By Rajiv Shah
A new study, “Inequity in maternal health care service utilization in Gujarat: analyses of district-level health survey data”, carried out by four prominent scholars, Deepak Saxena, Ruchi Vangani, Dileep V. Mavalankar, and Sarah Thomsen, and published in a Swedish research journal, Global Health Action, has reached the drastic conclusion that “inequities in maternal health care utilization persist in Gujarat”, despite the Gujarat being “one of the most economically developed states of India.” It underlines, “Structural determinants like caste group, wealth, and education were all significantly associated with access to the minimum three antenatal care (ANC) visits, institutional deliveries, and use of any modern method of contraceptive. There is a significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence.”
The scholars comment, “Two decades after the launch of the Safe Motherhood campaign, India still accounts for at least a quarter of maternal death globally. Gujarat is one of the most economically developed states of India, but progress in the social sector has not been commensurate with economic growth.” It is in this context that the authors try to use “district-level data to gain a better understanding of equity in access to maternal health care and to draw the attention of the policy planners to monitor equity in maternal care.”
The study says, “Poverty is the most important determinant of non-use of maternal health services in Gujarat. In addition, social position (i.e. caste) has a strong independent effect on maternal health service use.” It advises the policy makers to take a “more focused and targeted efforts towards the disadvantaged groups… in order to achieve targets and goals laid out as per the millennium development goals (MDGs). In particular, the Government of Gujarat should invest more in basic education and infrastructural development to begin to remove the structural causes of non-use of maternal health services.”
Published in March 2013, the study says, “MDG aims at reducing maternal mortality and improving reproductive health. In India, the maternal mortality ratio (MMR) dropped from 600 deaths per 100,000 live births in 1990 to 390 in 2000 and to 200 in 2010. Despite overall progress, however, wide disparities between different populations exist at the sub-national level, both between and within Indian states. For example, the latest MMR estimates show a gap of 382 deaths per 100,000 live births between Assam (MMR 390) and Kerala (MMR 8)."
As for Gujarat, its MMR is estimated to be 148 per 100,000 live births, which the study says is “favourable in relation to the India-wide rate of 200”. Yet, the fact is, “though Gujarat is an industrially developed state, the MMR of Gujarat is relatively high compared to the states of Tamil Nadu (97/100,000) and Kerala (MMR 8/100,000), whose per capita income is less than Gujarat.” In addition, it adds, “Given the disparities in socio-economic measures within the state, it is likely that there are significant differences in maternal health outcomes between different population groups within the state. Furthermore, the interaction between structural determinants such as education, caste and income make it difficult for policymakers to identify where the greatest gaps remain in achieving MDG, and reducing health inequities, in Gujarat.”
India-wide phenomenon: Exploring reasons for high MMR, the scholars look into how antenatal care (ANC) services are delivered in India. They say, “In India, ANC services are included in primary health care services for pregnant women and management of the fetus. According to national guidelines, ANC services consist of a set of professional pregnancy checkups, tetanus and other immunizations, prophylaxis through iron and folic acid tablets, blood pressure check-up, advice and information regarding delivery methods and services, nutrition, and postnatal care. The main source of ANC is a network of health centers throughout the country, each serving a population of three to five thousand. These are staffed by trained personnel (auxiliary nurse midwife – ANM) who provide prenatal and postnatal care at the center, who make home visits for pregnant women, help in child delivery and provide immunization services to the infants.”
They add, “Postnatal care (PNC) has a stronger element of hospital-level care compared to antenatal care. PNC services may involve treatment of complications that might have occurred during the delivery and severe health conditions of the newborn, requiring skilled personnel and hospital facilities. The PNC services provided at community level include counseling on family planning, breastfeeding practices, nutrition, management of neo-natal hypothermia, early detection of postpartum complications and referral for such problems. The higher-level health care facilities are intended to provide these services as well as take care of post-delivery complications.”
Especially focusing on “poor women, the poorly educated, adolescents, and members of scheduled castes (SCs) and scheduled tribes (ST)”, the study suggests, “Both the population living in urban slums and the poor living in rural areas have less access to maternal and reproductive health care compared to the non-poor living in the same areas.” It adds, “Caste and economic status are closely interlinked, with women from marginalized caste groups often also being poor, and thus doubly disadvantaged… The main sources of inequity in maternal health – place of residence, education, income, gender norms, and caste – are strong predictors of access to maternal health services.”
