KAP Report On Child and Maternal Health

A STUDY OF KNOWLEDGE, ATTITUDE AND PRACTICE OF CHAMARS, NAT / MUSAHAR
AND MUSLIMS TOWARDS REPRODUCTIVE AND CHILD HEALTH
REPORT ON
A STUDY OF KNOWLEDGE, ATTITUDE AND PRACTICE OF
CHAMARS, NAT / MUSAHAR AND MUSLIMS TOWARDS
REPRODUCTIVE AND CHILD HEALTH
PREPARED BY DR. SHAILA PARVEEN

ASSOCIATE PROFESSOR
DEPTT. OF SOCIAL-WORK
M.G.KASHI VIDHYAPITH
VARANASI
IN COLLABARTION JANMITRA NYAS/PVCHR
SUPPORTED BY CHILD RIGHTS AND YOU

CRY
1
Preface
Reproductive health or maternal health refers to the health of women during
pregnancy, childbirth and the postpartum period. While motherhood is often a positive
and fulfilling experience, for many women, it is associated with suffering, ill-health,
gender discrimination and sometimes death also. The major direct causes of maternal
morbidity and mortality include hemorrhage, infection, high blood pressure, unsafe
abortion, and obstructed labor. Globally, every minute, at least one woman dies from
complications related to pregnancy or childbirth that means 529 000 women a year.
More than three million babies are stillborn, more than four million newborns die
within the first days or weeks of life, and altogether 10.6 million children a year die
before their fifth birthday, according to WHO's latest figures. Uttar Pradesh is the
largest state in India in terms of its population which has become a cause of concern in
many quarters. It is evident that state health care services, particularly relating with
maternal and child health interventions are being labeled as inadequate to the extent.
Performance of these services have to be improved a lot to catch up the race with other
states. The indices of human development relating with rural areas and socially
disadvantaged groups such as levels of literacy, gender disparity, provision of basic
needs like health care and drinking water show in general, poor performance. Village
health infrastructure is also in very bad shape and every stakeholder is keeping
themselves away from ground reality. Inefficient administration and wrong policies are
going to take long time for a positive change but rural people can be made aware about
their entitlements and rights so that they can demand timely fulfillment of these
entitlements and rights. Development of maternal health services rural areas is possible
only when masses will come forward and protest against ongoing irregularities. A
dedicated response is needed to stimulate delivery of maternal health services in rural
areas as well as mobilize marginalized sections of the society. Panchayati Raj
Institutions also have greater role & responsibilities towards healthy motherhood and
childhood but they have failed in delivering their duties and achieving their goals as
mandated in constitution of India. Prevailing condition of maternal health and child
health in rural India is not so good and millions of Indians are living in frustrated
environment. In this research the focus has been centered to understand the knowledge
attitude and practice toward health , hygiene and reproductive and child health. This
research is focused on Varanasi district of UP . This comparative study has been
conducted to find out the basic cause of slow progress in low performing districts and to
search the best practices of high performing distri with the relevant analysis of different
aspects.
Chapter I gives a detailed introduction about national and state level maternal health
services and their present Policy and programmes related with maternal child health
issues have been discussed in Chapter II is showing overall research design &
methodology of this research .This chapter comprises selection of research plan,
Hypothesis, objective of the study, scope of the study , primary preparation ,Research
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design ,Selection procedure of district and blocks, sampling plan, collection of data tools
and techniques, Interview schedule ,Observation and data processing etc. Chapter III pr
ovides information on background of research area and respondents on basis of a
household survey conducted in four four blocks and one urban slum area taken for our
intervention. This chapter provides information on background characteristics of
districts and respondents. This chapter includes gender and cast pattern, education
status, monthly income patterns and utilization patterns of basic amenity. Chapter IV
comprises analysis of data collected from the respondents. Information base for the
analysis in this chapter is the household survey with women between the age group of16-
45. This chapter compares the situation of all the three communities knowledge ,atitude
and practice which includes obstetric care .antenatal, delivery and postnatal care;
childrens immunization services. Further, respondents awareness about NRHMs
interventions and major schemes at village level, ASHA, JSY, VHSC and VHND is also
provided in this chapter. Chapter V is consists of the status of Aaganwadi centres
running in these blocks.Chapter VI provides focus group discussionwith the women and
some Case studies of the malnutrition children situation in Varanasi.Chapter VII
contains final conclusion and suggestions relating with maternal and child health
services and interventions .It is widely recognised that the determinants of health are
social and economic rather than purely medical. The poor health of people from the
lower castes, their social exclusion and the steep social gradient are due to the unequal
distribution of power, income, goods and services. Caste is inextricably linked to and is a
proxy for socio-economic status in India. The restricted access of those from the lower
castes to clean water, sanitation, nutrition, housing, education, health care and
employment is due to a toxic combination of poor social policies and programmes,
unfair economic arrangement and bad politics.The structural determinants of daily life
contribute to the social determinants of health and fuel the inequities in health between
caste groups.
Viewing health in general as an individual or medical issue, reducing population health
to a biomedical perspective and suggesting individual medical interventions reflect a
poor understanding of issues. Social interventions should form the core of all health and
prevention programmes as individual medical interventions have little impact on
population indices, which require population interventions. At a time when the country
commits itself to the Agenda 2030 and attain the Sustainable Development Goals
(SDGs), such records of violence, disturbances and exclusions have every potential to
overpower these commitments. Amartya Sen once said, there cant be famine in a
democracy. If caste and gender continue to be factors that pre-determine childrens
futures, we cannot the achieve SDGs in India. Sustainable Development Goals replaced
the Millennium Development Goals (MDGs) which were not fully achieved. The 17
SDGs with 169 targets were adopted by the UN General Assembly on the 25th
September 2015. The outcome document describes itself as a transformative plan of
action for people, planet and prosperity that all countries and all stakeholders will
implement. The SDGs are to be achieved between 2016 and 2030. India is a signatory to
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this framework and people in India are concerned about how this framework will be
translated into national development goals. In this study we try to bring to the fore a
report of selected groups which are excluded from society and discuss the situation of
status of reproductive and child health of three excluded communities. Inequalities that
exist relating to access to public goods prevent a life with dignity for all, this must
change if we want to attain the SDGs. Yet, the SDGs are not all encompassing and do
not possess mechanism to deal with the exclusions caused by the market economy or the
right to access resources.
This report is an attempt to understand the Knowledge attitude and practice of
Musahar/Nat community, Chamar community and Muslim community in Varanasi. I
would like to take this opportunity to thank JAN MITRA NYAS AND PVCHR for
giving me the opportunity to prepare this report. The report has received several inputs
from the case studies and secondary material provided by all participating
organisations. My sincere thanks also to all friends and colleagues from these
organisations and their partner/member groups as well as experts who shared their
responses and suggestions to the draft report..This final report tries to incorporate as
much of them as possible. We would also like to thank Dr. Lenin Raghuwanshi and Ms.
Shruti Nagwanshi and Ms, Shabana Khanfor their valuable contribution to all stages of
the study. We would also like to thank our interviewer for their support in data
collection efforts.
We trust that the findings of this study will be of value, both in improving health
outcomes through more informed decision-making and in designing new projects.
Thanking you again and all and looking forward to work on the Framework of Action!
s
Dr. Shaila Parvven

Associate Professor
Deptt. Of Social Work
Mahatma Gandhi Kashi Vidyapith
Varanasi.U.P.
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CONTENTS
Preface
Listof tables
List of graphs
Chapters Page Number
1. Introduction 8-36
2. Research methodology 37-48
3. Demographical profile of the respondent 49--62
4. Data Analysis. (Knowledge ,attitude and practice ) 63-85
5. Assessment of the Aganwadi Centre 86-94
6. Focus Group discussion and Case Study 108-112
7 Conclusion ,Suggestion and action plan 112-117
Annexure
1. Bibliography 118-127
2. Interview Schedule 128-135
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Sl. Table Name of table Page

No. No. No.
1. 1.1 Key indicators and current status of maternal and child health 9
2. 1.2 Actual and projected infant mortality ratio 10
3. 1.3 Varanasi sex ratio, child marrigeand child labour 32
4. 1.4 Detail of varanasi district on institutional delievery underweight children 32
5. 1.5 Varanasi detail on immunization 32
6. 1.6 Varanasi detail on maternal mortality rate 32
7. 2.1 U.P. data on maternal health services 33
8. 2.2 Status of four blocks in Varanasi 38
9. 3.1 Age wise distribution of the respondent 51
10. 3.2 Education- wise distribution of the respondent 51
11. 3.3 Incomewise distribution of the respondent 52
12. 3.4 Residence- wise distribution of the respondent 53
13. 3.5 House- wise distribution of the respondent 53
14. 3.6 Land- wise distribution of the respondent 55
15. 3.7 Family -wise distribution of the respondent 55
16. 3.8 Marital statuswise distribution of the respondent 56
17. 3.9 Occupation- wise distribution of the respondent 57
18. 3.10 Housing characteristic wise distribution of the respondent 58
19. 4.1 Hand wash practice 64
20. 4.2 Health and hygiene practice 65
21. 4.3 Accessibilty of Health facilities 65
22. 4.4 Responce of the respondent towards reproductive health 66
23. 4.5 Knowledge about family planning 68
24. 4.6 Knowledge about safe sex 69
25. 4.7 Number of living children of the respondent 69
26. 4.8 Reason for not using contraceptive of respondent 70
27. 4.9 Knowledge regarding pregnancy 71
28. 4.10 Ante natal care 73
29. 4.11 Place of delievery of the respondent 74
30. 4.12 Immunization of the children 75
31. 4.13 Reason for not getting immuniztion 76
32. 4.14 Breast feeding practices 77
33. 4.15 Dietary practices of lactating mothers 78
34. 4.16 Knowledge regarding breastfeeding among the respondent 79
35. 4.17 Abortion practice among the respondent 79
36. 5.1 Primary information regarding AWCs 87
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Sl. No. List of Figures Fig No Page No.
1. Causes of maternal health 1.1 11
2. Age wise distribution of the respondnet 3.1 51
3. Education wise distribution of the respondnet 3.2 52
4. Income wise distribution of the respondnet 3.3 52
5. Residence wise distribution of the respondnet 3.4 53
6. House wise distribution of the respondnet 3.5 54
7. Land wise distribution of the respondnet 3.6 55
8. Family wise distribution of the respondnet 3.7 56
9. Marital wise distribution of the respondnet 3.8 57
10. Occupation wise distribution of the respondnet 3.9 58
11. Electricity wise distribution of the respondnet 3.10 59
12. Source of drinking water 3.11 60
13. Fuel used for cooking 3.12 60
14. Use of toilet 3.13 61
15. Hand wash practice 4.1 65
16. Accessibility of health services 4.2 66
17. No. of living Children 4.3 71
18. Reasons for not using contaceptive 4.4 71
19. Ante natal care knowledge 4.5 73
20. Place of deleivery 4.6 74
21. Benefits of JSY to the mothers 4.7 81
22. Accomodation fees paid for the institutional delevery 4.8 81
23. Nutrition provided to pregnant women 4.9 82
24. BCG vaccine given to the children after birth 4.10 83
25. Visit of ANM within 42 days of birth 4.11 84
26. First time bath to the neonatal 4.12 84
27. Operational place of AWCs 5.1 88
28. Sitting arrangement of Children at AWCs 5.2 88
29. Availability of Utensils to cook hot food 5.3 89
30. Availability of Plates /Bowls for children 5.4 90
31. Drinking water facility at AWCs 5.5 90
32. Weighing machine at AWCs 5.6 91
33. Availability of growth chart 5.7 91
34. Availability of referral services 5.8 92
35. Facilities in AWCs 5.9 92
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Abbrebiation
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
AWW Anganwadi Worker
BCC Behavior Change Communication
CHC Community Health Center
CMO Chief Medical Officer
DLHS District Level Household and Facility Survey
ICDS Integrated Child Development Services Scheme
IEC Information, Education and Communication
IFA Iron and Folic Acid
IPC/C Interpersonal Communication/Counseling
IPHS Indian Public Health Standards
JSSK Janani Shishu Suraksha Karyakram
JSY Janani Suraksha Yojana
MoHFW Ministry of Health and Family Welfare
NFHS National Family Health Survey
NHSRC National Health Systems Resource Center
NRHM National Rural Health Mission
PHC Primary Health Center
PIP Program Implementation Plan
PMU Program Management Unit
PRI Panchayati Raj Institute
RCH Reproductive and Child Health
RKS Rogi Kalyan Samiti
TBA Traditional Birth Attendant
VHSC Village Health and Sanitation Committee
WHO World Health Organization
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CHAPTER 1 Introduction
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CHAPTER 1
Introduction
India has a unique opportunity now to improve the health and nutritional status of its people.
The country is in a position to invest increasing amounts of resources in social sectors as a
result of economic progress. With recognition of the importance of health and nutrition for
national development, the prospects for improved and equitable health and nutrition are now
better than they have ever been. Reproductive health, and child health and nutrition are core
priorities for any country, more so for India with the worlds greatest burden of maternal,
newborn, and child deaths. In 2008, 18 million children (age <5 years), including 1 million
neonates, died and 68 000 mothers died.India also has the greatest number of undernourished
children, with about 52 million stunted children (age <5 years)in reproductive health, and
child health and nutrition does not compare favourably with some other countries in Asia that
gained independence at about the same time as India. India still has a long way to go to reach
its declared goals.We review the current situation of reproductive health, and child health and
nutrition in India, identify policy and programmatic gaps, and suggest a way forward. To
maintain focus on the main themes, we do not cover some equally important and related
issues such as child development and micronutrient malnutrition. The description of methods
used in this report is provided in the below table .
Table 1.1
Key indicators, and current status and national goals for maternal, newborn, and child health
Status (year) Goals and targets (year)
Child (age <5 years) 74 per 1000 livebirths (200506); Millennium Development Goal 4:
mortality rate 69 per 1000 livebirths (2008);4 38 per 1000 livebirths (2015)
63 per 1000 livebirths (2010)6
Infant mortality rate 53 per 1000 livebirths (2008)4 National Population Policy (2000) and
National Rural Health Mission:
<30 per 1000 livebirths (2010);
XI Plan: 28 per 1000 livebirths (2012)
Neonatal mortality rate 35 per 1000 livebirths (2008)4 National Plan of Action for Children 2005:
18 per 1000 livebirths (2010)
Maternal mortality 254 per 100 000 livebirths National Population Policy (2000) and
ratio (200406)5 National Rural Health Mission
<100 per 100 000 livebirths (2010);
Millennium Development Goal 5
<100 per 100 000 livebirths (2015)
Total fertility rate 27 (200506)3 National Rural Health Mission: 21 (2012)
Prevalence of 43% (200506)3 National Plan of Action for Children 2005:
underweight among reduce by half (2010); Millennium
children (age <5 years) Development Goal 1: 27% (2015)
Key indicators, and current status and national goals for maternal, newborn, and child health
Burden and underlying disorders.
Trends in key indicators.
The estimated population of India is 116 billion individual and is projected to be 148 billion
people by 2030, surpassing China as the worlds most populous nation The total fertility rate
in 200506 was 27 versus 34 in 19989 is now 21 (replacement level) in urban areas, and
30 in rural areas. In 200506, 56% of married women were using contra ception compared
with 41% in 199092and 48% in 199899. The estimated maternal mortality ratio showed a
36% reduction from 398 per 100 000 livebirths in 199708 to 254 per 100 000 livebirths in
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200406 However, this decrease is not sufficient to achieve a maternal mortality ratio of less
than 100 per 100 000 livebirths to meet national goals or the Millennium Development Goal
(MDG) by 2015. According to the National Family Health Survey-3 (NFHS 3) the mortality
rate for children (age <5 years) in India was 74 per 1000 livebirths in 200506. The Institute
of Health Metrics and Evaluation estimated a mortality rate of 626 per 1000 livebirths for
2010. At the current rate of progress, India will not be able to achieve the MDG 4 target of 38
per 1000 livebirths by 2015 In 2008, infant mortality rate in India was 53 per 1000 livebirths.
The national goal is to attain a rate of less than 30 per 1000 livebirths by 2010. Our analyses
show that most states, and rural areas as a whole, will not achieve this even by 2015. With the
exception of Goa and Kerala, which already have infant mortality rates of fewer than 30 per
1000 livebirths, only Tamil Nadu, West Bengal, and Maharashtra are likely to achieve this
target (In 2008, a neonatal mortality rate of 35 per 1000 livebirths,4 meant that more than two-
thirds of infant deaths happened in the first 28 days of life.
Table 1.2
Actual and projected infant mortality rates (per 1000 live births) in the main states
Actual infant mortality rate Projected
(Year ) infant
mortality rate
for 2015
1990 2000 2008
India
Total 80 68 53 43
Rural 86 74 58 47
Urban 50 43 36 31
States
Andhra Pradesh 70 65 52 43
Assam 76 75 64 56
Bihar 75 62 56 51
Delhi 43 32 35 38
Goa 21 23 10 5
Gujarat 72 62 50 41
Haryana 69 67 54 45
Himachal Pradesh 68 60 44 34
Karnataka 70 57 45 37
Kerala 17 14 12 10
Madhya Pradesh 111 87 70 58
Maharashtra 58 48 33 24
Meghalaya 54 58 58 58
Orissa 122 95 69 52
Punjab 61 52 41 33
Rajasthan 84 79 63 52
Tamil Nadu 59 51 31 20
Uttar Pradesh 99 83 67 56
West Bengal 63 51 35 25
*
Base year was 2000.

