referral
ulcers, and swelling newborn
in the scrotum or Routine syphilis
testing in antenatal Management of referred
groin
women cases and feedback to
Partner notification referral source
and referral Routine prophylaxis
for gonococcal
Routine prophylaxis infections of the
for gonococcal newborn
infections of the
newborn Management of
referred cases and
feedback to referral
source

Note: Health interventions that are not a part of the present program are highlighted.

45
undertaken in government programs to assess the feasibility and effectiveness of training
paramedical workers to use the syndromic approach and risk assessment techniques for the
diagnosis and management of selected RTIs and STIs at the subcenter level.

Routine screening and treatment of syphilis during prenatal care is recommended for areas
with high prevalence. The cost-effectiveness estimates for treatment of syphilis vary greatly,
depending upon its prevalence, assumptions about the risk of transmission, and the case-
detection strategy used. Screening for syphilis using the Rapid Plasma Reagin (RPR) test,
which provides immediate results, followed by treatment with penicillin (where indicated),
has been found to be a simple and inexpensive approach with significant payoffs for infant
health (Schulz et. al, 1992).

Schulz and co-workers have estimated the cost of this intervention for 1,000 pregnant women
at 10 percent seroprevalence to be $600. If the intervention was perfectly effective, it could
prevent 17 spontaneous abortions, 19 perinatal deaths, and 14 syphilitic infants for every 1,000
pregnant women. The cost for 1,000 pregnant women at 1 percent seroprevalence is $420 and
in this case, the intervention would prevent two spontaneous abortions, two perinatal deaths,

Routine screening and treatment of syphilis during prenatal care is

recommended for areas with high prevalence. Routine antibiotic
prophylaxis for gonorrhea in the newborn, a cost-effective intervention,
is also recommended.

and two syphilitic infants (Schultz et al, 1992). However, such a program could not be expected
to be perfectly effective because women may attend the prenatal clinics late, sporadically, or
never and also because some women and their partners may not be treated. Also, the screening
test is not 100 percent sensitive and specific. Nonetheless, this intervention reduced adverse
outcomes by 61 percent in Lusaka (Hira et al, 1990).

The most serious consequence of gonorrhea in pregnant women is the occurrence of ophthalmia
neonatorum, a severe eye infection that can cause blindness in newborns. Routine antibiotic
prophylaxis for this condition in the newborn, which costs only $1.40 per case averted, is
recommended (Table 4) rather than screening and treatment of all pregnant women (Schulz
et. al, 1992). The prevalence of gonococcal infection in pregnant women in developing
countries is reported to be between 0.5 and 22 percent. At least 30 percent of infants exposed
to the infection during birth, develop gonococcal eye infections if prophylaxis is not given
(WHO, 1984). When the mother is concurrently infected with gonococcus and chlamydia the
transmission rate to the newborn is significantly higher -- 68 percent vs. 31 percent (Schultz
et al, 1992).

46
The Syndromic Approach for Management of STIs

WHO has developed a simplified syndrome-based approach for management of patients with
STIs to provide health workers with a tool to improve the diagnostic process. Syndromic
management is based on identifying consistent groups of symptoms and easily recognized signs
- syndromes - and providing treatment which will deal with the majority of organisms
responsible for producing each syndrome. Since the syndromic approach is based on symptoms,
it is not applicable for women who are infected but do not have any symptoms. Syndromic
management for urethral discharge in men and genital ulcers in men and women has proved
to be useful. It has resulted in adequate treatment of more infected cases. It is relatively simple
and cost-effective. Field trials are also underway to determine the sensitivity and specificity of
an approach based on an assessment of risk that the patient is infected.