Available literature suggests, the study says, that between 1992 and 2006, “use of antenatal care services in India increased by 12%, but only 2% of this increase occurred in the poorest wealth quintile.” It adds, “Inequity may also be attributed to differential literacy rates on the basis of place of residence and gender. Currently in India, 65% of the female population is literate compared to 82% among males. Female literacy is strongly correlated with maternal health outcomes. In India, 29% of women with no education received at least one antenatal care visit, as opposed to 88% of women with 12 years or more of education.”
The study further says, “Social class is considered to be the most powerful predictor of health results worldwide. In India, social class is divided along caste and tribal affiliation. The category of ‘scheduled tribe’ is generally the poorest and most disadvantaged in terms of health outcomes, although SCs and ‘other backward castes’ (OBCs) also experience greater levels of social exclusion and marginalization compared to members of the other castes. For example, according to the third National Family Health Survey (NFHS-3), access to any ANC during the last birth in the previous five years was only 73.9% for STs, and around 85% for both SCs and OBCs, while it was 95.3% for others.”
Gujarat situation: Suggesting that geographical advantage of Gujarat is the main reason for the state’s economic advancement compared to other states, the scholars say, “Strategically located on the West Coast of India, Gujarat is also a gateway to the rich land-locked northern and central parts of the country. Because of its location on the coast, Gujarat also has access to all major port-based countries, including the United Kingdom, Australia, China, Japan, Korea, and the Gulf countries.”
Pointing towards overall social gap, the scholars say, “The population of Gujarat is estimated at 60.3 million, which is approximately 4.99% of the Indian population. The literacy rate in Gujarat is on the increase and was 79.31% as per 2011 population census. Of that, male literacy stands at 87.23% while female literacy is at 70.73%, a gender gap of 16.5%. Approximately 43% of the population of Gujarat lives in urban areas. The overall literacy rate is 79%, although there is a difference between urban (88%) and rural areas (73%).”
It is in this context that the scholars attempt to study “the relationship between the different sources of inequity in maternal health in the state of Gujarat in order to help policymakers identify the groups that need to be targeted to increase the likelihood of achieving MDG in this state.” The analyses in this study, the scholars say, “are based on a conceptual framework designed by the Commission on the Social Determinants of Health (CSDH), set up by WHO to aid researchers, policy makers, and health planners in their work to reduce health inequity. The determinants include both structural and intermediary determinants.”
They add, “The structural determinants include the socio-economic and political context, as well as markers of social position such as education, income, social class (i.e. caste), gender, and ethnicity. The weight and relevance of the assigned social position is influenced by the socio-economic and political context, including governmental policies, cultural values, and the macroeconomic conditions, and its impact on equity in health and well-being is mediated by different intermediary determinants such as living conditions and exposure that directly influence health, as well as access to and quality of care received when encountering the health system.”
Basing on secondary data analysis on raw data of the District Level Household and Facility Surveys (DLHS) for the state of Gujarat, the scholars say, “DLHS is a household survey designed to provide information on family planning, maternal and child health, reproductive health of ever-married women and adolescent girls, and utilization of maternal and child health care services at the district level for India. A multi-stage stratified systematic sampling design was adopted for DLHS covering 50 primary sampling units (PSUs) from each district. Information from a total of 24,513 ever-married women age 15–49 years was included in the analyses.”
The structural determinants selected for the study were “education, caste, and wealth index.” The intermediary determinants were “age, place of residence of mother, and age at marriage of mother.” The outcome variables represent three important components of optimal maternal health care: “institutional delivery, use of any modern contraceptive method, and at least three antenatal care visits (the recommended minimum in India). Modern contraceptive methods included sterilization, pills, IUD, injectable, and/or condoms. Institutional delivery included delivery in a hospital, clinic, or at a health center.” In the DLHS, “wealth index is computed at the national level by combining household amenities, assets, and durables, and then divided into quintiles. In this analysis the poorest and second wealth quintile were grouped into the ‘poor’ category while the non-poor included the top three quintiles. Education status was divided into non-literate, less than 5 years of education and 5 or more years of education.”