Data from the Registrar General of India.
Actual and projected infant mortality rates (per 1000 livebirths) in the main states
More than 48% of children (age <5 years) are stunted (height for age <2 Z score), 43% are
underweight (weight for age <2 Z score), and about 20% have wasting (weight for height <
2 Z score) Between 199899 and 200506, stunting showed a steady but slight reduction in
the prevalence of 1% per year. At the current rate of decline, India will not achieve the
national goals for child nutrition or the MDG 1 target for child nutrition, which is to reduce
the prevalence of underweight among children (age <5 years) to 27% by 2015 India consists
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of 28 states and seven union territories with diverse social, demographic, economic,
geographic, and health systems. Wide differentials exist across states in the indicators for
reproductive health, and child health and nutrition
Causes of maternal and child mortality:-
The leading causes of maternal deaths in India are haemorrhage, sepsis, complications of
abortion, and hypertensive disorders More than half of deaths in children (age <5 years) occur
in the neonatal period; infections (including sepsis, pneumonia, diarrhoea, and tetanus),
prematurity, and birth asphyxia are the three major causes of death in this period (The
remaining 45% of deaths occur in children aged between 1 month and 59 months, and the
major causes are pneumonia and diarrhoea.
Fig 1.1
Causes of maternal deaths in India (19972003)
34 37
8
5 11
Haemorrage
Sepsis
HypertensiveObstructed
Labour
Complication of abortion
Other disorder
Causes of maternal deaths in India (19972003) :-