First level management of STIs using the syndromic approach should be organized at the PHC
and possibly at the subcenter levels. Syndrome-based treatment of both urethral discharge
(most commonly caused by gonorrhea and chlamydia) and genital ulcer disease in symptomatic
men is recommended. Symptomatic women with genital ulcers or pelvic inflammatory disease
should also be diagnosed and treated using clinical algorithms developed by WHO. By
following the step-by-step guidelines developed by WHO, health workers can match patients’
symptoms with those for locally prevalent STIs and provide treatment accordingly. In the better
developed regions and states, PHCs should be upgraded to provide laboratory services for the
diagnosis and treatment of selected RTIs and STIs such as syphilis, trichomona vaginalis,
candida albicans and bacterial vaginosis. At least those infections that can be diagnosed by
microscopic examination should be treated at PHCs.

Comprehensive services for diagnosis and management of RTI and STI should be organized

There is an urgent need to implement pilot projects to assess the

feasibility, effectiveness, and cost of the syndromic approach for the
management of symptomatic STIs in different settings. Addressing the
problem of asymptomatic infections, which are common among
women, presents a greater challenge.

at district hospitals and referral centers including medical colleges and other selected
institutions. Drugs for treating STIs should be included in the national list of essential drugs
and drug distribution should be encouraged through commercial channels and subsidized.
There is an urgent need to implement pilot projects to assess the feasibility, effectiveness, and
cost of the syndromic approach for the management of symptomatic STIs in different settings.
Addressing the problem of asymptomatic infections, which are common among women,
presents a greater challenge.

47
WHO has recommended STI management protocols for the PHC level (WHO, 1991). However,
if the ANM at the subcenter level is expected to carry out pelvic examination for IUD insertion,
she could, perhaps, be trained to use some of these protocols for the management of STIs in
women (van Dam, 1995).

Diagnosis and Treatment of Gynecological Problems

Services for gynecological problems are presently provided at district and subdistrict hospitals
and other CHCs. Services for the management of selected gynecological problems should be
organized at PHCs, especially at those PHCs that have women physicians. Counseling and
referral services for gynecological problems related to menstrual hygiene, safe abortion, safe
delivery and the prevention of RTIs and STIs should be provided at the PHC level. At the
subcenter level, ANMs should be trained to detect problems and to refer cases. In addition,
referral systems should be established between subcenters, PHCs and CHCs where facilities are
available for the diagnosis and treatment of gynecological problems.

Services for the prevention and treatment of a number of gynecological problems, such as RTIs
and STIs and those related to pregnancy, delivery and abortion complications have been
discussed in other sections of the paper. Services should be designed to address particular
problems of adolescents, including unmarried adolescents as programs for this target group
begin to be developed. Gynecological problems of older women, who have passed the
reproductive period, have yet to receive the attention of researchers and program planners.
Problems related to menopause and those that occur in the post-menopausal period and later
years have received scant attention in India. Research should be undertaken to study these
problems and to identify those that should receive attention. The magnitude of specific
problems as well as the cost-effectiveness and feasibility of organizing services should be
addressed. Some criteria should be developed to determine which service interventions should
receive priority and how services can be incrementally expanded to address particular priority
problems.

While a detailed discussion of gynecological problems is not within the scope of this paper, a
discussion of priority problems including RTIs and STIs as well as those related to pregnancy,
delivery and the postpartum period is provided in the sections above and a brief discussion of
key issues related to cervical cancer and infertility in the section below.

Screening and Treatment of Cervical Cancer

Cancer is one of the three leading causes of adult female mortality in both developed and
developing countries. While breast cancer is the most frequently occurring cancer among
women in the industrialized countries, cervical cancer is the most common malignancy in
developing countries where it accounts for 20 to 50 percent of all cancers and 80 to 85 percent

48
of all malignancies of the female genital tract (Belsey and Royston, 1987). In India, the
incidence of cervical cancer ranges from 15.4 to 46.5 per 100,000 women laden Council of
Medical Research, 1990).