On analysis of the data it was found that “of the 24,513 ever-married women aged 15–49 years who were interviewed for the DLHS in Gujarat in 2007–2008, 7,533 had their last live/still birth since 1 January 1, 2004. Of these, 76.5% lived in rural areas, 37.9% were married before the age of 18, 40.4% were non-literate, 29.1% belonged to STs, 13.2% SC and 36.9% were SEBC.” This indicated that “those who were 15–24 years old, residing in the urban area, belonging to non-ST or SC groups, and having five or more years of education were more likely to have attended at least three ANC visits, to have delivered in an institution, and to be currently using any modern method of contraception at the time of survey were compared to women belonging to other categories.”
However, the scholars find that “after controlling for structural determinants (wealth, caste, and education status), the odds of not receiving ‘at least three ANC visits’ was higher among poor women, STs, SCs, SEBC category, non-literate, or educated less than 5 years.” Similarly, they say, “the odds of not having ‘institutional deliveries’ was higher among the poor, STs, , SCs, SEBC, non-literate, or educated for less than 5 years.” In the same way, “non-use of modern contraceptive methods was higher in poor, STs, and non-literate women.”
Giving the example of ANC, scholars underline, “In the stratified analyses, being poor was associated with less utilization of ANC services independently of caste category. Women who were poor among the ‘other’ caste category were 5.65 times less likely to use ANC services than the non-poor in the same caste category. Poor women belonging to an ST were 5.32 times less likely to use ANC services than the non-poor advantaged groups. Similarly women in the poor SC category were 5.1 times less likely to utilize ANC services than the non-poor ‘others’. There were no differences between the poor in the different caste groups. However, there was evidence of effects on ANC use due to caste status among the non-poor. Women belonging to an ST, but not poor were 2.37 times less likely to use ANC services than the non-poor advantaged groups (‘other caste’).”
Further, “being poor was also associated with less utilization of ANC services irrespective of the place of residence.” Thus, “rural poor and urban poor were 5.22 and 5.19 times less likely to utilize the ANC services respectively in comparison to the urban non-poor.”
Policy implications: The results of the study indicate, say the scholars, that “it is not unrealistic to assume near universal use of maternal health services if the structural determinants identified above are addressed. Women who are urban, literate, wealthier, younger, ever-married at 18 or above use services more than their rural, illiterate, older, and ever-married younger counterparts. Over 80% of urban women are delivering in institutions. Similarly, over 80% of the non-poor attended at least three ANC visits (the recommended minimum in India) during their last pregnancy. Educational levels also show an apparent ‘dose-response’ relationship with use of all maternal health services studied here. That is, the more education one has, the more likely one is to use ANC, institutional delivery, and modern methods of contraception. The relationship between mother’s education and use of maternal health services is already well documented.”
Hence, “what is significant for policymakers to note here is that the high levels of use among the wealthy, urban, and educated women indicate what is possible to achieve in Gujarat.” Furthermore, the study results show that “there are fewer disparities in access to family planning services amongst the disadvantaged populations. This also begs the question ‘what are the family planning programmes doing right that other maternal health programs are not?’ It also indicates that it should be possible to reach the poor and disadvantaged classes with other maternal health services.”
The scholars conclude, “Gujarat has experienced rapid growth and is one of the wealthiest states in India and also showing improvement in overall health status. However, improvements in the health of the general population do not lead to the removal of disadvantage in society. To achieve the desired targets under MDG in an equitable manner, there is an urgent need to review the existing policies implemented by the state to reduce such health inequalities. Furthermore, the State of Gujarat should also design systems to monitor equity. Greater attention needs to be directed towards the assessment of health deprivation among the poor.”
They add, “Availability alone may not be sufficient, unless it is supported by a policy of greater subsidization of health facilities through special schemes for maternal health care. Targeted interventions need to be initiated for better delivery of services and tools directly to those who are in greatest need. Additionally, decisions on resource allocation for public health need to be taken along with other pertinent factors, which will affect the efficacy of the policy matrix in total, such as poverty rates and education. Perhaps the state should recognize the fact that expenditures on health and education are complementary in nature and, if combined, will produce large individual and social benefits. In this sense, this analysis may help the policy planners and hopefully provide a road map for the path ahead.”