Undernutrition is the cause of a third to half of deaths among children (age <5 years).
Reduction in rates of undernutrition has been slow but steady and is likely to speed up as a
result of improvements in socioeconomic status Transgenerational effects, however, could
mean that full-scale change will take decades. Roughly a third of infants (78 million) are
born with a low birthweight (<2500 g) every year, accounting for 26% of the global burden,
the largest for any country. 60% of these infants are born at term after fetal growth restriction.
The first 2 years of life, particularly the earliest months, are crucial for addressing
undernutrition that arises as a result of a combination of low birthweight, suboptimum
feeding, and infections such as diarrhoea. Early undernutrition predisposes to irreversible
effects on educational attainment, adult height, income, and the birthweight of subsequent
offspring. A third of infants have wasting and a fifth are stunted at birth and within the first 6
months of life During the first few months, exclusively breastfed infants generally remain free
from infections and are not predisposed to further undernourishment. However, introduction
of animal milk between 3 months and 5 months triggers a rise in morbidity due to infections
and an increase in the rates of underweight and stunting. Late introduction and inadequate
quantity of complementary feeds, and an increase in infections, lead to a further rise in rates
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of underweight and stunting between the ages of 6 months and 11 months). The main reason
for a steady increase in the prevalence of undernutrition in the second year of life is the intake
of inadequate and low-energy foods. Because of the faltering growth and increase in stunting
with increasing age, the prevalence of subnormal body-mass index (BMI) shows a
progressive fall from a third in the first 6 months to a sixth by the third year.
By use of the New Delhi Birth Cohort longitudinal database we noted that low birthweight
increased the odds of underweight, stunting, and wasting in the first 5 years of life, and the
effect generally decreased with increasing age). At 6 months of age, 28% of underweight and
stunting and 22% of wasting were attributable to low birthweight. From the age of 1 year to 5
years, 1621% of wasting, 816% of stunting, and 1619% of underweight were attributed to
low birthweight.
The immediate causes of poor reproductive health, and child health and undernutrition have
underlying social, economic, and environmental determinants: literacy, womens status,
sociocultural beliefs, caste, taboos, and, above all, income level. Analysis of data from NFHS-
3 showed that illiteracy, low wealth index, rural habitat, and perceived small size at birth were
significantly associated with neonatal and infant mortality For low birthweight, maternal age
at childbirth of less than 20 years was associated with a roughly 50% excess risk compared
with childbirth at older age. Antenatal care seemed to protect strongly against low
birthweight. These analyses indicate the importance of delaying childbirth until after 20 years
of age, and providing antenatal care and birth spacing as interventions to improved child
survival.
The nutritional status of Indian women is inadequate: 33% of married women (aged 1549
years) are too thin (ie, BMI <185 kg/m2), and 11% are too short (ie, height <145 cm) In
2004, more than 75% of women were anaemic. The reported prevalence of anaemia in pregn
ant women from large-scale surveys range from 743% to 962%. Added to these burdens are
the challenges of the epidemiological transition. Overnutrition is emerging as an important
public health problem126% of women and 93% of men aged 1549 years have a BMI of
25 kg/m2 or more, and is more common among people living in urban areas. It is associated
with a rising prevalence of diabetes mellitus and cardiovascular diseases; an estimated 80
million people are expected to need health care for diabetes mellitus by 2030 in India.
Another challenge is rapid and unplanned urbanisation. Current estimates suggest that 30% of
Indias population live in towns and cities, and this proportion is projected to increase to 40%
(550 million) by 2026. Overall health indicators are generally better in urban than in rural
areas, but the aggregate data are not sufficiently informative; the health of individuals who are
poor and living in urban areas does not differ substantially from that of the rural population .
Scope of current programmes :-
The main national programmes are the Reproductive and Child Health Programme, National
Rural Health Mission (NRHM; panel 1), and the Integrated Child Development Services
(panel 2). Janani Suraksha Yojana, a conditional cash transfer scheme to promote deliveries in
institutions, is another major initiative that is part of NRHM. Health and nutrition are
multidimensional and cross the traditional boundaries between sectors and ministries,
requiring improvements in water, sanitation, habitat, connectivity, industry, and food security.
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Although we recognise that the landscape is intersectoral, in this report we focus mainly on
the reproductive health, and child health and nutrition programmes. Policies and programmes
for reproductive health and child health include most of the interventions across the life-cycle
and service-delivery continuum discussed in The Lancet Series about neonatal, child, and
maternal survival. Inclusion of interventions in a policy or programme document, however,
does not mean that they will achieve sufficient coverage for effect, as is the case for India
(India has not achieved coverage of more than 55% for any of the priority interventions for
reproductive health, and child health and nutrition. For example, only 46% of infants were
exclusively breastfed in the first 6 months of life in 200708, and just 24% received solid or
semisolid feeds and breastfeeds at 69 months. A wide variation exists between states (and
across districts within them (Improvement of the status of reproductive health, and child
health and nutrition requires state-specific and district-specific insights and approaches..
Panel 1
Indias reproductive and child health programmes
Until the advent of the National Rural Health Mission (NRHM) in 2005, Indias
programmes for maternal and child health and family planning were fragmented and
inconsistent, and mostly vertical family planning in the 1960s and early 1970s,
immunisation in the 1970s and 1980s, and diarrhoeal disease in the late 1980s and early
1990s. The country did not take a comprehensive view of the needs of the communities,
outreach programmes, and facilities. Inadequate health systems (human resources,
infrastructure, supplies, monitoring), with low political visibility of health and low health
spending, were never adequate to support the action that was needed to improve the health
of women and children. Hence, India often missed most of the goals.
In 1992, India launched the Child Survival and Safe Motherhood (CSSM) Programme by
bringing together interventions for child survival (immunisation, control of diarrhoeal
disease, acute respiratory Infections, vitamin A, essential newborn care) and maternal
health (antenatal care, deliveries in institutions, emergency obstetric care). In 1997, the
programme for family planning and the CSSM Programme were merged to create the
Reproductive and Child Health Programme. The focus on reproductive and child health
shifted to births in institutions and emergency obstetric care as the key strategy for
reduction of the maternal mortality rate.
2005 was a watershed year for the health sector in India. The government launched the
NRHM. This mission included increased investment in public health, improvements in
health systems, focus on communities, decentralisation, and demand-side interventions to
improve the effectiveness of the programmes. The programme for reproductive and child
health was integrated into the NRHM. Although the NRHM has a wide scope, its prime
focus is on reduction of maternal and child mortality rates. Key strategies include
deployment of more than 750 000 new health workersaccredited social health activists),
and 47 000 additional auxiliary nurse midwives and 27 000 new nurses; integration of
disease control programmes in the communities or population; setting up of 450 000 village
health and sanitation committees (made up of local elected representatives, an anganwadi
14
worker, accredited social health activists, local school teacher, and representatives of self-
health groups); strength ened primary health-care infrastructure (civil work, equipment,
and supplies); ensuring quality to meet Indian public health standards; provision of
uncondinational grants at subcentres for autonomous action for health locally;
strengthened programme management capacity by deployment of management
professionals in states and districts; funds provided directly to the districts from the centre;
and establishment of 29 000 patient-welfare commit tees at facilities for local decision
making and use of funds. A total of 1031 mobile medical units are operational and
emergency transport system has been made operational in 12 states with 2919 ambulances.
An assessment of NRHM by an international advisory panel showed that the demand for
public health facilities has gone up. NRHM strategies have had a positive effect on
antenatal care, institutional deliveries, and immunisation. However, the effect on infant
mortality rate has not been impressive. The NRHM has not succeeded in removing the
regional imbalance in health infrastructure in the subcentres and primary health centres.
Panel 2
Integrated Child Development Services (ICDS)
Services provided by this programme include supplementary nutrition, non-formal
education, immunisation, health check-ups, referral services, and nutrition and health
education. These are provided at a centre called the Anganwadi (a courtyard play centre)
that is located within the village itself. The anganwadi worker, a woman selected from the
local community, is the key functionary. She, with assistance from a helper, is responsible
for the population of an average village (about 1000 people).
The anganwadi worker surveys all the families in the community and identifies children
younger than 6 years, and pregnant and lactating women. Eligible individuals are given
supplementary feeding support for 300 days per year. On average, the daily supplement is
expected to provide 500 calories and 1215 g of protein to children, and 600 calories and
1820 g of protein to pregnant or lactating women. Children who are severely
malnourished are given an additional 300 calories and 810 g of protein on the basis of
medical advice. The anganwadi worker also monitors and plots the growth of children who
attend the Anganwadi centre by weighing them periodically and plotting the data on
weight-for-age growth cards. Additionally, she is entrusted with the responsibility of
nutrition and health education of women aged 1545 years.
Launched in 1975, the programme has gradually increased from 33 projects to 7073
projects in 2009, catering to about 873 million beneficiaries through a network of about 1
million Anganwadi centres.35 The allocation of funds for the scheme has steadily increased
over the years from INR26 0128 million in the 8th Five Year Plan (199297) to INR440
000 million in the 11th Five Year Plan (200712).
The effect of the ICDS programme has been the subject of intense scrutiny in the past two
decades, the findings of which are not encouraging. The programme has not been able to
achieve the necessary results despite three decades of existence. Results of studies have
shown little or no association between the presence of an ICDS centre and the nutritional
15
status of children. Focus on children younger than 3 years is inadequate, thus missing the
critical window of opportunity to avert an avoidable undernutrition. About 20% of children
younger than 6 years live in areas that do not have an anganwadi centre (National Family
Health Survey-3).
Even in those areas that do, almost three-quarters of children did not receive any
supplementary food from an anganwadi centre in the 12 months before the survey. A
similar proportion of women did not receive supplementary food from an Anganwadi
centre during their previous pregnancy.
Although ICDS might not have succeeded in substantially reducing the burden of
undernutrition, the presence of an anganwadi worker and a physical site for health and
nutrition activities (Anganwadi centre) in villages and poor urban areas offers a great
opportunity to improve nutritional status and provide health-care services for mothers and
children.
Gaps in programmes and strategic directions
Child health
In this section, we identify the programmatic gaps in reproductive health, and child health and
nutrition. A summary of specific suggestions to address these gaps is presented in. Integrated
Management of Neonatal and Childhood Illnesses, the Indian adaptation of the generic
strategy for Integrated Management of Childhood Illness, was introduced in 2005. It includes
home visits in the first week of life by anganwadi workers. Postnatal home visits, a strategy
that was developed on the basis of the work by Bang and colleagues in Gadchiroli, have now
been recommended by WHO and UNICEF. The scale-up of Integrated Management of
Neonatal and Childhood Illnesses has, however, been tardy. Although training was initiated in
223 districts, only 43 achieved more than 80% coverage for all categories of workers.
Nonetheless, by June, 2009, 202 015 providers (>85% of whom were frontline workers
anganwadi workers, auxiliary nurse midwives, and accredited social health activists) had been
trained (Mohan P, Unicef India, New Delhi, India, personal communication). For many
smaller countries this number would be universal coverage, but in India it is more than ten
times fewer than the number of trainees needed in just the high-burden districts. The reasons
for the slow implementation, aside from the numbers required, include lack of capacity for
training and supervision, lack of ownership by and convergence with the Integrated Child
Development Services, lack of review and monitoring nationally and in states, inability to
integrate the referral component, and non-availability of line supervisors.
While Integrated Management of Neonatal and Childhood Illnesses was becoming
established, programme managers overlooked the need to continue pushing for increased
population coverage of pre-existing interventions, especially for diarrhoea and acute
respiratory infections in districts and blocks where rollout of the Integrated Management of
Neonatal and Childhood Illnesses was not planned immediately. Little progress has occurred
in their coverage. For instance, in 200708, 34% of children received oral rehydration
solution for diarrhoea compared with 30% in 200204.
Facility-based care of infants and children has also not been given enough attention.
Consequently, when the number of deliveries in institutions increased as a result of Janani
16
Suraksha Yojana, the availability and quality of newborn care was inadequate UNICEFs
facility-based newborn-care programme to operationalise special-care newborn units in
district hospitals and stabilisation units in subdistrict facilities, with technical support from the
National Neonatology Forum, needs to be expanded by state governments. Inpatient care of
sick children should be linked to these newborn-focused efforts.
Because treatment of pneumonia, diarrhoea, and neonatal infections is important, ways to
ensure early identification of sick infants and children, provide primary treatment in the
community, and refer the children to facilities, if indicated, are urgently needed. Results of
studies have shown a care-seeking bias against girls. For every two male neonates, only one
female neonate is admitted to a health facility (district hospital or a tertiary-care institution).
Financial incentives for care seeking might need to be considered, particularly for female
infants and children. Ideally, neonates with sepsis should be treated in health facilities.
However, most are not taken to such facilities, and auxiliary nurse midwives urgently need to
be trained and empowered to administer intramuscular injections of gentamicin and oral
antibiotics, either on an ambulatory basis or at home. Additionally, physicians practising
ayurveda, unani, siddha, and homoeopathy might be involved in this task. Another important
option is to involve the private sector in the care of sick neonates and children.
Evidence shows that community health workers can be effective in substantially reducing the
number of child deaths, especially through case management. Experience from India, both
from research and in the programme setting, justifies encouragement of home-based and
community-based care of neonates and children. With the introduction of one accredited
social health activist (a school-educated local female health worker) per 1000 population,
under the NRHM, there is great potential to strengthen care of neonates and children in the
community. An opportunity exists to introduce the home-based newborn-care model,
especially in areas where access to health facilities and care seeking are inadequate. After an
avoidable delay of years, training of accredited social health activists for such a role has been
started; however, completion of training is likely to take 35 years in the high priority
districts. Training must be followed by effective supervision, supplies, and payment to
accredited social health activists for the strategy to be effective and sustainable. The role of
these health workers in promoting immunisation and providing treatment for diarrhoea and
acute respiratory infections also needs to be further strengthened.
The proportion of infants aged 1223 months who were fully vaccinated (BCG, measles,
diphtheria, pertussis, and tetanus, poliomyelitis) increased to 54% in 200708, from 46% in
200204. This increase in uptake happened after a phase of stagnation in the preceding
decade. However, India still lags behind the rest of the world in immunisation coveragethe
global average for diphtheria, pertussis, and tetanus is 81% compared with 64% in India.
Existing immunisation services have not ensured reliable, regular supply and distribution of
vaccines, despite India being a major producer of vaccines. The situation is made worse by
operational deficiencies such as defunct cold chain equipment, vacant staff positions, weak
surveillance of vaccine-preventable diseases (other than poliomyelitis), erratic
implementation of a fixed-day, fixed-place strategy, and lack of active targeting of potential
non-acceptors. Community participation in routine immunisation is inadequate,
17
communication activities to encourage behaviour change have not been prioritised, and
communities view polio vaccine as the only important vaccine. 55 Some states have tried
innovative approaches to increase coverage, including deploying alternative vaccinators.
Other examples are Muskaan ek abhiyan, an incentive-based scheme in Bihar with
programme monitoring at the highest administrative department, and Shishu Samrakshak
Maah in Chhattisgarh, which provides immunisation with other child health interventions.
The perception among public health activists is that the weight of international
recommendations, the opinion of professionals from the private sector, and lobbying by
industry, rather than scientific evidence and context of the programme, tend to affect the
introduction of vaccines. A judicial intervention in response to a civil society plea in this
respect has led to a comprehensive review of vaccine policy recently.
Maternal health
Under the NHRM, the Government of India has taken steps to improve maternal health. The
three key efforts are encouraging delivery in institutions through incentives from Janani
Suraksha Yojana, supporting the development of services for emergency obstetric care, and
training auxiliary nurse midwives and nurses for 23 weeks to gain competencies as skilled
birth attendants. Janani Suraksha Yojana provides a cash incentive to women who give birth
in health centres or government hospitals. If a woman delivers in a facility, she is entitled to
receive INR1400 (US$35), and the health worker (accredited social health activist) who
accompanies her to the facility receives INR600 ($15) for transportation expenses and as an
incentive. In urban areas and high-performing states, the incentives are low and are restricted
to women living below the poverty line. In just 5 years, beneficiaries of Janani Suraksha
Yojana have increased 13 times, from 074 million in 200506 to nearly 10 million in 2009
10, thus representing almost 40% of the 26 million women who deliver in India every year.
Budgetary allocation for Janani Suraksha Yojana increased from $85 million to $275 million
in 200809. From the point of view of delivery in public sector health facilities, cash
incentives seem to stimulate demand and enhance use. In just 1 year, for instance, the states of
Rajasthan and Madhya Pradesh showed an increase in deliveries in government facilities by
36% and 53%, respect ively. Janani Suraksha Yojana has helped to overcome financial
constraints that prevented women from going to the hospitals for delivery.
After 23 years of implementation of Janani Suraksha Yojana, high odds of births in facilities
were reported among users of the scheme and a reduction of about four perinatal and two
neonatal deaths per 1000 livebirths. The findings of the study confirmed substantial use of
Janani Suraksha Yojana by individuals who were poor, as had been shown in other less robust
assessments. An increase of 80%, from 298% to 378% in deliveries in rural institutions
between 200204 and 200708is generally attributed to Janani Suraksha Yojana.
Although the experience with Janani Suraksha Yojana shows that India can embark on bold,
big initiatives for maternal, newborn, and child health, there are major concerns and
challenges. Most mothers and babies are discharged within hours of delivery because
hospitals lack amenities and families want to return home after receiving the cash incentive.
Therefore, there is not enough time for newborn-care counselling, establishment of
breastfeeding, stabilisation of post-partum mothers, and detection of danger signs in mothers
18
and infants. Deliveries might be made by unskilled support staff rather than by skilled nurses
or doctors, and best practices such as partography, neonatal resuscitation, and kangaroo
mother care are not followed. The system of referral in emergency departments is inadequate.
Payments to families and accredited social health activists are delayed in some places, and
instances of corruption have also been reported. Another serious issue is the effect of Janani
Suraksha Yojana on other initiatives for maternal, newborn, and child health. Since the
management capacity of the health system has not been optimally augmented for Janani
Suraksha Yojana, its magnitude, high political visibility, and a huge number of transactions
result in the neglect of other vital programmes. Janani Suraksha Yojana is a unique initiative
and its full effect and implications have yet to emerge. The challenge is to strengthen,
streamline, and deepen its implementation, and to increase the equity quotient and ensure
continued independent monitoring and assessment.
NRHM has also triggered innovative approaches in states. Tamil Nadu, for example, has
operationalised strategically located primary health centres for basic emergency obstetric care
and referral services, developed subdistrict hospitals for emergency obstetric and neonatal
care, and instituted an audit of maternal deaths. The delivery rate in institutions is now 98%.
Importantly, maternal care has shifted from large to small hospitals, and from the private to
the public sector.
Gujarat has shown that public-private partnerships can increase access to delivery in
institutions and emergency obstetric care. The Government of Gujarat by recognising the
shortage of obstetricians in the public system in rural areas, and at the same time their
presence in the private sector in nearby towns, developed an innovative partnership. The
Chiranjeevi scheme provides childbirth and services for emergency obstetric care in private
hospitals under the care of qualified private obstetricians, free of cost to families but paid for
by the government. More than 800 obstetricians have joined the scheme and have undertaken
more than 300 000 deliveries for clients who are poor, with acceptable rates of caesarean
section. At about $46 per delivery, the government has negotiated a low average rate of
payment per delivery, including caesarean sections The model is being replicated in other
states. Referral services, specifically emergency ambulance services, have also improved in
12 states through public-private partnership. The services are free of cost and highly popular.
In Assam, outreach services are being delivered to isolated islands of the Brahmaputra river
by use of innovative boat clinics.
Most states have a shortage of anaesthetists and obstetricians. Only 31% of community health
centres have obstetricians, surgeons, and paediatricians. The Government of India has
developed in-service courses in emergency obstetric care (16 weeks duration) and life-saving
skills in obstetric anaesthesia (18 weeks duration) for general medical officers with the aim
of deploying them in district hospitals and community health centres. Although in the right
direction, the scale-up of such multiskilled approaches is unlikely to close the gap in human
resources soon. Postnatal care continues to be insufficient, with only 51% of women receiving
any in 200708. Since home deliveries are likely to remain a reality for some time, and
mothers often leave hospital within a day of delivery in an institution, postnatal care needs to
19
be provided at home. Accredited social health activists should provide such care to neonates
and mothers by making home visits.
Family planning and sexual health
In principle, reproductive health is not about population control but a matter of rights,
informed choice, good health, and wellbeing. Most of the increase in the population will
occur among communities that are poor, and the challenge to ensuring that health, education,
employment, and amenities are provided to a large population is formidable. India rejected
the coercive family planning policies that were implemented in China, and it has no reason to
go back to a regime of targets. Rather, the focus should be on how to address the unmet need
for contraception and ensure access to adolescent, maternal, and child care. To improve
reproductive health in the long term, engagement with young people is essential (panel 3).
Panel 3
Reproductive health issues for young people in India
With a huge population that is young, investments in the health of young people are crucial
for the countrys productivity and development. Young women and men, both in and out of
school, have to be reached to educate them about good reproductive and sexual health, and
to lay a foundation for healthy lifestyles.
Women in India continue to get married at a young age: 18% of women aged 2024 years
were married by the time they were 15 years old and almost 47% before the minimum legal
age (18 years) for marriage. Early marriage is followed by early pregnancy. The National
Family Health Survey reports that 28% of women aged 2049 years had given birth by the
time they were 18 years old, and 24% of those aged 18 years had already begun
childbearing (had a livebirth or were pregnant with their first child).
Early childbearing poses a risk to both the mother and infant. Young women who marry
early are much worse offthan are those who marry late: they are more likely to have
pregnancy-related complications and less likely to seek timely care; they are less likely to
deliver their first child in an institution, more likely to experience violence within marriage,
and more likely to have loss of pregnancy. For young women, early marriage might also
pose substantial risks of acquiring infection from their husbands.
Premarital sexual relations are increasingly noted15% of young men and 4% of young
women aged 1524 years had had premarital sexual relations according to the results of
the Youth in India: Situation and Needs study, a subnational study done in Andhra
Pradesh, Bihar, Jharkhand, Maharashtra, Rajasthan, and Tamil Nadu. Moreover, the
individuals involved in sexual relations were largely uninformed (eg, just two-fifths and
three-fifths of sexually experienced young men and women were aware that a woman can
get pregnant during first sexual intercourse). Most young people did not use a condom,
and, often, the sexual relations were unwanted or forced.
Unmet need for birth spacing was high among young women25% and 15% among those
aged 1519 years and 2024 years, respectively. Although overall 82% of demand for
contraception was achieved among all women, just 32% and 61% were achieved among
women aged 1519 years and 2024 years, respectively.3
20
Results of several facility-based studies have shown that 130% of women who seek
abortions are young and unmarried. The programme for reproductive health and child
health includes the framework of services targeted at adolescent reproductive and sexual
health services for the young people.
Despite the fact that the emphasis of the programme for reproductive and child health is on
client choice and use of non-terminal methods, female sterilisation accounts for about two-
thirds of the prevalence rate for contraception, a proportion that has not changed since
199092. The unmet need for contraception, both for birth spacing and termination, is
substantial. Indeed, 13% of married women reported that they were not using contraception
even though they wished to delay further pregnancies or stop further childbearing
altogether. The unmet need for contraception among young married women is high (27%
and 21% for women aged 1519 years and 2024 years, respectively). Difficulties in
obtaining contraception include a lack of awareness of non-terminal methods (notably
among young women little communication with couples, and an imbalance in gender
relations that make access to contraception difficult for women. At the same time,
deficiencies exist in the programmeshealth-care providers do not always inform women
about the options available or counsel clients about potential side-effects of the different
methods; not all physicians at peripheral health centres are trained in the methods of
sterilisation, and not all paramedical staff have appropriate skills in inserting intrauterine
devices.
Prevention of unsafe abortion :-
Despite the liberalisation of abortion services since the early 1970s, access to safe abortion
remains restricted, particularly in rural areas. Of the estimated 67 million abortions per year,
only 1 million are thought to be provided by certified cadres at authorised centres. The typical
woman seeking an abortion is married and aged 2029 years, but a large number are young
and unmarried, often seeking abortion in the second trimester. Many factors affect access to
safe abortion services. The distribution of registered abortion facilities and certified providers
is uneven across and within states. Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh
together have 40% of the population but less than 17% of all approved abortion facilities.
Moreover, most abortion facilities are located in urban areas, whereas more than 70% of
Indian women live in rural areas. Aside from the inaccessibility of facilities, other obstacles
include a lack of trained providers, perceived poor-quality care, little awareness that women
are legally entitled to abortion, cost, and for young and unmarried women there is the fear of
disclosure.The Government of India has made concerted efforts to increase access to abortion
services. For example, the National Population Policy recommended expanding the provision
of abortion to the primary health centres. Certification procedures have been rationalised,
training of medical officers in manual vacuum aspiration has been expanded, non-surgical
abortion (using drugs) at gestational age of 7 weeks or less was legalised in 2002, and, to
make them more accessible, rules and regulations were further amended so that abortions can
now be undertaken by certified providers in unregistered facilities, as long as they have access
to a registered facility for backup. Although impressive, these efforts remain insufficient to
meet the needs of women seeking abortion services.
21
Selective abortion :-
In India, men and women across all wealth strata, education groups, castes, tribes, religions,
and states have a preference for sons. For example, 81% of ever-married women and 74% of
ever-married men wanted at least one son, and a quarter of men and women wanted more
sons than daughters. The high prevalence of sex-selective abortion after prenatal diagnostic
testing is a cause for concern. Although the government tried to address this practice by
introducing a law in 1994, it has not been able to prevent many such abortions. Prevalences of
sex-selective abortions that were reported in community-based studies ranged from 3% to
17%. Indirect estimates derived from data reported by NFHS-2 indicate that, among women
who received ultrasound or amniocentesis during antenatal check-ups, 64% of female fetuses
were assumed to have been aborted. The child sex ratio recorded in the 2001 census was 927
girls per 1000 boys (age 06 years), worse than the estimated 945 girls per 1000 boys in the
1991 census. Sex ratios are very low in Punjab, Haryana, Delhi, Gujarat, and Rajasthan (793,
820, 865, 878, and 909 girls, respectively, per 1000 boys). Some states are now showing a
trend towards improvement.
Early age at childbirth :-
The median maternal age at first delivery in India is 199 years; about 30% of girls give birth
before the age of 20 years, and account for 21% of all deliveries. We have estimated that the
risks of neonatal mortality and low birthweight are increased by almost 50% if maternal age
at childbirth is less than 20 years. Early childbearing is also associated with excess maternal
mortality. In a national study done by the Indian Council of Medical Research at ten
institutions, maternal mortality among adolescents was 645 per 100 000 livebirths compared
with 342 per 100 000 livebirths in women aged 2034 years.
Child nutrition :-
Indias inability to improve child nutrition arises from the present policy that lacks an
evidence base for effectiveness. The National Plan of Action for Children 2005 committed
India to reducing malnutrition and low birthweight in children (age <5 years) by half from
2005 to 2010 This reduction was impossible in view of the evidence that changes in fetal and
child growth are not biologically amenable to quick improvements. Although the first 2 years
of life, particularly the earliest weeks and months, are important for prevention of
undernutrition and the serious and long-term consequences associated with it, this age group
has not received sufficient focus. Panel 2 shows that the focus of the Integrated Child
Development Services is provision of supplementary nutrition and education for children
aged 36 years. In a time and motion study, anganwadi workers spent 40% of their time on
education of this age group, 36% on provision of supplementary nutrition, 16% on record
keeping, and 9% on the rest of their activities. Little time was left to work with infants or for
activities such as home visits, growth promotion, health and nutrition education, and
community mobilisation.
This lack of attention to young children is one of the conceptual inadequacies of the
Integrated Child Development Services. Other deficiencies include a lack of home visits to
newborn infants, thereby missing a chance to support breastfeeding, one of the most
potentially effective interventions for child health; a lack of emphasis on feeding low-
22
birthweight infants, a high-risk group; inadequate efforts to help vulnerable groups (girls, low
castes, tribal populations, poor families); a focus on food supplements at the expense of
education to improve feeding practices; poor content and quality of take-home supplements
for young children; inadequate convergence between health and nutrition programmes and
systems; and an approach to the management of severe acute malnutrition that is not
sufficiently robust. These inadequacies in design need to be addressed before progress can be
made in nutrition. Although severe acute malnutrition in children has gradually declined in
prevalence, it has not really been addressed systematically. The emphasis has been on
inpatient rehabilitation, but recognition of the need to implement community and domiciliary
approaches is increasing. Progress has been hampered by the lack of treatment regimens that
have undergone rigorous assessment and uncertainty about the usefulness of ready-to-use
therapeutic foods. Most stakeholders do not judge severe acute malnutrition to be a medical
emergency. The way forward is to undertake controlled research to compare feasible
regimens, including locally manufactured, culturally acceptable, ready-to-use therapeutic
foods. shows the suggested strategic directions for policy and programmes for child nutrition.
SOCIO ECONOMIC DISPARITIES AND HEALTH
Muslims:-
In India, Muslims form the largest religious minority group, constituting 14.2% of the
total population (Census, 2011). Nationally, the proportion of Muslims to the total
population rose from 13.4% in 2001 to 14.2% in 2011 to the total population. The Indian
state of Assam recorded the highest proportional increase of in Muslims amongst the
states inhabitants, it rose from 30.9% in 2011 to 34.2% in 2011. Several studies have
highlighted out various expressions and incidents of denial of rights, marginalization
and social exclusion of Muslims across India.
There are disproportionately large numbers of Muslims living in poverty. The Sachar
Committee report calculates that almost one-third (31%) of the Indian Muslims are
living below poverty line. Similarly, the National Council for Applied Economic
Research (NCAER) notes that three out of every ten urban Muslims are poor (that is,
living on a monthly income of Rs.550 and less). And, one in five rural Muslims are below
poverty line with an average monthly income of Rs.338 per year.
The Monthly Per Capita Expenditure (MPCE) reflects the living standard of a family.
National Sample Survey Organization examines that in 2009-10, at all-India level, the
average monthly per capita expenditure (MPCE) of a Muslim household was Rs. 980
while that of a Sikh household was Rs. 1,659. The average MPCE for Hindus and
Christians amounted to 1,125 Rupees and 1,543 Rupees, respectively. Pew Research
(2014) shows that Muslims average per capita spending a day is Rs. 32.7 ($0.52), while
it is Rs. 37.5 for Hindus, Rs. 51.4 for Christians and Rs. 55.3 for Sikhs. In addition,
impact of poverty alleviation programmes is minimal on Muslims. Human Development
Report (2011) of India cites that compared to SC/STs and other social and religious
groups, poverty levels are highest amongst Muslims, in both rural and urban areas.
23
Similar situation is articulated by the Sachar Committee report. These data imply that
Indias Muslims have the lowest living standard in the country.
Looking at employment in formal sectors, Muslims, in general, trail behind the national
average by 60% and OBC2 Muslims by 80%. Even in landholdings, Muslims are far
below the national average: general Muslims 40% and Muslim OBCs 60%, whereas
Hindu OBCs are approximately 20% below the national average (Sachar Committee
Report). Further, in no state of the country is the level of Muslim employment
proportionate to their percentage in the population. For instance, in West Bengal where
Muslims constitute 25% of the population, the representation in government jobs is as
low as 4%. They have a considerably lower representation in government jobs, PSUs
and management cadres in the private sector. Their participation in police and Army
services is nearly 4%. Other figures on Muslim representation in civil services, state
public service commissions, railways, department of education, etc., are equally
appalling (also see: Sachar Committee report; Justice Ranganath Mishra Commission
Report, 2007). Other Backward Class (OBC) is a collective term used by the
Government of India to classify castes which are socially and educationally
disadvantaged. It is one of several official classifications of the population of India, along
with Scheduled Castes and Scheduled Tribes (SCs and STs).
Data on educational status among Muslims are quite disheartening. The Sachar
Committee finds that 25% of Muslim children in the 6-14 years age-group either never
went to school or else dropped out at some stage. The report shows that up to the
matriculation level, Hindu OBCs trail behind the national average by 5%, while the
figures for Muslims in general and OBC Muslims is 20% and 40% respectively. And up
to graduation level, general and OBC Muslims lag behind the national average by 40%
and 60% respectively. While literacy rate has improved for all the social groups, among
Muslims it is the lowest urban literacy in the SC group has increased by 8.7 points and
among the ST group by 8 points, among Muslims, it has increased only by 5.3 points
(NSSO, 2005). Healthcare functionaries like ASHA, Anganwadi workers, practice
untouchability and do not touch Dalit Muslim women and children so as to avoid
being impure. This hampers institutional deliveries and immunization of children
(Singh, 2013). Marginalization of Muslims is also reflected in health indicators. The
decrease in the under-5 mortality rate for Muslims between 1998-9 and 2005-6 is 12.7
points whereas it is 31.2 for SCs and 30.9 for STs. Many studies (Khanam, 2009; Singh,
2013; Hasan, 1996, Mander, 2007) have, beyond doubt, proved that majority of poor
Muslims are the prime victims of custodial torture and deaths. Similarly, the Tata
Institute of Social Sciences (2012) observes that 36% of the Jail inmates are Muslims
while the population of Muslims in the state is close to 10.6%. The findings of the report
are in conformity with the Sachar Committee report and general observation of Human
Rights activists.
Centre for Equity Studies (2011), during evaluation of flagship programmes for
minority development, documents ample evidences to show governments biases and
apathy against Muslims in planning, selection of beneficiaries and implementation of
24
schemes and programmes. Consequently, the Muslim community remains in deplorable