There is an established association between RTIs and cervical cancer (Mishra and Sinha, 1990;
Indian Council of Medical Research, 1990; Murthy et al, 1990). Early onset of sexual activity
and multiple sexual partners increase the risk of cervical cancer (Menon et al, 1988). The high
incidence of cervicitis that is not due to conventional STI pathogens, has also been postulated
as a risk factor for cervical cancer among Indian women (Luthra et al, 1992). There is an
established causal link between the human papilloma virus and cervical cancer.

Cervical cancer screening is an important intervention for prevention but at present very
limited screening facilities are available to Indian women. While 15 percent of the world’s
cervical cancer cases exist in India, screening facilities are available only to a very small
minority of urban women. Research is needed to identify simple and effective screening
procedures and to determine the minimum, and thus the most cost- rere frequency of
screening required for detecting and treating cervical cancer.

Indian researchers have focused on evaluating what is referred to as down-stage screening for
the early detection of invasive cancers by the visual inspection of the cervix before symptoms
of cervical cancer develop (Luthra and Sehgal, 1990). This research shows that it is possible
to identify a significant proportion of cases for referral through such screening of signs and
symptoms (Luthra et al, 1988). While more studies are needed to assess the feasibility and
effectiveness of using auxiliary health workers to detect and refer suspected cancer cases from
rural areas, the early results of such research in India indicate that there is a potential for
implementing this strategy (Luthra et al, 1990). There is an urgent need to implement pilot
projects for assessing the feasibility and effectiveness of screening and management of cervical
cancer in different urban and rural settings.

Prevention and Treatment of Infertility

Since child-bearing is highly valued and childlessness can have devastating consequences for
Indian women, infertility is perceived to be a very serious problem. Infertility could be a sequela
of STIs and also an outcome of poor obstetric and gynecological practices, particular illegal
abortions resulting in infection. Little research is available on these causes of infertility.
Programs for the prevention and control of RTIs and STIs and for safe abortion and safe delivery
services would have an important impact on preventing infertility. These programs could be
implemented at different levels of the health service system including at the peripheral levels
(as discussed in earlier sections of the paper), to prevent infertility in women. Genital
tuberculosis is an important cause of infertility in India. Therefore, services for the prevention
and treatment of tuberculosis would also have an important impact on preventing infertility.

49
Diagnosis and treatment of all causes of infertility requires sophisticated facilities and,
therefore, services for treating women who have primary or secondary infertility can only be
provided in select institutions where such facilities exist. Some efforts are underway to plan a
few centers with such facilities. The focus of primary health care programs should be on the
prevention of infertility.

Screening and Management of Breast Cancer

Breast cancer is a serious problem worldwide and a growing problem in India. Research on this
problem is limited to a few hospital-based cancer registries which show an incidence of 15-25
per 100,000 (Gulati, 1994). There are some data to show that Indian women get breast cancer
about a decade earlier than their western counterparts. The mean age of occurrence is about 42

While breast cancer is the most frequently occurring cancer among

women in the industrialized countries, cervical cancer is the most
common malignancy in developing countries where it accounts for 20
to 50 percent of all cancers and 80 to 85 percent of all malignancies of
the female genital tract.

years in India compared to 53 years in white women (Park & Park, 1991). The problem of breast
cancer has not received any attention in the national health program. However, some efforts
should be initiated to address this growing problem. A beginning could be made in urban
settings where facilities are available. Pilot projects should be undertaken to examine the issues
involved in organizing programs for the screening and management of breast cancer. Some of
the questions to be addressed in such pilots are: How should women be taught to do self
examinations? How can women be screened at peripheral institutions by auxiliary personnel?
How should referral systems be organized for women who require investigations and
treatment? And what are the cost implications of organizing programs for the screening and
management of breast cancer?