A new study, “Inequity in maternal health care service utilization in Gujarat: analyses of district-level health survey data”, carried out by four prominent scholars, Deepak Saxena, Ruchi Vangani, Dileep V. Mavalankar, and Sarah Thomsen, and published in a Swedish research journal, Global Health Action, has reached the drastic conclusion that “inequities in maternal health care utilization persist in Gujarat”, despite the Gujarat being “one of the most economically developed states of India.” It underlines, “Structural determinants like caste group, wealth, and education were all significantly associated with access to the minimum three antenatal care (ANC) visits, institutional deliveries, and use of any modern method of contraceptive. There is a significant relationship between being poor and access to less utilization of ANC services independent of caste category or residence.”
The scholars comment, “Two decades after the launch of the Safe Motherhood campaign, India still accounts for at least a quarter of maternal death globally. Gujarat is one of the most economically developed states of India, but progress in the social sector has not been commensurate with economic growth.” It is in this context that the authors try to use “district-level data to gain a better understanding of equity in access to maternal health care and to draw the attention of the policy planners to monitor equity in maternal care.”
The study says, “Poverty is the most important determinant of non-use of maternal health services in Gujarat. In addition, social position (i.e. caste) has a strong independent effect on maternal health service use.” It advises the policy makers to take a “more focused and targeted efforts towards the disadvantaged groups… in order to achieve targets and goals laid out as per the millennium development goals (MDGs). In particular, the Government of Gujarat should invest more in basic education and infrastructural development to begin to remove the structural causes of non-use of maternal health services.”
Published in March 2013, the study says, “MDG aims at reducing maternal mortality and improving reproductive health. In India, the maternal mortality ratio (MMR) dropped from 600 deaths per 100,000 live births in 1990 to 390 in 2000 and to 200 in 2010. Despite overall progress, however, wide disparities between different populations exist at the sub-national level, both between and within Indian states. For example, the latest MMR estimates show a gap of 382 deaths per 100,000 live births between Assam (MMR 390) and Kerala (MMR 8)."
As for Gujarat, its MMR is estimated to be 148 per 100,000 live births, which the study says is “favourable in relation to the India-wide rate of 200”. Yet, the fact is, “though Gujarat is an industrially developed state, the MMR of Gujarat is relatively high compared to the states of Tamil Nadu (97/100,000) and Kerala (MMR 8/100,000), whose per capita income is less than Gujarat.” In addition, it adds, “Given the disparities in socio-economic measures within the state, it is likely that there are significant differences in maternal health outcomes between different population groups within the state. Furthermore, the interaction between structural determinants such as education, caste and income make it difficult for policymakers to identify where the greatest gaps remain in achieving MDG, and reducing health inequities, in Gujarat.”
India-wide phenomenon: Exploring reasons for high MMR, the scholars look into how antenatal care (ANC) services are delivered in India. They say, “In India, ANC services are included in primary health care services for pregnant women and management of the fetus. According to national guidelines, ANC services consist of a set of professional pregnancy checkups, tetanus and other immunizations, prophylaxis through iron and folic acid tablets, blood pressure check-up, advice and information regarding delivery methods and services, nutrition, and postnatal care. The main source of ANC is a network of health centers throughout the country, each serving a population of three to five thousand. These are staffed by trained personnel (auxiliary nurse midwife – ANM) who provide prenatal and postnatal care at the center, who make home visits for pregnant women, help in child delivery and provide immunization services to the infants.”
They add, “Postnatal care (PNC) has a stronger element of hospital-level care compared to antenatal care. PNC services may involve treatment of complications that might have occurred during the delivery and severe health conditions of the newborn, requiring skilled personnel and hospital facilities. The PNC services provided at community level include counseling on family planning, breastfeeding practices, nutrition, management of neo-natal hypothermia, early detection of postpartum complications and referral for such problems. The higher-level health care facilities are intended to provide these services as well as take care of post-delivery complications.”
Especially focusing on “poor women, the poorly educated, adolescents, and members of scheduled castes (SCs) and scheduled tribes (ST)”, the study suggests, “Both the population living in urban slums and the poor living in rural areas have less access to maternal and reproductive health care compared to the non-poor living in the same areas.” It adds, “Caste and economic status are closely interlinked, with women from marginalized caste groups often also being poor, and thus doubly disadvantaged… The main sources of inequity in maternal health – place of residence, education, income, gender norms, and caste – are strong predictors of access to maternal health services.”