conditions of poverty and victimization. Likewise, Sachar Committee report (2006) and
Ranganath Mishra Commission Report (2007) affirm that the nodal institutions and
systems such as National Commission for Minorities and Ministry of Minority Affairs
have not effectively taken up hardcore issues of undue violence, discrimination of
Muslims and thereby failed to ensure justice and equality.
Muslims constitute an underprivileged minority in India, ranking below Hindus in many
respects. In 2005, a committee was gathered to conduct a systematic study of the social,
economic and educational status of the Muslim community of India. The report of this
commission, referred to as the Sachar report, concludes that Muslims exhibit deficits and
deprivation in practically all dimensions of development (Sachar, 2006, p. 237). The deficits
are particularly salient in the areas of female schooling and economic status.
Muslims in India have a much higher total fertility rate (TFR) compared to that of other
religious communities in the country. Demographers have put forward several factors behind
high birth-rates among Muslims in India. According to sociologists Roger and Patricia Jeffery
(2004), socio-economic conditions rather than religious determinism is the main reason for
higher Muslim birth-rates. Indian Muslims are poorer and less educated compared to their
Hindu counterparts. However, other sociologists point out that religious factor can well
explain high Muslim birth-rates. In a recent study Jeffrey et al (2008) showed how the
differential in religious views between Muslim and Hindu women is consequently the reason
for differentials in contraception usage. Surveys indicate that Muslims in India have been
relatively less willing to adopt family planning measures and also, Muslim girls get married at
a much younger age compared to Hindu girls. According to Paul Kurtz (2010), Muslims in
India are much more resistant to modern contraceptive measures compared to Hindus and as a
consequence, the decline in fertility rate among Hindu women is much higher compared to
that of Muslim women. The reason for the lower willingness to adopt family planning can be
explained by the religious restrictions which ordain no use of family planning by individuals
following Islam. The early marriage and concurrence with this religious decree can be rooted
with the lower level of education attained by Muslims, especially by Muslim women. The low
status of women and a strong preference for male children are two most patriarchal
constraints in India. Women want to have children but it is very difficult to take decisions
when they face an unplanned pregnancy (Tayabba and Khairkar, 2011). It was found in the
study that, despite unwillingness to conceive, most of the couples do not use any method of
contraception. Health concerns, side effects, failure of the method and some socio-
demographic issues such as education, age, residential region, number of living children,
status of women and religion play a major role in the use of contraception . A study by
Zachariah (1990) found that 40 percent of women from Southern India were not using any
contraception because their husbands objected to their doing so. Men most commonly knew
of female sterilization, followed by male sterilization and knowledge of the other available
contraceptives was even more limited (Balaiah et al 1999). In attempt to practice some sort of
contraception, it was seen that Muslim couples often practice coitus interruptus, the act where
the man withdraws the penis during intercourse, before ejaculation (Sharma and Pasha,
25
2011a). The current scenario shows a high usage of methods like Rhythm and Withdrawal
which are counted as Traditional methods and a markedly high usage amongst Muslim
women over Hindu women. Given this tendency, we examine the trends in usage of
traditional methods and especially their high use amongst Muslim women within our current
study as well. In a recently published article, the authors examined the DLHS data and found
that amongst the sample, there is a relatively insignificant effect of religiosity on
contraceptive choices (Sharma and Pasha, 2011b).
The Dalits :-
Based on the Varna System, Caste is a concept indigenous to India. There are estimated to be
170-200 million Dalits (which literally meaning broken people, previously this group was
known as the untouchables), constituting 17% of the Indias population at the bottom of the
caste system. The Punjab region in northern India registers the highest proportion of
Scheduled Castes (SC) at 28.9%, in the stat of Mizoram in north east India, the lowest
proportion of SC population of 0.03% were registered (Census, 2011). The caste system
continues to determine political, social and economic life of the people in Hindu societies.
Dalits are typically considered low and impure based on their birth and traditional occupation,
thus they face multiple forms of discrimination, violence, and exclusion from the rest of
society. One out of every six Indians frequently faces discrimination and violence and is
denied of basic human rights and dignity for being Dalit. Caste-based social systems extend
beyond India and more than 260 million people worldwide suffer from this hidden apartheid
of segregation, exclusion, and discrimination (Human Rights Watch, 2007).
Caste system, in its worst manifestation, is reflected in the form of untouchability. The
lower caste called Shudras are considered untouchables. Though outlawed by the Constitution
of India, practicing untouchability is still a stark reality in many parts of the country. Findings
of a study conducted in 565 villages of 11 states in India (Shah, Mander, Thorat, Deshpande
and Baviskar, 2006), demonstrate that in 38% of government schools Dalit children are forced
to sit separately during lunch means. In 20% of government schools they are not even
permitted to drink from same water source. About one-third of public health workers refused
to visit Dalit homes and nearly half were denied access to common water sources. In 14.4%
of villages, Dalits were not permitted even to enter the panchayat building (cast council) and
in 12% of villages surveyed, they were denied voting rights.
The study (Shah, et al. 2006) further revealed that 35.8% Dalits were denied entry into village
shops. After waiting at a distance, the shopkeepers kept the goods they bought on the ground,
and accepted their money similarly without direct contact. Almost three-fourths of the Dalits
were not permitted to enter non-Dalit homes. With varying proportions, Dalits were not
allowed even to wear clean, bright or fashionable clothes or sunglasses. They could not ride
their bicycles, unfurl their umbrellas, wear sandals on public roads, smoke or even stand
without head bowed. Results show that 64% of Dalits were restricted to enter temple, ranging
from 47% in Uttar Pradesh to 94% in Karnataka. About half of Dalits were barred from
accessing cremation grounds. They even live in segregated colonies or ghettos (Tolas), which
are in Southern part of the village so that upper caste people do not have to breathe in the
polluted air coming from the Dalit quarter (south ghetto). Many Dalits are tortured and
26
subjected to humiliation like being garlanded with shoes, their faces blackened or being
forced to other cruel and inhumane treatment. The practice of untouchability, along with other
related social norms, has significantly restricted the social interactions of Dalits with other
fellow beings of their village (Raghuvanshi, 2012). The National Human Rights Commission
(NHRC) report (2012) shows that a crime is committed against a Dalit in every 18 minutes in
India; every day three Dalit women are raped; two Dalits are murdered and two Dalits houses
are burnt; and every week: 13 Dalits are murdered; and six Dalits are kidnapped or abducted.
Most Dalits continue to live in extreme poverty, without land or opportunities for better
employment or education. With the exception of a small minority who have benefited from
Indias policy of quotas in education and government jobs, Dalits are relegated to the most
menial of tasks, as manual scavengers, removers of human waste and dead animals, leather
workers, street sweepers, and cobblers. Dalit children make up the majority of those sold into
bondage to pay off debts to dominant-caste creditors. Dalit women face the triple burden of
caste, class, and gender. Dalit girls have been forced to become prostitutes for dominant-caste
patrons and village priests. Sexual abuse and other forms of violence against women are used
by landlords and the police to inflict political lessons and crush dissent within the
community. Less than 1% of the perpetrators of crimes against Dalit women are ever
convicted (Human Rights Watch, 1999). NHRC 2012, brings out that the conviction rate
under SC/ST Prevention of Atrocities Act is merely 15.7% and pendency is as high as 85.4%.
The repercussion of caste based social discrimination is visible in the economic condition of
Dalits too. The study by Shah, et al. (2006) further highlights that in 25% of the villages
Dalits were paid lower wages than other workers. They were also subjected to much longer
working hours, delayed wages and faced verbal and even physical abuse. In 35% of surveyed
villages, Dalit producers were barred from selling their produce in local markets. Instead they
were forced to sell in the anonymity of distant urban markets where caste identities blur,
imposing additional burdens of costs and time, and reducing their profit margins. The NHRC
(2012) notes that 37% Dalits are living below poverty line. Dalits are still either landless or
own very little land. Only 6% Dalits own land, which may be either too small or infertile to
be a source of subsistence (Human Rights Watch, 2000). Findings of the Gandhi Peace
Foundation and the National Labour Institute survey (1979) show that 87% of bonded
labourers were from the SC or ST community.
On inaccessibility or restricted accessibility to health services, NHRC (2012) bring out that
more than half (54%) of the Dalit children are undernourished, 21% are severely underweight
and 12% die before their fifth birthday. Infant Mortality Rate among Dalits is 83 per 1000 live
births. Only 27% Dalit women avail institutional deliveries. In 33% of villages, public health
workers refused to visit Dalit homes.
The NHRC (2010) brings out that 45% of Dalits in India are illiterate. Dalit women, in rural
areas, have an appalling rate of illiteracy 62.2%. Adding to the Gandhi Peace Foundation
and the National Labour Institute survey, it is estimated that between 90-94% of bonded
labourers were illiterate. It shows how vulnerability accelerates if Dalits are illiterate. Without
education, bonded labourers are often unable to access alternative non exploitative
employment opportunities. Mahadalit Ayog (2007) finds that 91% Musahars (who
27
traditionally fall outside the caste system and were previously regarded as outcasts) are
illiterate. And shockingly, 98% of Musahar women are illiterate. The situation is hardly
better with their childrens education in comparison of about a-third of Dalit children in
the 5 to 14 year age group attending schools, among Musahars, less than 10 percent of
children study, while dropout rates are nearly 100%. For this, enduring power of
exploitative institutions, particularly caste is largely to be blamed (Mahadalit Ayog, 2007).
Exclusion of population from the mainstream economic development process needs to be
understood in the context of traditional Indian social system. A thousand year old caste
system has resulted in the formation of a highly marginalized population. Caste determines
an individuals socioeconomic position, occupation, and many other aspects of life,inherited
from his or her parents. Out of four main divisions, the Brahmins, who are entitled to be the
priests, scholars, and philosophers are at the top of the hierarchy, with the Shudras or the
laborers and servants, also known as untouchable, at the bottom. The traditional Hindu caste
system excludes the lower castes including the s, from mainstream society and exploits them
in various nature (Mohindra, Haddad, & Narayana, 2006; Padel & Das, 2010;Snaitang, 2004).
The advantageous position within the social structure with privileged access to resources
provides the upper castes with more opportunities than for the lower castes. Thus there is an
association between socioeconomic position and caste of an individual (Mohindra et al.,
2006). communities in such context are situated in the peripheral or marginal position of the
overall Indian socioeconomic stratum.
The scheduled cast eof India constitute about 8.2% of the total population. Majority of Indian
population are non-s and mainly are followers of Hindu (82.41%) religion (Census of India,
2011). Even though scheduled cast are not perceived as untouchable lower caste Hindu
population by the mainstream upper-caste Hindus, they are marginalized and considered as
backward and primitive jati or caste with a pariah status (Mitra, 2008). This perception
however, did not help the s. Whereas, lower caste Hindus enjoyed minimal opportunities to
integrate with mainstream society and to share few common custom and traditions, the s have
been excluded and isolated from the mainstream society (Mitra, 2008). Regardless of the s
perspectives toward caste systems, they are the victims of an imposed oppressive caste-based
social structure (Snaitang, 2004).
The increasing disparities in socioeconomic and demographic indicators between s and rest of
the population of India demonstrate the peripheral, marginalized and exploited condition of s
(Mohanty, 2002). Major initiatives have been taken by the Indian government since
independence in 1947 to improve the backward conditions of communities with a view to
eliminate the social exclusion and to assimilate them into the mainstream society. However,
the so-called development projects have achieved very limited success so far, due to critical
failure to comprehend the distinctive characteristics of the scheduled caste areas and
schedule tribes (Mohanty, 2002, p. 96). Even though objectives of such projects resonate
with the Indian constitutional commitment to protect rights and improve s socioeconomic
condition (Mohanty, 2002), it appears that such measures have barely reached their targets.
Unlike women from other social groups in India, Dalits women face three overlapping
disadvantages. First they face the disadvantage of being women with all the attendant
28
difficulties of living in a male patriarchal society. Secondly, they suffer the disadvantage of
being Dalits as they face the opprobrium that higher caste Hindu society instinctively heaps
upon the lower castes. Thirdly, by virtue of being Dalits they are more likely to spend a
lifetime in poverty. Given this trinity of disadvantages, the problems of Dalits women are
distinct from, and arguably considerably more severe than, that of higher caste women who
apart from gender handicap are not burdened by perceptions of inferiority or by a life of
poverty. This is evidenced by the fact that compared to higher caste women; human
development outcomes are far more inferior for Dalits women. In 2001, a lower proportion of
Dalits women (41 per cent) in rural areas were literate as compared to 58 per cent non-Dalits
women. While nationally (across rural India) about 40.5 per cent of all women were
underweight, the incidence of under nutrition was eight per cent higher for Dalits women.
Moreover, Dalits mothers and their children had relatively poor access to public health
services as compared to other social groups. For example, Dalits children from these excluded
groups had an immunisation rate which was 20 per cent lower than that for non-Dalits and
non- children. This paper argues that high deprivation levels of Dalits women can be
attributed to social exclusion. The social exclusion and associated discrimination of Dalits
women result from their caste identity. It is this exclusion-induced deprivation which
differentiates Dalits women from the rest of the women. It would be naive to claim that Dalits
women face problems just like other (non-Dalits) women. In addition to being women, they
are burdened by their caste and poverty which are concomitant of their caste and gender.
Against this background, this study investigates inequalities in health outcomes among Indian
women who belong to different social group's .Aaccording to the National Family Health
Survey.20 Poverty and undernourishment of SC mothers also impacts their children. Among
children younger than five years of age, a higher proportion of Dalit children were
malnourished as compared to upper castes 51 percent of Dalit children were underweight,
whereas for upper-caste children, the prevalence of underweight was 36 percent, which is still
disturbingly high but significantly better than among the Dalit children. Limited Access to
Maternal Health Care Dalit women have lower access to maternal health care than upper-
caste women. A lower proportion of Dalit mothers had access to antenatal care (ANC) as
compared to women from the upper-caste groups: 74% percent of Dalit mothers and 85.2
percent of upper castes received ANC in 200506.21 The data also indicate that a lower
proportion of Dalit mothers gave birth in a health facility as compared to upper-caste mothers:
32.9 percent of Dalit mothers gave birth in a health facility compared to 51 percent of upper-
caste mothers.22 Slow Progress in Indicators of Human Development Poverty and
Malnutrition It is important to add here that although the status of Dalit women over
theperiods under consideration has shown improvement, the rate of improvement has been
slower among Dalit women as compared to upper-caste women, as the data indicate. Hence,
disparities between the upper-caste women and Dalit women persist, indicating a lower level
of human development among them. For example, an analysis by Thorat and Dubey23
indicates that in rural areas, during 19932010, poverty declined at a rate of 2.5 percent per
annum on an average 1. However, the upper castes experienced the highest decline (2.8
percent) followed by Dalits (2.4 percent). A lower decline in poverty rates is also experienced
29
by the Dalits as compared to the upper castes in urban areas Slow progress in malnutrition
rates is seen in the case of the Dalits as compared to the upper castes. Between 19992000
and 20042005, the proportion of underweight children declined on an average (at a rate of
0.9 percent). Similar to poverty rates, the rate of decline in malnutrition rates was lower for
Dalits (-0.9 percent) as compared to that of the upper castes (-2.3 percent).
The progress in institutional delivery was also slower in the case of Dalit women (3.6 percent
per annum) as compared to others (4.5 percent per annum) .
Thus keeping in mind theabove situation of muslim and Dalits womrn reproductive and
health conditions this studyhas been done in Varanasi district The total population of
Varanasi is 37 lac and which of them 5 lac is Muslim population and which constitute
18.5% of total population. 435,545 is schedule caste population and their distributin is
Chamar (308,100), Khatik (31,251) and Dhobi (21,206) which is 13.88percent of total
population There are eight block and 90 wards in Varanasi district. Total Area of Varanasi
is 15.35 Sq.km. and longitude is 83degree, latitude 25degree 20 minutes.
Varanasi
Administration setup:
There are three main tehsil in Varanasi district. First one is Varanasi, second one is Pindra
and another is Rajatalab. Total area of district is 1535 sq. km. Out of this, 415 sq.
km.(27.04%) is in Varanasi tehsil and 415 sq. km.(27.03%) is in Rajatalab tehsil and 705 sq.
km (45.93%) is in Pindra tahsil. As per censes 2011, there are 1327 revenue villages is in
Varanasi district. Out of this 1258 inhibited villages and 69 non-inhibited villages. There are
8 Nos. of Block in Varanasi district. Out of 8, 3 Nos. of Block is in Varanasi tahsil namely
Chiraigaon, Cholapur and Kashi Vidyapeeth & partially Harhuan and 2 Nos. of Block is in
Rajatalab tahsil namely Sewapuri, Arajiline & partially Kashi Vidyapeeth and 3 Nos. of
Block is in Pindra tahsil namely Baragaon, Pindra, and partially Harhuan. There are 108 Nyay
panchayat and 702 gram panchayat in Varanasi district and also 8 Assembly Area.
Health Facilities in District :-
The rural health care system is a three-tier structure. It has Sub-center at the most peripheral
level, Primary Health Centre at the intermediate level and Community Health Centre at
the secondary level. The population covered by a Sub Centre, Primary Health Centre and
Community Health Centre are 3,000-5,000, 20,000-30,000 and 100,000,
respectively. In addition, there are Private Voluntary Health Facilities, also. As per UP
government organizational set up, the district is headed by a District Magistrate, who is also
the chairperson of the Integrated District Health Society of Varanasi district. The district
health set up of UP government is headed by the Chief Medical Officer followed by an
Additional CDMO as second-in-command. The Chief Medical Superintendent looks after the
UP government hospitals in the district. There are 379 government health care facilities in the
district, as can be seen from the table given below.
Category Number District Hospitals (Male & Female) 03
No. of CHC 05 .No. of PHC 08 .No. of APHC 22 .No. of FW/MCH Centres 293 .Female
Hospitals 01 .Regional Diagnostic Centres 01 .Urban Health Posts/ Maternity Centres 15
.Leprosy Hospitals (Temp. Hospitalization Wards) 02 .Other allopathic Hospital 12
30
.Ayurveda Hospitals 07 .Homeopathic Hospitals 03 .Medical Colleges 02 .ANM Training