Service for the Adolescent

Rationale for Providing Reproductive Services to Adolescents

The adolescent period is important for several reasons. Adolescent girls are exposed to the
hazards of pregnancy when they are not emotionally and physically ready for child-bearing.
Early age of marriage results in a high incidence of teenage births in India (Government of
India, 1988). Teenage pregnancy poses serious health hazards for the mother and child

50
 (Pachauri and Jamshedji, 1981; Nair et al, 1963; Ghosh and Ghosh, 1976). A majority, nearly
two-thirds, (according to some data) of 6-14 year old girls in the countries of the Indian sub-
continent are anemic and a considerable proportion of the anemia in this group is of a moderate
or severe degree (Gopalan, 1992). Adolescents, therefore, constitute an important segment of
the population for whom reproductive health programs should be designed and implemented.

Thus far, the Indian adolescent has been bypassed by all health programs. During 1990, the
Year of the Girl Child, planners and researchers focused on the problems of the adolescent girl
in India and some efforts were initiated to address the special needs of this important target
group. Health programs for the adolescent girl have special significance because these
programs would not only affect the health and nutrition of the adolescents themselves, but
would also have long-term intergenerational effects by reducing the risk of low birth weight and
minimizing subsequent child mortality risks (Gopalan, 1989 and Srikantia, 1989). It is
suggested that integrated programs for health, education, employment and other related
services should be provided for adolescents (Gopalan, 1984).

In most developing countries, while the needs of children and pregnant women are acknowledged
in national strategies and programs, the unique health needs of the critical population 10-19
years of age are usually overlooked or expected to be integrated with services for children or
adults. In India, neither services nor research have focused on the adolescent’s health and
information needs. In a country in which adolescents 10-19 years of age represent almost one
quarter of the population, the consequences of this neglect take on enormous proportions
(Jejeebhoy, 1994).

Adolescent Fertility

There are several notable features of adolescent fertility in India. First, almost all adolescent
fertility occurs within marriage. Second, fertility among adolescents is high, contributing to a
significant proportion of overall fertility in the country. Research results suggest that one in ten
adolescents, irrespective of marital status, and one in four married adolescents 15-19 years of
age are already mothers. In 1981 there were over 13 million currently married adolescent girls
and as a result of early marriage and social pressures on early childbearing, there were over
three million adolescent mothers in the country. Third, although there are signs of declining
adolescent fertility rates, fertility declines among adolescents appears to be more gradual than
among older women. Fourth, despite declining adolescent fertility rates, the absolute numbers
of adolescent mothers in India continue to increase as a result of population growth. And fifth,
- complications of pregnancy are systematically higher among adolescents than among adult
women (Jejeebhoy, 1994).

Finally, while little is known about fertility among unmarried adolescents as a special group,
existing anecdotal and qualitative accounts suggest that the situation of unmarried adolescent

51
 mothers and their children is particularly bleak. For example, unmarried adolescents constitute
a sizable proportion of abortion seekers. What is especially disturbing is the fact that unmarried
adolescents are more likely than older women to delay seeking abortion services because of
ignorance about where to go for services, fear of social stigmatization, and a lack of awareness
that a pregnancy has occurred (Jejeebhoy, 1994). Studies in Bombay (Divekar et al, 1979),
Solapur (Solapurkar and Sangam, 1985) and Baroda (Bhatt, 1978) show that adolescents are
significantly more likely than older women to have a second trimester abortion. Studies also
suggest that a growing proportion of adolescents, boys in particular, experience STIs
(Jejeebhoy, 1994). .

Adolescents constitute an important segment of the population for whom

reproductive health programs should be designed and implemented.

Data on contraceptive practice among adolescents are restricted to information on currently

_ married adolescents 15-19 years of age. These data indicate that few adolescents practice
contraception. The 1988 national survey of family planning practices (Operations Research
Group, 1990) reports that nationally, no more than 8.6 percent of married girls 15-19 years of
age were using contraception. Thus, adolescents are far less likely to practice contraception
than are older women, including women 20-24 years of age. However, issues related to family
planning are different for adolescents than for older women because some of the fertility is
‘ wanted fertility, especially among married adolescents. First births, which are of higher risk
and lead to poor pregnancy outcome are concentrated in this group.