Available literature suggests, the study says, that between 1992 and 2006, “use of antenatal care services in India increased by 12%, but only 2% of this increase occurred in the poorest wealth quintile.” It adds, “Inequity may also be attributed to differential literacy rates on the basis of place of residence and gender. Currently in India, 65% of the female population is literate compared to 82% among males. Female literacy is strongly correlated with maternal health outcomes. In India, 29% of women with no education received at least one antenatal care visit, as opposed to 88% of women with 12 years or more of education.”
The study further says, “Social class is considered to be the most powerful predictor of health results worldwide. In India, social class is divided along caste and tribal affiliation. The category of ‘scheduled tribe’ is generally the poorest and most disadvantaged in terms of health outcomes, although SCs and ‘other backward castes’ (OBCs) also experience greater levels of social exclusion and marginalization compared to members of the other castes. For example, according to the third National Family Health Survey (NFHS-3), access to any ANC during the last birth in the previous five years was only 73.9% for STs, and around 85% for both SCs and OBCs, while it was 95.3% for others.”
Gujarat situation: Suggesting that geographical advantage of Gujarat is the main reason for the state’s economic advancement compared to other states, the scholars say, “Strategically located on the West Coast of India, Gujarat is also a gateway to the rich land-locked northern and central parts of the country. Because of its location on the coast, Gujarat also has access to all major port-based countries, including the United Kingdom, Australia, China, Japan, Korea, and the Gulf countries.”
Pointing towards overall social gap, the scholars say, “The population of Gujarat is estimated at 60.3 million, which is approximately 4.99% of the Indian population. The literacy rate in Gujarat is on the increase and was 79.31% as per 2011 population census. Of that, male literacy stands at 87.23% while female literacy is at 70.73%, a gender gap of 16.5%. Approximately 43% of the population of Gujarat lives in urban areas. The overall literacy rate is 79%, although there is a difference between urban (88%) and rural areas (73%).”
It is in this context that the scholars attempt to study “the relationship between the different sources of inequity in maternal health in the state of Gujarat in order to help policymakers identify the groups that need to be targeted to increase the likelihood of achieving MDG in this state.” The analyses in this study, the scholars say, “are based on a conceptual framework designed by the Commission on the Social Determinants of Health (CSDH), set up by WHO to aid researchers, policy makers, and health planners in their work to reduce health inequity. The determinants include both structural and intermediary determinants.”
They add, “The structural determinants include the socio-economic and political context, as well as markers of social position such as education, income, social class (i.e. caste), gender, and ethnicity. The weight and relevance of the assigned social position is influenced by the socio-economic and political context, including governmental policies, cultural values, and the macroeconomic conditions, and its impact on equity in health and well-being is mediated by different intermediary determinants such as living conditions and exposure that directly influence health, as well as access to and quality of care received when encountering the health system.”
Basing on secondary data analysis on raw data of the District Level Household and Facility Surveys (DLHS) for the state of Gujarat, the scholars say, “DLHS is a household survey designed to provide information on family planning, maternal and child health, reproductive health of ever-married women and adolescent girls, and utilization of maternal and child health care services at the district level for India. A multi-stage stratified systematic sampling design was adopted for DLHS covering 50 primary sampling units (PSUs) from each district. Information from a total of 24,513 ever-married women age 15–49 years was included in the analyses.”
The structural determinants selected for the study were “education, caste, and wealth index.” The intermediary determinants were “age, place of residence of mother, and age at marriage of mother.” The outcome variables represent three important components of optimal maternal health care: “institutional delivery, use of any modern contraceptive method, and at least three antenatal care visits (the recommended minimum in India). Modern contraceptive methods included sterilization, pills, IUD, injectable, and/or condoms. Institutional delivery included delivery in a hospital, clinic, or at a health center.” In the DLHS, “wealth index is computed at the national level by combining household amenities, assets, and durables, and then divided into quintiles. In this analysis the poorest and second wealth quintile were grouped into the ‘poor’ category while the non-poor included the top three quintiles. Education status was divided into non-literate, less than 5 years of education and 5 or more years of education.”