School 02 .Nursing Training School 02 .Other govt. health training Institute 01
In January, 2014 Banaras Hindu University (BHU), Varanasi held a discussion on 'Social
determinants of health' in the 275th session on Sunday said that promotion and protection of
health of people is essential for sustained economic and social development and contribute to
a better quality of life. Socio-economic situation of a country has definite influence on the
health of its population. Health status is primarily determined by the level of socio-economic
development such as the GNP, education, nutrition, employment and housing because lower
socio-economic status leads to higher prevalence of diseases.
According to the Data from the various Government sources state as following:
Comparative detail of district wise on Sex-ratio, child marriage and child labour of year
2011.12 and 2012.13
The sex ration of children between age group (0-4) years increased in comparison to
the year 2011 2012 and 2012 2013. The Annual health survey data stated in year
2011 2012 is 850 and in 2012 2013 were 863.
The Child marriage of male and female child decreased. The male child marriage
2011 2012 reported 5.3 and in 2012 2013 it was 4.8.
The percentage of child labor increased. In 2011 2012 it reported 2.6 and 3.0 in
2012 2013. Annual health survey 2011 2012 and Annual health survey 2012
13.
Comparative detail of district wise on Institutional delivery, underweight

children, breast feeding, Child Mortality rate and death of children below 5
years in year 2011.12 and 2012.13
The institutional delivery of pregnant mother increased. In 2011 2012 it
reported 64.8 and 66.1 in 2012 2013.
In 2012 23.5 born less than 2.5 kg and 22.1 in year 2012.2013.
27.5 children were immediately breast feeding one hour after delivery and 26.4
in 2012.2013
In 2011 2012 76 % child mortality rate reported and 72 in years 2012 2013.
97 children died after years and 90 in 2012 2013 Annual health survey 2011
2012 and Annual health survey 2012 13
Comparative data of complete immunization of children between age group 12 23
months in year 2011.12 and 2012.13
The immunization of children increased in comparison to 2011 2012 and 2012
2013 of children between ages group 12 23 months. In 2011 98933 children
were immunized and in 2012 2013 94508 children.
Comparative detail of Mother Mortality Rate divisional wise of Uttar Pradesh
for year 2011.12 and 2012.13
The numbers of mother mortality rate decrease. In 2011 2012 it reported 343
and 123 in 2012 2013 Annual health survey 2011 2012 and Annual health
survey 2012 13
31
Comparative detail on Mother mortality rate in division in year 2011.12 and