Programs for Adolescents

Programs designed to address the reproductive health needs of adolescents face special
challenges since they must take into account complex and often conflicting factors such as:
@ the roles and preferences of parents and community leaders in providing information to
adolescents;
@ the widely varying social situations and sexual behavior of adolescents since, married
adolescents, unmarried adolescents, street kids, and abused young people have different
reproductive health needs;
@ theconflicting pressures and confounding information that influence adolescents’ behavior;
and
@ gender differences and societal norms for sexual behavior and access to information and
services.

Program experience on reaching adolescents is limited. Some NGO programs and government
programs have attempted to redress this gap. There is, for example, a non-formal education
program for girls. More recently, the ICDS Programme has extended its activities to include

52
 adolescent girls. The ICDS Programme, originally intended to provide nutritional
supplementation and health and nutrition education for pregnant and lactating women and
nutritional supplementation and early childhood education for their pre-school aged children,
_ has recently expanded its services to incorporate programs for out-of-school adolescent girls,
11-18 years of age. This program operates through Girls’ Clubs (Balika Mandals) in 507 blocks
at present. Its activities, however, are limited to the provision of nutritional supplementation
and health check-ups, along with some health education. While training is a major component
of the program for 15-18 year old adolescents, the content of this training is focused on
motherhood skills such as nursing, first aid, child health and nutrition care. Reproductive
health and sexual issues are not addressed. Despite its limitation, the program is notable
because, for the first time, the needs of adolescent girls have been specifically addressed in a
government program. The experience of this program should be carefully documented. The
ICDS Programme presently covers about 40 percent of India’s rural population and, therefore,
offers considerable potential for upscaling.

With the advent of AIDS, several NGOs have begun to implement programs on HIV/AIDS
education and sexuality for youth (Ford Foundation, 1994). More recently, the National AIDS
Control Organization has initiated a program, ‘University Talks AIDS,’ targeted to college
students. Thus, some sex educational programs have begun to be initiated. Several NGOs
working with women are also undertaking reproductive and sexual health programs targeted
to women including adolescent girls (Pachauri, 1994b).

53
54
Ill. Critical Factors for Effective Implementation
of Reproductive Health Services

Health, Sexuality and Gender Information, Education and Counseling

Most government programs have generally ignored the fact that reproduction takes place
through sexual relations, which are conditioned by broader gender relations. A review of
conventional demographic and family planning literature illustrates that the population field
has neglected issues related to sexuality, gender roles and relationships and has focused largely
on outcomes, such as contraceptives safety and effectiveness, unwanted pregnancy, and more
recently on infection. Clearly, social constructions of sexuality and gender relations impact on
reproductive health. But, because they are generally considered to be politically sensitive, these
issues have been neglected. A proposed approach is to place sexuality and gender relations at
the center of reproductive health programs; to empower women to ensure that their health needs
are addressed; and to encourage male participation by ensuring that men take responsibility for
family planning, family support, and child rearing (Germain, et al, 1994). Given that the
gender inequalities favor men in most societies in India, it is important to ensure men’s
involvement in these programs.

To date, most reproductive health programs have focused on women. Family planning
programs have targeted women to achieve fertility reduction goals. Maternal and child health
programs have also focused efforts on reaching women. Men have tended to be excluded and
side-lined by these service programs. In their efforts to improve women’s status and to empower
women, NGOs have also focused exclusively on women. In fact, several women’s NGOs have
explicitly excluded men from their programs. While there was rationale for adopting this
approach in the past, there are good reasons to make some changes now.

Education and counseling for women and men should form an integral component of all the
interventions that are included in the recommended package of reproductive health services.
A special effort should be made to strengthen these interventions as they have suffered neglect
at the level of implementation in the Health and Family Welfare Programme.