On analysis of the data it was found that “of the 24,513 ever-married women aged 15–49 years who were interviewed for the DLHS in Gujarat in 2007–2008, 7,533 had their last live/still birth since 1 January 1, 2004. Of these, 76.5% lived in rural areas, 37.9% were married before the age of 18, 40.4% were non-literate, 29.1% belonged to STs, 13.2% SC and 36.9% were SEBC.” This indicated that “those who were 15–24 years old, residing in the urban area, belonging to non-ST or SC groups, and having five or more years of education were more likely to have attended at least three ANC visits, to have delivered in an institution, and to be currently using any modern method of contraception at the time of survey were compared to women belonging to other categories.”
However, the scholars find that “after controlling for structural determinants (wealth, caste, and education status), the odds of not receiving ‘at least three ANC visits’ was higher among poor women, STs, SCs, SEBC category, non-literate, or educated less than 5 years.” Similarly, they say, “the odds of not having ‘institutional deliveries’ was higher among the poor, STs, , SCs, SEBC, non-literate, or educated for less than 5 years.” In the same way, “non-use of modern contraceptive methods was higher in poor, STs, and non-literate women.”
Giving the example of ANC, scholars underline, “In the stratified analyses, being poor was associated with less utilization of ANC services independently of caste category. Women who were poor among the ‘other’ caste category were 5.65 times less likely to use ANC services than the non-poor in the same caste category. Poor women belonging to an ST were 5.32 times less likely to use ANC services than the non-poor advantaged groups. Similarly women in the poor SC category were 5.1 times less likely to utilize ANC services than the non-poor ‘others’. There were no differences between the poor in the different caste groups. However, there was evidence of effects on ANC use due to caste status among the non-poor. Women belonging to an ST, but not poor were 2.37 times less likely to use ANC services than the non-poor advantaged groups (‘other caste’).”
Further, “being poor was also associated with less utilization of ANC services irrespective of the place of residence.” Thus, “rural poor and urban poor were 5.22 and 5.19 times less likely to utilize the ANC services respectively in comparison to the urban non-poor.”
Policy implications: The results of the study indicate, say the scholars, that “it is not unrealistic to assume near universal use of maternal health services if the structural determinants identified above are addressed. Women who are urban, literate, wealthier, younger, ever-married at 18 or above use services more than their rural, illiterate, older, and ever-married younger counterparts. Over 80% of urban women are delivering in institutions. Similarly, over 80% of the non-poor attended at least three ANC visits (the recommended minimum in India) during their last pregnancy. Educational levels also show an apparent ‘dose-response’ relationship with use of all maternal health services studied here. That is, the more education one has, the more likely one is to use ANC, institutional delivery, and modern methods of contraception. The relationship between mother’s education and use of maternal health services is already well documented.”
Hence, “what is significant for policymakers to note here is that the high levels of use among the wealthy, urban, and educated women indicate what is possible to achieve in Gujarat.” Furthermore, the study results show that “there are fewer disparities in access to family planning services amongst the disadvantaged populations. This also begs the question ‘what are the family planning programmes doing right that other maternal health programs are not?’ It also indicates that it should be possible to reach the poor and disadvantaged classes with other maternal health services.”
The scholars conclude, “Gujarat has experienced rapid growth and is one of the wealthiest states in India and also showing improvement in overall health status. However, improvements in the health of the general population do not lead to the removal of disadvantage in society. To achieve the desired targets under MDG in an equitable manner, there is an urgent need to review the existing policies implemented by the state to reduce such health inequalities. Furthermore, the State of Gujarat should also design systems to monitor equity. Greater attention needs to be directed towards the assessment of health deprivation among the poor.”
They add, “Availability alone may not be sufficient, unless it is supported by a policy of greater subsidization of health facilities through special schemes for maternal health care. Targeted interventions need to be initiated for better delivery of services and tools directly to those who are in greatest need. Additionally, decisions on resource allocation for public health need to be taken along with other pertinent factors, which will affect the efficacy of the policy matrix in total, such as poverty rates and education. Perhaps the state should recognize the fact that expenditures on health and education are complementary in nature and, if combined, will produce large individual and social benefits. In this sense, this analysis may help the policy planners and hopefully provide a road map for the path ahead.”
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