2012.13
Name of No. ICDS/MMR in district

District
March March 2013 January, 2014
2012
Death Death Audit Death Audit
Varanasi 5 8 8 33 33
Chandauli 3 6 6 26 1
Gazipur 2 2 2 3 2
Jaunpur 6 8 8 9 9
Varanasi 16 24 24 71 45
Division
Annual health survey 2011 2012 and Annual health survey 2012 - 13
The Varanasi is a division of Jaunpur, Chandauli and Gazipur. In Varanasi 5 deaths
reported in the month of March, 2012, 8 deaths in March, 2013 and 33 deaths in
January, 2014.
Silk weaving is the dominant manufacturing industry in Varanasi. Weaving is typically done
within the household, and most weavers in Varanasi are Muslim, Dalits etc.[1] Varanasi is
known throughout India for its production of very fine silk and Banarasi saris, which are often
used for weddings and special occasions. A cluster of villages engaged in weaving the
exquisite Banarasi sarees is in the midst of a serious health crisis. More than 1 lakh
people from this once prosperous region have fallen prey to aggressive tuberculosis.
Poor living conditions, working in dark rooms and constant inhalation of minute silk
threads have weakened the lungs of these artisans. With an average monthly income of
not more than Rs. 3, 000, it is a living hell for the skilled weavers.
A report on suicide and malnutrition among weavers in Varanasi was prepared by the
Peoples Vigilance Committee on Human Rights in collaboration with Action Aid, an
international anti-poverty agency. It said that about 175 weavers have fallen prey to financial
hardships since 2002. The Economic Survey (2009-10) estimates that over 50 % weavers
children are malnourished. There is a high prevalence of TB, particularly multi-drug resistant
tuberculosis (MDR-TB). The survey also said that while the human development index of
India is steadily improving, weavers and their children in Varanasi continue to die either by
committing suicide or succumbing to malnutrition.1
Varanasi Sex-ratio, child marriage and child labour of year 2011.12 and 2012.13
Table: 1.3
32
Name of Sex ration from Child marriage Children labour

District 0-4 years (Percentage) (Percentage)
2011.12 2012.13 2011.12 2012.13 2011.12 2012.13
Male Female Male Female
Varanasi 850 863 5.3 12.3 4.8 12.0 2.6 3.0
Detail of Varanasi district on Institutional delivery, underweight

children, breast feeding, Child Mortality rate and death of children below 5 years in
year 2011.12 and 2012.13
Table: 1.4
Name of Institutional delivery Children born less Breast feeding within CMR Children death after 5 years
District than 2.5 KG one hour after
delivery
2011.12 2012.13 2011.12 2012.13 2011.12 2012.13 2011.12 2012.13 2011.12 2012.13
Varanasi 64.8 66.1 23.5 22.1 27.5 26.4 76 72 97 90
Annual health survey 2011 2012 and Annual health survey 2012 13
Varanasi data of complete immunization of children between age group 12 23 months

in year 2011.12 and 2012.13
Table: 1.5
Name of 2011- 12 2012 2012 13
district Source 2013 (Source AHS.12 13) in
RTI Source percentage
RTI
Varanasi 98933 94508 65.2
Varanasi detail of Mother Mortality Rate divisional wise of Uttar Pradesh for year
2011.12 and 2012.13
Table: 1.6
Division Year 2011 - 12 Year 2012 - 13
Varanasi 343 128
Thus at present JAN MITRA NYAS is working with this marginalised community Muslim
weaver , Musahars /Nats and Chamars to find out the gaps in their reproductive health and
Child Health and can bridge these help as everyone has has the right to health.
33
ENDNOTES:-
1. Epstein (1998) defined social bias in the following terms: Wherever you stand on the social ladder,
your chances of an earlier death are higher than it is for your betters.
2. Dalit women face sexual violence; and discrimination in access to legal redress, equal wages, and
benefits from government programmes targeted at womens welfare
3. Dalits refer to those 18 million Indians who belong to the Scheduled Castes. They are also broadly
identified with the untouchable castes. The untouchable castes are so called because the higher caste
Hindus consider Dalits as polluting or unclean and, hence avoid any sorts of physical contact with
them which also includes non-acceptance of food and water.
4. OBC: Those people who do not belong to the Scheduled Castes or Scheduled Tribes but belong to
other economic and socially backward groups.
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37
Chapter-2 Research Methodology
38
Chapter-2
Research Methodology
This chapter deals with the elements of scientific research in present study. It defines the
research problems. Need and the Significance of the study:-
It is very loud and clear that rural areas are most backward areas in the country. Basic health
care facilities are not available at satisfactory level and poor people are facing very tough
conditions. Many governmental agencies agree on the fact that there should be more and more
emphasis on development of medical facilities in these backward areas. Civil Society
Organization has shown the naked picture of mismanagement of resources at ground level.
The research problem selection was very crucial for whole research work. If maternal
healthcare schemes have been implemented well then no pregnant women would have faced
any kind of trouble. Working with villagers will provide great opportunity to understand basic
health needs, awareness pattern, tolerance level of rural people, and resource management
capabilities of rural people also. Working on this problem will facilitate the good
understanding of various health issues within the community and its impact on their overall
well being.
It is well known that early marriage; repeated pregnancies, short intervals between
pregnancies, maternal anemia are some of the factors which contribute to maternal and child
ill health. According to the National Family Health Survey of 2005 -06 women who received
various maternal health services in UP compared to the all India figures is given below:
Table no.2.1
Indicator India UP Percentage diff

ANC visit in first trimester 43.9 43.9 70.8
Weighed 63.2 20.9 202.4
BP measured 63.8 25.6 202.4
Urine sample taken 58.1 24.7 135.2
Blood sample taken 59.5 22.1 169.2
Abdomen examined 72.0 43.1 67.1
Told where to go for complications 41.1 18.9 117.5
Data shown clearly that woman in UP received much less services compared to the country as
a whole. Five others direct complications account for more than 70% of maternal deaths:
hemorrhage (25%), infection (15%), unsafe abortion (13%), eclampsia (very high blood
pressure leading to seizures 12%), and obstructed labor (8%). Some causes of maternal
death, unavailable, inaccessible, unaffordable, or poor quality care is fundamentally
responsible. They are detrimental to social development and wellbeing, as some one million
children are left motherless each year.
Services necessary for reducing MMR and IMR
Nutritional supplementation
Contraceptive services
Safe abortion services
Full Ante natal care and early detection of complications
39
Safe delivery with quick referral services

Emergency obstetric care services available within 2 hours.
These include services for control of convulsions, caesarian operation, blood

transfusion and resuscitation of the new born.
Children breastfed within one hour of birth.
Children 12-23 months fully immunized (BCG, measles, and 3 doses each of
polio/DPT).
Children age 0-6 months exclusively breastfed.
Children age 6-9 months receiving solid or semi-solid food and breast milk
We must give these information and required support to our women beneficiaries for
improvement of their reproductive health, help her through a pregnancy, and care for her and
her newborn well into childhood. The vast majority of maternal deaths could be prevented if
women had access to quality family planning services, skilled care during pregnancy,
childbirth and the first month after delivery, or post-abortion care services and where
permissible, safe abortion services. A working health system with skilled personnel and
generation of awareness about womens health are keys towards saving pregnant women's
lives.
Lack of awareness and low importance of womens health is the prime reason in rural areas
where mothers are excluded from life-saving care at childbirth. In Our country "numerous
women and children are excluded from even the most basic health benefits: those that are
important for mere survival. Often the poorest, show a pattern of massive deprivation, with
only a small minority, usually the urban rich, enjoying reasonable access to health care, while
an overwhelming majority is excluded. Among those left out, women and their children suffer
most. Being poor or being a woman is often a reason for being discriminated against, and may
result in abuse, neglect and poor treatment, poorly explained reasons for procedures,
compounded by views sometimes held by health workers that women are ignorant. The care
that women are offered may be untimely, ineffective, unresponsive or discriminatory.
The right to health is a fundamental right and the poorer health indices of half the population
is a cause for concern. Many researchers and activists are no longer convinced that we can
succeed in improving womens health or status unless society attempts to confront its gender
bias openly. For too long we have been refusing to discuss womens health issues openly with
society. It would appear that nothing short of a social revolution would bring about an
improvement in the health of Indian women. Many approaches have been suggested. They
will all need to include approaches which examine, understand and confront gender
discrimination in social, cultural andreligious spheres. There is an urgent need for a detailed
re-examination of public health statistics for India, disaggregated by gender and region.
In this study we are going to undertake an assessment of service providers of grassroots
level maternal health system for getting better results on Maternal and child health. Also,
study attempts to investigate the maternal and child health problems, along with existing
mother and child health care facilities at Aaganwadi centre ,PHC and sub center level, and
40
levels of utilization of MCH services by womens and community members . we are also
studying the Knowledge attitude and practices of the exceptionally marginalized
communities of Chamars,Nats/Musaharsand extremely deprived muslim weavers in
varanasi.
This current study can bridge the gap between these two collaborative aspects to some
extent. The objective of this study is to examine reproductive health and children health
knowledge ,attitude and practice among the women and Muslim weaver women in
Varanasi in India .
Definition of the major terms

KAP Survey Model :- A Knowledge, Attitude and Practices (KAP) survey is a quantitative
method (predefined questions formatted in standardized questionnaires) that provides access
to quantitative and qualitative information. KAP surveys reveal misconceptions or
misunderstandings that may represent obstacles to the activities that we would like to
implement and potential barriers to behavior change. Note that a KAP survey essentially
records an opinion and is based on the declarative (i.e., statements). In other words, the
KAP survey reveals what was said, but there may be considerable gaps between what is said
and what is done.
Nats - Nat are a nomadic community found in North India. They are one of number of
communities that are said to be of Rajput origin, and have traditions similar to
the Bazigar caste meaning "where he wins, whenever and whatever he plays" . The
word nata in Sanskrit means a dancer, and the Nat were traditionally entertainers and
jugglers. They have fourteen sub-groups, the main ones being the Nituria, Rarhi, Chhabhayia,
Tikulhara, Tirkuta, Pushtia, Rathore, Kazarhatia, Kathbangi, Banwaria, Kougarh, Lodhra,
Korohia, and Gulgulia or Gauleri. The Nat maintain strict clan exogamy, and each clan of
equal status. In Uttar Pradesh, the Nat community now consists of two groupings, the Brijbasi
Nat, who are settled, and the Bajania, who are nomadic. he Nat are a poor landless
community and they are mainly engaged as unskilled labourers. They have now abandoned
their traditional occupation of rope dancing They live in multi-caste villages, but occupy their
own distinct quarters. As a dalit community, they often suffer from societal discrimination.
Each of their settlement contains an informal caste council, known as a biradari panchayat.
The panchayat acts as instrument of social control, dealing with issues such as divorce and
adultery.[11]
Musahar: - The Musahars are a Hindu out caste (without any Caste). For their growth and
development they have been given scheduled caste status for political benefits as SCs have
reservation in the Indian 'reservation system'. The poor community which was earlier very
weak is found in the states of Bihar and Uttar Pradesh in India, and Terai of Nepal. They are
also known as Banbasi,[1] and on the plateau as Manjhi.[ The Musahar were traditionally rat
catchers, and there is still uncertainty as to their exact origin The Musahar were once rat
catchers, but this activity has been abandoned. They are now mainly landless agricultural
laborers. They are one of the most marginalized groups in India, and have suffered
discrimination. Although the Musahar are Hindu, they believe in a number of tribal deities.
41
In Bihar, the Musahar are employed in the stone quarries of the state. Many have also
immigrated to the states of Punjab and Haryana, and are employed as agricultural laborers.
They speak Bhojpuri, but many now have working knowledge of Hindi. The Musahar are
found throughout Bihar.
In the rural areas, Musahar are primarily bonded agricultural laborers, but often go without
work for as much as eight months in a year. Children work alongside their parents in the
fields or as rag pickers, earning as little as 25 to 30 rupees daily. The Musahar literacy rate is
3 percent, but falls below 1 percent among women. By some estimates, as many as 85 percent
of some villages of Musahars suffer from malnutrition and with access to health centers scant,
diseases such as malaria and kala-azar, the most severe form of leishmaniasis, are prevalent.
Muslim Weavers :- The Momin Ansari (Urdu: ) or Ansari, are a Muslim
community, found mainly in West and North India, and the province of Sindh in Pakistan. A
small number of Ansaris are also found in the Terai region of Nepal. In North India, the
community are known as Ansari, The Momin Ansari (Urdu: ) or Ansari, are a
Muslim community, found mainly in West and North India, and the province of Sindh in
Pakistan. A small number of Ansaris are also found in the Terai region of Nepal. In North
India, the community are known as Ansari, The Ansaris of North India are mainly a landless
community, but some are small- and medium-scale farmers. They have always been
connected with the art of weaving.
Chamars :- Chamar is one of the untouchable communities, or dalits, who are now classified
as a Scheduled Caste under modern India's system of positive discrimination. As
untouchables, they were traditionally considered outside the Hindu ritual ranking system
of castes known as varna. They are found mainly in the northern states of India and in
Pakistan and Nepal. The term chamar has also been used as a pejorative word for anyone
whom the describer considers to be of low standing.
Rreproductive Health:- reproductive health, or sexual health/hygiene, addresses the
reproductive processes, functions and system at all stages of life. Reproductive health implies
that people are able to have a responsible, satisfying and safer sex life and that they have the
capability to reproduce and the freedom to decide if, when and how often to do so. One
interpretation of this implies that men and women ought to be informed of and to have access
to safe, effective, affordable and acceptable methods of birth control; also access to
appropriate health care services of sexual, reproductive medicine and implementation of
health education programs to stress the importance of women to go
safely through pregnancy and childbirth could provide couples with the best chance of having
a healthy infant. Essential Components of RCH Programme.
1. Prevention and management of unwanted pregnancy.
2. Maternal care that includes antenatal, delivery and postpartum services.
3. Child survival services for newborns and infants.
4. Management of Reproductive Tract Infection (TRIs) and Sexually Transmitted
Infections (STIs).
42
Objectives of the Project:-

In-depth understanding and analysis of the behaviour, practices , existing myths and
superstitious beliefs of different varied communities on the existing mother and child care
rearing practices and their related health seeking behaviour.
Activities :- Assessment of the behaviour and KAP knowledge attitude and practice of
different communities- musahars, chamars, weavers etc will be observed and studied in the
first three quarters. The study will include issues such as health and hygiene practices, ANC
and PNC, immunisation, importance of breast feeding within one hour of delievery, exclusive
breast feeding, supplementary nutrition after six months, interval between births, health
seeking behaviour, safe delievery, fooding habits and patterns, cleaniness, gender bias and
other related issues.
1. To assess maternal and child health care delivery system of PHC /CHC and sub
center level.
2. To assess the level of utilization of maternal and child health services by the
community.
3. To assess the knowledge, attitudes and opinion of the womens regarding the
maternal and child health issues.
4. To find out the care barriers in maternal and child health services.
5. To identify the gaps to be strengthen.
6. To provide feedback to health planners in terms of utilization pattern of the modern
health care services.
7. To identify the actual need of health care facilities for pregnant and lactating women.
Scope of the study:-