55
Gender Sensitization of the Health Bureaucracy

The health care system in India is a bureaucratized, top-down, male dominated hierarchy. To
date, women’s voices have largely been missing from health policy debate. There is a growing
concern among women health advocates that women’s views and perspectives must be
incorporated in policies and programs that are designed for them. In order to effectively

Strong advocacy efforts are needed to involve and empower a range of

different constituencies, including activists, feminists, NGOs and
researchers, to catalyze a process of networking with a growing number
of organizations so that the reproductive health ideology and the ethos is
effectively internalized and programs responsive to clients’ needs are
designed with the active involvement and participation of all.

integrate sexuality information and counseling with reproductive health programs in a

‘gender-sensitive’ way, not only is it important to make this an explicit job responsibility of all
service providers at the various levels of the health care system, but it is also necessary to
sensitize all health planners and service providers to gender issues. Clearly, a long-term process
of gender sensitization and training will be needed to effect social change within the present
rigid bureaucratic system.

Advocacy for Reproductive Health

Currently, there are major information gaps at all levels ranging from a lack of understanding
of the ideology and the concept of reproductive health and gender issues to questions about what
changes are needed at the policy and program level to implement services. This lack of
information presents a major deterrent to implementing reproductive health programs. In a
country as large and diverse as India, multiple constituencies must be informed and empowered
before any process of change can be affected.

Advocacy programs are needed at the central and state levels to engage decision-makers in
policy dialogue. A range of different constituencies including government and non-government
organizations, as well as activists and researchers should be involved to catalyze a process of
networking with a growing number of organizations in discussions on reproductive health and
related family and gender issues so that there is common understanding about the concept as
well as the design and implementation of services to address reproductive needs.

Establishment of Effective Referral Systems

The establishment of effective two-way referral systems between the community level and the

a)
various levels within the health service system is critical for the effective implementation of
reproductive health services. Such referral systems are needed for implementing all the health
interventions included in the essential package of reproductive health services. It is of
paramount importance to organize effective referral systems for saving women’s lives during
obstetric emergencies and for saving the lives of new born infants with complications. There
are several examples of successful referral systems in the NGO sector (Pachauri, 1994b). The
Panchayati Raj system provides an opportunity for mobilizing community leaders to help
organize transportation for emergency referrals. Although the panchayats are presently
nascent organizations that have yet to define their roles in implementing health programs and
developing linkages with government and NGO institutions, these decentralized institutions
have considerable potential for taking on this responsibility. The establishment of referral
systems could be a starting point for developing linkages between the government’s health
service system, NGOs, the community and institutions of the Panchayati Raj for decentralizing
planning and implementation so that health programs are accountable to the community and
can more effectively address community needs.

57
98
IV. Conclusion

To translate the reproductive health concept into policies and programs, two important issues
must be addressed: First, a paradigm shift is essential. A change in focus from a top-down,
target-driven population control approach to a gender sensitive, client-based approach to
address reproductive health needs, is necessary. Second, reproductive health programs must
be designed to enhance access and improve the quality of services, particularly from the
perspective of the user. There is a need to specially focus on women since they constitute the
major client group or users of these programs and also have the greatest problem of access, both
physical and social to health services. On the other hand, it is equally important to promote male
responsibility and enhance the involvement of men.

Because there is tremendous diversity in India among the various regions and states and even
within states as well as between urban and rural areas, no single package of services can be
recommended. The framework proposed in this paper, could be used for defining reproductive
health programs for different settings. The Government, NGOs and the private sector must
work .in partnership to promote reproductive health policies and programs. Strong advocacy
efforts are needed to involve and empower a range of different constituencies, including
activists, feminists, NGOs and researchers, to catalyze a process of networking with a growing
number of organizations so that the reproductive health ideology and the ethos is effectively
internalized and programs responsive to clients’ needs are designed with the active involvement
and participation of all.

59
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