Asia-Pacific Population Journal - Volume 16, Issue 2, 2001

“Pregnancy is special, let’s keep it safe” was the theme for World Health Day in 1998. Even if agreement existed on the best way to ensure a safe pregnancy in a resource-poor setting, provision is only half the story; the level and nature of the demand for a “safe” pregnancy also needs evaluating. How women themselves perceive the dangers of pregnancy and how they react to those dangers are important questions to answer.

In most developing country settings, pregnancy and childbirth are accepted as normal events of life and it is not surprising that problems associated with pregnancy are also accepted without much ado. A new approach to measuring maternal mortality indicates that there are about 585,000 maternal deaths annually worldwide, 99 per cent of them in developing countries (AbouZhar and others, 1996). Over 20 million babies are born in India every year. The maternal mortality ratio ranges from 400 to 550 deaths per 100,000 live births, with wide variations between different states (Bhat and others, 1992). However, mortality represents just the tip of the iceberg. It has been estimated that for every maternal death, there are over 100 acute morbid episodes indicating an overall figure of 62 million morbidities annually (Koblinsky, 1993). Though these are crude estimates, they highlight the magnitude of the problem.

In Sri Lanka, a well-organized system of maternal and child health services provides care to mothers and children. However, the services provided before delivery differ markedly from those following delivery, when most of the care and attention is bestowed on the newborn and not on the mother. This difference may be seen with regard to both the formal health delivery system and the general attention given to the mother by the family. Although the pregnant mother receives attention from the maternal health services, it is not for the mother herself, but rather because she is carrying the baby. This is not surprising in a society where a woman’s main role is childbearing and child-rearing — a role that the mothers themselves accept. But because of such attitudes, mothers do not receive the necessary care during the postpartum period from the formal health delivery system, their families or even from themselves.

Few community-based studies in India have investigated the determinants of women’s self-reports of reproductive tract infections and other forms of gynaecological morbidity. One of the most striking findings to emerge from the few that have done so is the strong association between the use of female sterilization, or in some cases the intrauterine device (IUD), and reported or diagnosed gynaecological morbidity.

In developing countries, reproductive morbidity commonly affects the quality of women’s lives but, until recently, this form of ill health has been largely ignored both by health planners and researchers. The tools required to assess the nature and magnitude of the problem in different settings need to be developed if the rhetoric of the 1994 International Conference on Population and Development is to be translated into realistic action.

The concept of “unmet need” for family planning refers to a discrepancy between the fertility goals expressed by women and their actual contraceptive practices (Concepcion, 1980). The most fundamental discrepancy is non-use of contraception despite an expressed preference for limiting births. High levels of unmet need are a principal rationale for the existence of family planning programmes.

Selective abortion of female foetuses has been documented in India as early as the late 1970s when amniocentesis for genetic screening became available (Ramanama and Bambawale, 1980), but it was only with the increasing availability of ultrasound technology in the mid-1980s that the practice became widespread. Most of the existing evidence on sex-selective abortion comes from micro-studies in northern India. These have demonstrated a widespread acceptance of the practice, and several researchers have documented indirect evidence in the form of increasing sex ratios at birth in hospitals or within communities (Booth and others, 1994; Gu and Roy, 1995; Khanna, 1997; Sachar and others, 1990 and 1993; Sahi and Sarin, 1996). While abortion (also called medical termination of pregnancy, or MTP) on broad social and medical grounds has been legal since 1972, sex selection is not. The state of Maharashtra, where the present study was conducted banned prenatal sex selection in 1988; the Prenatal Diagnostic Techniques Bill made sex detection tests illegal throughout India in 1994.

The primary health care system in Sri Lanka has an international reputation for its contributions to reducing the rates of infant and maternal morbidity and mortality. These results have been achieved in part through a comprehensive system of early identification of expectant mothers, careful follow-up and monitoring, almost universal hospital deliveries, postpartum follow-up for three months after delivery, an effective immunization programme, nutrition supplements and the reporting of infectious diseases. A key to this system is the “public health midwife” (PHM) who identifies pregnant mothers, ensures their regular attendance at maternal and child health (MCH) clinics, makes monthly home visits, advises pregnant mothers on nutrition and health, facilitates hospital admission for delivery and responds to emergencies. They also provide postnatal follow-up of mother and child (Ministry of Health and Indigenous Medicine, 1998).

For most couples, procreation is a natural biological urge and an integral part of a stable marital relationship. Motherhood is an important social position actively sought by many women. Although motherhood is seen as an essential stage in women’s lives (Phoenix and others, 1991), it is frequently romanticized and idealized as a woman’s supreme achievement (Ussher, 1990). It is also symbolically important because it shapes the cultural and social identities of women. It demonstrates their physical and psychological adequacy and, as producers of the next generation, gives them identifiable social functions (Busfield, 1987; Rapoport and others, 1977). This is especially true in India, as in the rest of Asia, where childbearing is traditionally essential to a woman’s social and cultural identity.

Despite its well-established links to other aspects of reproductive illhealth, such as sexually transmitted infections (STIs) and unsafe abortion (Berer, 1999), infertility is the most neglected component in the reproductive health programmes of many developing countries.

Sexual behaviour is one of the most central, yet mysterious aspects of human life. For many people, it is virtually taboo to discuss such matters in traditional Indian settings, where attitudes remain, by and large, conservative (Bang and others, 1989). Research into sexual behaviour in India has been almost entirely confined to urban populations, particularly among groups of people thought to be at high risk of HIV infection (Pachauri, 1992; National AIDS Control Organization, 1994). Little is known about the sexual behaviour of people in rural areas, who comprise nearly 70 per cent of the country’s population. An understanding of sexuality and gender-based power relations is important to issues of reproductive health because they underlie many relevant behaviours and conditions. Family planning policies and programmes should address a broader spectrum of sexual behaviour and consider questions of sexual enjoyment and risks, and confront ideologies of male entitlement that threaten women’s sexual and reproductive rights and health (Dixon-Muller, 1993).

The incidence of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) has increased significantly in Nepal in recent years. As of 31 May 2000, there were 1,541 identified HIV-positive cases in the country, of which 69.9 per cent were adolescents and young adults aged between 14 and 29 years (Ministry of Health, 2000). The major transmission route in this country is through heterosexual relations with non-regular sex partners and commercial sex workers (Karki, 1998). In view of the hidden nature of the problem, the actual size of the infected population is likely to be considerably larger.

First sexual intercourse is a significant event in a man’s life, whether or not it happens within the context of marriage. In the wake of the HIV pandemic, sexual initiation before marriage has become a focus of attention. From an intervention point of view, the proportion of young people who are sexually active, especially before they form stable partnerships, is an important area of concern. Early age at sexual debut and the number of pre-marital partners have been shown to be correlated with risk behaviour later in life (White and others, 2000). Contextual data on sexual partners and circumstances are needed to understand and assess the risk associated with early sexual experiences, and thereby design appropriate policies and programmes.

In India, programmes and research concerned with women’s health until very recently have focused mainly on the reproductive functions of married women. The recent paradigm shift in the Government’s primary health programme was intended to increase the attention given to gynaecological problems and other aspects of women’s health. Nonetheless, the attention given to the health problems of adolescent girls is still meagre, even though adolescence is a time when looking after health and nutrition can help to build a buffer against the heavy physical demands of the reproductive years. High rates of gynaecological morbidity have been reported in rural populations, adolescents included (Bang and others, 1989; Koenig and others, 1998). However, the health knowledge and problems of adolescents have so far received only minimal attention (Koblinsky and others, 1993).