The constitution of India provides many empowering provisions to provide better health care
facilities to all marginalized sections and poor communities specifically women. But at
present, no section of the society is in a condition that one can say that they dont have any
health problems. So, to assess all these situations one has to go through deep analysis and
interpretation. For solid conclusion a unit area has to be selected for data collection and
intervention also. By doing this, sentiments of the common people, administrative behavior,
irregularities in health schemes implementation, corruption, lack of awareness, lack of
information, prevailing status of maternal and child healthcare facilities and other relevant
factors can be counted easily.
Primary preparation :-
For the study it is very important to select correct medium of information, to collect some
specific details regarding rural development programs and to visit the whole area where
intervention or research work has to start. Many civil society organizations have evaluated
government health schemes NRHM and ICDS. Collecting these social audit reports or impact
analysis brief findings provided much needed data base. Discussion with guide, CSOs, health
experts, common people, and elective representatives of the villages provided sound
guidelines for the effective handling of the study.
Common people are most important stakeholder of the total exercise. So tapping their
sentiments, feelings experiences and difficulties would provide very sharp edge to the study.
It will become a genuine exercise containing solutions and findings regarding health problems
43
of rural people.As PVCHR and JANMITRA NYAS is already working in the Musahars /Nat
,Chamar and in Muslims community so less problems were facade by the women in
developing a rapport with the beneficiaries Primary preparation for the study also includes
understanding psychology of rural people and specifically women. This helped enormously
during the data collection exercise. People do want to express their problems through
answering question and body language. One has to be very calm, cool and patient while
interacting with respondents.
Before starting the study the researche team went through relevant literature on maternal
health, child health care policies and programmes, health care administration and
management etc. In order to get a general idea about the problems to be studied, a
questionnaire has been prepared for interviewing the relevant respondent.
Research Design :-
The term design means drawing an outline or planning or arranging details. It is a process
of making decisions before the situation arises in which the decision has to be carried out.
Research design is planning a strategy of conducting research. It plans as to: what is to be
observed, how is to be observed ,when/where it is to be observed, why it is to be observed,
how to record observations, how to analyze/interpret observations, and how to generalize.
Research design is, thus, a detailed plan of how the goals of research will be achieved.
According to eminent social scientists there are three types of research as descriptive,
explanatory and exploratory. But black and champion have also painted out differences in
designs of three other types of researches too, as survey research, case study research and
experimental research. In this research, exploratory research design has been used in order to
figure out the grey areas in whole institutional reproductive health delivery system.
Selection of District and the Block :-
Uttar Pradesh is counted as backward state in the rural health perspective. Many districts
dont have good health infrastructure even now. UP is lagging behind in all key indicators of
health services. So the correct selection of the area for the study was very crucial.
Varanasi or Banaras (also known as Kashi) is one of the oldest living cities in the world.
Varanasi's prominence in Hindu mythology is virtually unrevealed. Varanasi is one of the
most populated areas. The total population of Varanasi is 37 lac and which of them 5 lac is
Muslim population and which constitute 18.5% of total population. 435,545 is schedule caste
population and their distributin is Chamar (308,100), Khatik (31,251) and Dhobi (21,206)
which is 13.881rcent of total population There are eight block and 90 wards in Varanasi
district. Total Area of Varanasi is 15.35 Sq.km. and longitude is 83degree, latitude 25degree
20 minutes.
In Varanasi Muslim are largest Minority with a population of 18.5% of total population
according to 2011 census. Most of the Muslims are weavers by profession living appealing
condition. There are 90 wards in which the Muslim population is very dense .
The wards which have taken for our study are
Harahua:- The block is situated in northern side of Varanasi district. The distance from
district head quarter is around 15 km. The total population of this block is 269669 in which
around 47777 scheduled caste and 21 Schedule Tribes people reside in this area. The main
44
livelihood option is agriculture only. Harhuwa block consists of 88 village panchayat. It is

totally rural area.
Badagaon:- The block is situated in Western side of Varanasi district near to the Varanasi
airport. The distance from district head quarter is around 30 km. The total population of this
block is 242188 lakh in which around 45135 scheduled caste people reside. The main
livelihood option is agriculture only. Badagaon block consists of 86 village panchayat. It is
totally rural area.
Pindra:- The block is situated in Northern west side of Varanasi district. The distance from
district head quarter is around 35 km. The total population of this block is 293264lakh in
which around 55663 scheduled caste and 22 scheduled caste people reside. The main
livelihood options are agriculture and landless labourer only. Badagaon block consists of
103 village panchayat.
Arajiline:- The block is situated in southern west side of Varanasi district. The distance from
district head quarter is around 25 km. The total population of this block is 284710 in which
around 52710 scheduled caste and 42 scheduled tribes people reside. The main livelihood
options are agriculture and landless labourer only. Arajiline block consists of 107 village
panchayat.
Table no.2.2
Status of situation of 4 blocks in Varanasi district Harahuan Badagaon Pindra Arajiline

Population density per square kilometer 1920.0 1270.0 1234.0 1449.0
according to 2011 census Thousand Thousand Thousand
Total percentage of SC/ST population 17.6 19.3 19.5 14.6
according to 2011 census
Total literacy rate 75.8 72.4 72.4 75.8
according to 2011 census
The total percentage of population of the village connected to the 41.2 62.7 39.2 62.7
pucca road in 2013-14
The total percentage of population receiving the facility of pure 98.2 100 100 99.0
drinking water in 2013 -14
The total percentage of primary school is constructed in population 80.6 92.5 81.0 71.8
area in 2013-14
The total percentage of the population receiving complete health 1.2 4.5 1.6 1.4
facilities in 2013-2014
The total percentage of allopathic hospital/Audhshala/Community 1.1 2.7 1.1 2.5
health center and primary health center in per lakh population
2013-14
The total percentage of availability of beds in allopathic 18.4 26.7 18.1 19.6
hospital/Audhshala/Community health center & primary health
center in per lakhs population 2013-14
The total numbers of primary health centers in per lakh population 0.7 2.3 0.7 2.2
2013-14
The total percentage of primary school in per lakh populations - 63.1 68.2 70.0 60.5
2013-14
The total percentage of middle level school in per lakh population - 31.4 32.1 35.5 35.3
2013-14
The total percentage of secondary schools in per lakh population 13.3 15.4 10.2 12.0
2013-14
45
Sampling Plan :-
A sample is a portion of people drawn from a larger population. It will be representative of
the population only if it has same basic characteristics of the population from it is drawn.
Sampling is not about what types of units will be interviewed/ observed but with how many
units of what particular description and by what method should be chosen.
In this research, Census method has been followed .All the women available from age group
16 - 45 from these communities have been selected as respondents using convenience
sampling method. Total 2,709respondents have been interviewed during data collection
process. During the interaction male members (preferably husband of the respondent) have
also been interviewed on some crucial issues for their perspective. 814 Women from Musahar
/Nat community, 935 women from Chamar community and 960 women from Muslim weaver
community were interviewed during this study.
Further, AWW, ANM, ASHA workers and Medical Officer of CHC and PHC have also been
consulted in order to clarify certain issues came up during the interaction with respondents.
Views of other Stake holders related with the NRHM/RCH/ICDS programs have also been
considered to analyze the grassroots level situation and figure out the grey areas in overall
reproductive health service delivery mechanism. Some studies published in development
magazines have also been used for analysis of data.
Collection of Data (Tools and techniques ) :-
Data collectionis very important phase of the whole study because if collected data is useful
and correct on the defined criteria then study will proceed in right direction otherwise total
efforts would be wasted. There are different kinds of tool and techniques of data collection.
Major tools and techniques are listed here-
Questionnaire and Interview Schedule
Interview Observation
Content analysis
Projective techniques
Published study
The researcher interviewed the respondent by applying the formal and personal interview and
unbiased observation techniques.
Interview Schedule :-
The set of structured questions in which answers are recorded by the interview himself is
called interview schedule or simply the schedule. It is distinguished from the questionnaire in
the sense that in the questionnaire the answers are filled in by the respondent himself.
Schedules are more important in securing information from the respondents. The wordings of
the questions in the schedule should be simple and if there is some complex questions
interviewer can explain that one easily. Questions in the schedule should cover all aspects of
research subject/ problem. Number of questions should be accordingly determined, not more
and less.
Observation :-
Observation is a method that employs vision as its main means of data collection. It implies
the use of eyes rather than of ears and the voice. It is accurate watching and noting of
46
phenomena as they occur with regard to the cause and effect or mutual relations. It is
watching other persons behavior as it actually happens without controlling it. Observation is
also defined as a planned methodical watching that involves constraints to improve
accuracy.
The Interview schedules were used to collect primary data. The interview schedules were
prepared after studying a lot of research literature, text books and consulting reproductive
health experts and development workers.
The design of the study was based on personal Observations, Interviews and Focus Group
Discussion. Through observation method, the various kinds of information were collected.
During the administration of the interview schedule the researcher opted more for an informal
rather than a formal interview. The Research Team visited many times to the brick kin , in
the fields ,in the handloom to build up trust and good rapport with the the respondent. It was
more or less like a discussion rather than questioning them. Focused group discussion
technique was applied to understand the attitude of female respondent. The main aim was to
know closely the knowledge regarding reproductive health and their practicing habits .
Data Collection:-
The data collection of proposed study was done through two different sources and levels.
(1) The two different sources were as below:-
(a) Primary Source (b) Secondary Source
(a) Primary source:-
Primary source of data collection was done through the prepared interview schedule,
observation and Focus Group Discussion.
(b) Secondary source:- The secondary source of data collection was to refer the various
magazines, books, articles, journals and analysis of the Governmental data. The output has
been used to the get final conclusion of study so that the final data and study can be further
used and deeply interpreted for future study.
Pilot study or pretesting of interview schedule:-
In order to test the validity and the reliability of the field instrument, a pilot study was
conducted on 25 respondent in each community The purpose of pilot study was to create the
field like situation and simulation for the researcher to build-up a necessary real report with
the community under investigation. The pilot study revealed some of the short comings of the
instrument. The Research Team suggested that some of the questions included in the
interview schedule were ambiguous and needed to be redesigned.
Through the experience of the pilot study, the interview schedule was redesigned and
modified to make it, more realistic, valid and reliable. In addition to this the pilot study also
helped the researcher in gaining importance insights in to the reproductive and child health
knopwledge and practice to enable the researcher to be better prepared to launch the main
work .e. how to bridge the gap. The Research Team revealed the important aspects of Muslim
weavers and Musahars /Nats ,Chamars and their community which should need to be probed
of the personal, the parental history of the respondent and the infrastructural faciliies available
for health, socio -economic status and their living condition. The Research Team prepared an
47
interview schedule of the questions which were divided on the basis of the different aspects of
study i.e. instruments / tools.
Aaganwadi Centre Observation Form:-
A survey form was prepared and used to assess the bases required for quality of services
being given in these centres. The physical facilities; routine; availability of resorces; growth
chart; weifging machine ,refferal slips workers and their quality and workload;registration of
the children,adoloscents, pregnant and lactating mothers and other aspects after registration
etc were analysis. There are some variables which have been included in observation schedule
in AWCs:-
Variables:-
Infrastructure
Medicine kit
Growth chart
supplimentary nutrition
hot cook meal
safe drinking water
Electricity
safe drinking water
toilets
infrastructure
separate kitchen
Primary health check up
A training programme was conducted to train the staff for baseline survey & data collection.
Guidelines for Focus Group Discussion (FGD):-
Focus Group Discussion with community people: -
The Focus Group Discussions with help of the local prestigious people and developing a
rapport was conducted to find out the perception of the female of Musahars /Nats , Chamar
and Muslim community towards reproductive health and children health.
Data Processing :-
Data processing mainly involves various manipulations necessary for preparing the data for
analysis. This process could be manual or electronic. It involves editing, categorizing the
open ended questions, coding, and computerization and preparation of tables and diagrams.
Information gathered during the stage of data collection varies in nature and quantity from
study to study. Checking also needs that data are relevant and appropriate and errors are
modified. Editing is required for proper coding and entering in the computer in larger studies.
Editing process begins in the field itself. Interviewers, soon after completing the interview,
should check the completed forms for errors and omissions. Editing also occurs
simultaneously with forming categories and requires re-arranging answers to open-ended
questions. .
Tabulation of Data :-
After editing which ensures that the information on the schedule is accurate and categorized
in a suitable form, the data are put together in some kinds of tables and may also undergo
48
some other forms of statistical analysis. There is nothing like statistical sophistication in
tabulation. It amounts to no more than counting of the number of cases falling into each of
several categories. Tabulation is not only total adding but counting frequencies in each
category. Tables are useful to the researchers and the readers in three ways
They present an overall view of the findings in a simpler way.
They identify trends.
They display relationship in a comparable way between parts of the findings. Each
table presents a specific description in its title, has columns and rows, and gives
information either in numbers or in percentages. Data arranged in a table provides
great help in analysis. Better analysis gives right direction in which study could
proceed. Comparing various aspects of problems becomes very easy through
tabulation.
Sources of Data:-
Respondents Answers collected through interview schedule and information collected
through observation technique have been the main sources of primary data.
Reports on NFHS-3 & DLHS -3, News articles &Case studies Published in daily news
papers, Books and magazines on reproductive health and other Literature available on MCH
care problems have been the main sources of secondary data.
Data Analysis and Interpretation :-
The analysis is the ordering of data into constitutional parts in order to obtain answers to
research questions. Analysis is the process from which hypotheses are checked, certain facts
and figures take shape which help ultimately in conclusion. However, merely analysis does
not provide answers to research questions. Interpretation of data is also necessary.
Interpretation takes the results of analysis, makes inferences and draws the conclusions about
the relationship. Thus, to interpret is to explain, to find meaning. In most cases, it is difficult
to explain raw data. Analysis paves way for correct interpretation of data. Data are interpreted
in two ways: one, the relations within the study and its data are interpreted; and two, the
results of the study and the inferences drawn within the data are compared to theory and to
other research results
The collected data was entered into the computer, all the respondents sheet was fed into the
computer. The tables and charts were created with the help of computer along with the
objective of the study. Cross tables and further analysis for testing of hypothesis was done.
49
Chapter 3 DEMOGRAPHIC PROFILE OF THE

