Maternal Health: A Case Study of Rajasthan
Iyengar, Sharad D., Iyengar, Kirti, Gupta, Vikram, Journal of Health Population and Nutrition
With a maternal mortality ratio (MMR) of approximately 445 per 100,000 livebirths, the state of Rajasthan contributes significantly to India's burden of maternal deaths (1). The context of Rajashan sets the stage for this high MMR, both in terms of its terrain and the sociocultural environment of women's lives. This paper reviews the context of maternal health in Rajasthan and the development and present status of maternal health services in the state.
With a land area approximating 10% for India, Rajasthan is the largest state in the country. More than 60% of the state's total land area is desert, characterized by extreme temperature, low rainfall, and sparse habitation (Fig. 1). It is also the eighth most populous state of India, with a total population of 56.4 million (Census 2001), three-quarters of which lives in rural areas (Table 1) (2). The decadal growth rate continues to be high compared to other states. Over 90% of the population follows the Hindu faith, followed by 9% Muslims (3). Hindus constitute a larger proportion (95%) in the southern and south-eastern regions. Most working people in Rajasthan are engaged in agriculture and animal husbandry, although the situation in some regions is changing gradually. In areas that are better irrigated, agricultural labour is more common whereas, in the tribal-dominated south of the state, the contribution of agriculture is negligible. Under-employment is widespread, and industrial employment is low (7.5%) (4). The tribal south and the semi-arid north-central regions exhibit high rates of migration for employment; two-thirds of households in the tribal south have reported migration, with nearly half of the family income derived from sources relating to migration (5). Since 1998-1999, Rajasthan has faced regular droughts (except in 2005-2006), especially in the arid western region. With rainfall at less than 30% of the annual average, there has been severe breakdown of the livelihood support-base 6). Since women are responsible for collecting natural resources, such as water, fuel-wood, fodder, and forest-produce, droughts are known to differentially affect them. With 45 years of the last 51 years witnessing partial or total drought, a considerable amount of the state's revenue has gone into drought-relief activities. Given these factors, it is not surprising that the poverty-level in the state is high at 20.1% (4). Among its four regions, southern Rajasthan has the highest poverty-level while the western region has the lowest.
Across caste and religious groups, a woman's personal and social status is tied to her being wife and mother. Marriage is consequently universal for girls and is governed by caste and kinship norms. Seventy- six percent of women (n=3,075) in the age-group of 20-49 years were married by the age of 18 years, according to the National Family Health Survey 3 (Table 2) (7). The literacy rate among currently married rural women was 36.2% in 2005-2006. The low family status and inadequate control by women over resources have affected many aspects of their lives. Son preference is reinforced, with women bearing more children in the quest for sons (total fertility rate in 2005-2006 was 3.2, and it was 3.6 for rural women) (7). High fertility, in turn, increases the lifetime risk of maternal death. On the other hand, in urban and some peri-urban areas, a lowering of fertility has combined with son preference in the form of sex-selective abortion. It is widely believed that this has resulted in a low juvenile [0-6 year(s)] sex ratio of 909 girls per 1,000 boys in Rajasthan (2) while the overall sex ratio is 921 females per 1,000 males (Table 1). The availability of sex-selection procedures is believed to be largely limited to district and divisional towns in the state.
Women's autonomy has direct bearing on health care-seeking behaviour and healthcare-use. The National Family Health Survey (NFHS) 2005-2006 revealed that 67% of women (n=3,892) did not have access to money, and 52% of women had no say in whether they themselves could seek healthcare (7). …