RESPONDENT
50
Chapter 3
DEMOGRAPHIC PROFILE OF THE RESPONDENT
Reproductive health and rights were deliberated at length in the International Conference on
Population and Development (ICPD) in 1994 at Cairo. India being signatory to the UN's
resolution at Cairo conference, along with 179 other participating countries, followed its
Programme of Action and brought around a major shift in its population policy from earlier
contraceptives-mix-target oriented to target-free approach in April 1996, which was
streamlined as client-centered-demand driven community needs assessment (CNA)
approach and renamed as Reproductive and Child Health (RCH) approach in October 1997.
The RCH approach comprised critical components like informed choice of quality
contraception, basically meant for safe and satisfying sex life, treatment of infertility,
prenatal, natal and post-natal care for mother, adolescent education meant for psychologically
preparing adolescents through information, education and communication for sexual and
reproductive career, management and treatment of HIV/AIDS, reproductive tract infections
(RTIs), sexually transmitted diseases (STDs), etc. These major paradigm shifts in Indias
population policies were reiterated and enshrined in the National Population Policy document
released in 2000 (MoHFW, 2000). Syndromic approach generally adopted in large scale
health surveys elicits information from respondents on their demographic, socioeconomic and
cultural characteristics which impact their reproductive behaviour and problems, morbidity
and general health problems and also their health care seeking behaviour.
The, socio-psychological context, lack of knowledge on medical and health issues, improper
diagnosis, lack of clinical testing, variations in survey design and procedures have also been
discerned to be responsible for highlighting the truer linkages amongst supply and demand
side factors influencing crucial RCH and general health conditions over space and time. Still
the merits of the community based surveys for eliciting self-reported reported health problems
seems to be appealing on pragmatic grounds like low cost, high feasibility and generalizations
(Bhatia, 2000). Possibly, the national level surveys like District Level Household Surveys and
the National Family Health Surveys, and Sample Registration Schemes, etc. based on uniform
sampling design and data collection procedures would be free from methodological
limitations discussed above. Further, such community-based surveys eliciting self-perceived
reproductive health problems need not be interpreted as providing accurate estimates of the
true prevalence of morbidity or mortality over different regions of the country. Nevertheless,
the self-reported problems have often been viewed to be useful in assessing womens need for
obstetric services. Further, extent of variations between self-perceived and measured
morbidity need not be a serious obstacle in highlighting the determinants of gynaecological
morbidity. A significant lacuna persists in understanding the factors influencing
gynaecological morbidity as well as consequences for womens lives (Shireen, 2004). This
study attempts to highlight significant socio-economic, cultural and demographic factors
51
influencing the reproductive morbidity in India. 7 Hitherto, theoretical literature and empirical
studies have emphasized the importance of several socioeconomic, demographic and cultural
factors such as age, age at effective marriage, parity, pregnancy wastage, rural-urban
residence, etc. impacting the prevalence and treatment seeking behaviour (Bang et. al. 1989;
Bhatia and Cleland, 1995; Rangaiyan and Surender, 2000; Rani and Bonu, 2003; Ramesh
Chellan, 2004). Apart from accessibility and affordability it is also clients perception about
the quality of health care, whether in private or public sector, which motivates for utilization
of the healthcare facilities (Gulati, 2004).
Age of respondent:- Age wise distribution of the respondent Table -3.1
Age Musahar / Nat Chamar Muslim Weaver Total

N1 % N2 % N3 % N1+N2+N3
14 - 24 289 35.50 255 27.30 270 28.13 814

25 - 34 215 26.42 431 46.30 455 47.39 1101
35 - 45 310 38.08 249 26.40 235 24.48 794
Total 814 100 935 100 960 100 2709
Fig -3.1
Muslim weaver
28.13 Chamar
100% 47.39
24.48
Musahar / Nut
90%
80%
70%
60%
50% 27.30
40%
46.30 26.40
30%
20%
35.50
10% 38.08
0% 26.42
Age
14 - 24
25 - 34
35 - 45
Education of respondent: - Education is perhaps the most basic SES component since it
shapes future occupational opportunities and earning potential. It also provides knowledge
and life skills that allow better-educated persons to gain more ready access to information and
resources to promote health. While most studies have examined years of completed
education, early educational experiences also may be important To the extent that education is
key to health inequality, policies encouraging more years of schooling and supporting early
childhood education may have health benefits.
Education- wise distribution of the respondent Table -3.2
Education Musahar / Nat Chamar Muslim Total

Weaver
N1 % N2 % N3 % N1+N2+N3
Illiterate 812 99.76 869 92.2 862 89.79 2543

5
Up to 5th 02 0.24 56 5.99 77 8.03 135
Matriculation -- -- 10 1.06 21 2.18 31
Total 814 100 935 100 960 100 2709
52
Fig -3.2
Mushar / Nat
Chamar
89.79
92.25 Muslim Weaver
99.76
100
80
60 8.03
2.18
Muslim Weaver
40 5.99 1.06
Chamar
20 0.24 0
Mushar / Nat
0
Education Illiterate Up to 5th Matriculation
Education is a very important indicator in terms of knowledge and understanding .If a female
is educated she can understand many things about her health and she can better take care of
her children's health. Our study shows that all the Nat / Musahars are illiterate; only two girls
were found educated till V standard. this situation is very pathetic, while among Chamar
respondent 10 girls were found educated till VIII standard (1.06%) and only 5.99% got
education till V standard and the maximum are illiterate (92.25%) almost same position is
with the Muslim respondents .Only 21 women were reported that they have studied till
matriculation and 8.03percent studied up to V standard and remaining 89.79 percent
respondent were illiterate.
Income of respondent:-
In addition to providing means for purchasing health care, higher incomes can provide better
nutrition, housing, schooling, and recreation. Independent of actual income levels, the
distribution of income within countries and states has been linked to rates of mortality
Income- wise distribution of the respondent Table -3.3
Income Musahar / Nat Chamar Muslim Weaver Total

INR N1 % N2 % N3 % N1+N2+N3
1000 - 2000 502 61.68 435 46.52 401 41.78 1338

2000 -4000 312 38.32 438 46.84 500 52.08 1250
4000 - 5000 -- -- 62 6.64 59 6.14 121
Total 814 100 935 100 960 100 2709
Fig - 3.3
Mushar / Nat
Chamar
80 52.08
61.68 41.78 Muslim Weaver
60 46.52
46.84
40 38.32 6.14
20 6.64 Muslim Weaver
0 Chamar
0
Income INR Mushar / Nat
1000 - 2000
2000 - 4000
4000 - 5000
53
This graph shows the very low economic condition of the respondent .Among all the three
communities' very low percentage earns between 4000- 5000 (96.50 %) average. None of the
Musahars and Nat earns up to 5000. Maximum numbers of the Musahars are not aware how
much they earn; they borrow money from the brick kin owner and work for borrowed money.
No accounts are kept for their money .Chamar respondents maximum are equally in both the
category 1000-2000 and 2000-4000 i.e. 46 percent and the same situation is of Muslim
weaver respondent.
Residential Area of respondent:-
Residence wise distribution of the respondent Table -3.4
Area Musahar / Chamar Muslim Total
Nat Weaver
N1 % N2 % N3 % N1+N2+N3
Rural 814 100 935 100 -- -- 1749

Urban -- -- -- -- 960 100 960
Total 814 100 935 100 960 100 2709
Fig - 3..4
Mushar / Nat
100
100
100 Chamar
100
Muslim Weaver
80
60
0
40
0 Muslim Weaver
20
0 0 Chamar
Area
Rural Mushar / Nat
Urban
It is evident from the graph that all the Musahars/Nat taken for our study are from
Rural background and Chamar are also from rural background whereas Muslim weaver
respondent are from urban background. Accessibility of health facility is very poor in rural
areas and many report and studies support it. The health facilities in Muslim areas is also very
poor, Sacchar Committee report has unveiled this issue.
Type of House:-
House- wise distribution of the respondent Table -3.5
Type of House Musahar / Chamar Muslim Total

Nat Weaver
N1 % N2 % N3 % N1+N2+N3
Kachha 162 20 150 16.04 210 21.87 522
Removable 652 37.10 50 5.34 15 1.60 717
( Not Permanent )
Kachha - Paccka (Mix ) -- -- 735 78.62 735 76.55 1470
Total 814 100 935 100 960 100 2709
54
Fig - 3.5
Mushar / Nat
21.87 Chamar
40 21.87
37.1
30 16.04 Muslim
20 16.04
1.6 Weaver
20
20
10 Muslim Weaver
5.34
0 Chamar
Type of House
Kuchha Mushar / Nat
Removable ( Not
Permanent) Kuchha - Puccka
(Mix )
Maximum number of the Mushars/ nats lives in temporary houses, only 20percent lives in
kaccha houses, All the Musahars lives those houses which are provided them by the brick kin
owners. As they work in the brick kin from October to May they live in those houses without
any water or electricity facility. When the brick kin stop their work in rainy season they move
to another place .Chamar respondent 78percent lives in mix pucca and kaccha houses while
6.04percent lives in kaccha houses and only 5. 5.38percent lives in temporary houses. Among
Muslim weaver respondent 76.53percent lives in mix kuccha pucca house, 21. 87percent lives
in kuccha houses only 1.6percent lives in temporary house.
55
Size land of respondent:-
Land- wise distribution of the respondent Table -3.6
Size of Musahar / Chamar Muslim Total

land Nat Weaver
N1 % N2 % N3 % N1+N2+N3
Landless 814 100 720 77 960 100 2494

Small -- -- 215 22.99 -- -- 215
Big -- -- -- -- -- -- --
Total 814 100 935 100 960 100 2709
Fig - 3.6
Mushar / Nat
100
Chamar
100
100
77 Muslim Weaver
90
80
70
60
50
40 22.99
30 0
0
20
0 Muslim Weaver
10
0
0 0 Chamar
Size of land Mushar / Nat

Landless
Small
Big
Among our respondent all of them Muslim weavers, Musahars / Nat are landless while 23%
Chamar women reported that they have a small land size property even 77% of the Chamar
respondent were also landless.
Type of Family:-
Family- wise distribution of the respondent Table -3.7
Type of Musahar / Chamar Muslim Total

family Nat Weaver
N1 % N2 % N3 % N1+N2+N3
Single 614 100 536 100 348 36.25 1498

Joint 200 37.1 399 5.34 612 63.75 1211
Total 814 100 935 100 960 100 2709
56
Fig - 3.7
Mushar / Nat
100
100
Chamar
100
63.75 Muslim Weaver
80
36.25
60
37.1
40
20 5.34 Muslim Weaver

Chamar
0
Mushar / Nat
Type of
Single
family Joint
Mostly respondent live in a nuclear family. Our study shows that --- percent of the respondent
from Musahars /Nat lives in nuclear family and only --- percent lives in joint family. Among
Chamar -- percent lives in nuclear family while --- percent lives in joint families. When we
see the Muslim respondent data we can notice that their condition is reverse maximum
63.75percent lives in joint families and only 36.25 percent lives in singular family.
Marital status of respondent: - Marriage is deemed essential for virtually everyone in India.
For the individual, marriage is the great watershed in life Some parents begin marriage
arrangements on the birth of a child, but most wait until later. In the past, the age of marriage
was quite young, and in a few small groups, especially in Rajasthan, children under the age of
five are still united in marriage. In rural communities, prepuberty marriage for girls
traditionally was the rule. In the late twentieth century, the age of marriage is rising in
villages, almost to the levels that obtain in cities. Legislation mandating minimum marriage
ages has been passed in various forms over the past decades, but such laws have little effect
on actual marriage practices.
Marital statuswise distribution of the respondent Table -3.8
Marital Musahar / Chamar Muslim Total

Status Nat Weaver
N1 % N2 % N3 % N1+N2+N3
Married 792 97.29 867 92 910 94.79 2569
Unmarried 12 1.49 53 6.39 30 3.11 95
Widow 10 1.22 15 1.61 5 0.50 30
Divorcee -- -- -- -- 15 1.5 15
Total 814 100 935 100 960 100 2709
57
Fig - 3.8
Mushar / Nat
94.79
97.29 92
Chamar
100
Muslim Weaver
90
80
70
60
50
40
3.11
30 0.5
20
6.39 1.5
1.61
10 0 Muslim Weaver
1.49
0 1.22 Chamar
0
Marital
Married Mushar / Nat
Status Unmarried
Widow
Divorcee
Among our respondent 97.29percent of the Nat /Musahars women reported to be married,
among Chamar 92percent were married while among Muslim weavers 94.79percent were
married in total only approximately 5 percent respondent were unmarried and very marginal
approximately 1 percent were found widow and 1.5percent of the respondent were divorcee
among Muslim weavers .Some of the men have kept two wives among Nat.
Occupation of respondent: - Much of women's work has traditionally been carried out
within the context of the family: growing growing food on a family plot; finding fuel,
gathering water and preparing foods for family members; spinning, weaving and sewing the
garments worn by that family; cooking and washing for the family and looking after its
children and its sick and elderly members. This remains the occupational environment in
which many women - particularly rural women in developing countries - work today.
Surprisingly little is known about the health hazards of this environment, in part because
women's household work has been under-recorded and undervalued and hence there has been
little incentive to examine it in detail. As women move beyond their traditional occupations,
they meet new health hazards which may either replace or add to their existing occupational
exposure.
Occupation- wise distribution of the respondent Table -3.9
Occupation Musahar / Chamar Muslim Total

Nat Weaver
N1 % N2 % N3 % N1+N2+N3
House wife -- -- 320 34.23 70 7.29 390

Working / Labor / 814 100 615 65.77 890 92.71 2319
Weaver
Total 814 100 935 100 960 100 2709
58
Fig - 3.9
92.71 Mushar / Nat
100
100
Chamar
90
80 65.77 Muslim
Weaver
70
60
34.23
50 7.29
40
30
Muslim Weaver
20
10
0 Chamar
0
Occupation Mushar / Nat

House wife
Working / Labour /
Weaver
It is indicated from the above table that all the Nats /Musahars are working .All the Musahars
work as a labourer in brick kin while nat women go out for tamasha on the rope etc. Even
65.77% Chamars women reported as laboure, only 34.23% of them are housewives while
among Muslims only 7.29% were reported as house wives. This shows the double workload
on women , they get up early morning at around 4 a.m. do their household work and go to
work then come back by 12 noon cook lunch again go back to work then come back after
sunset The Muslim women weavers who are involved in weaving they also have the same
work routine. This lifestyle impacts both their physical and mental health.
Housing characteristic of respondent:-

Housing characteristic - wise distribution of the respondent Table -3.10
Housing characteristic Musahar / Nat Chamar Muslim Weaver

Number % Number % Number %
Electricity Yes (Y) -- -- 620 66.31 780 81.25
No (N) N 100 315 33.69 180 18.75
Source of drinking Tap shared -- -- -- -- 420 43.75
Hand pump / 288 35.38 415 44.38 312 32.50

Bore well
Well 312 38.32 300 32.08 228 23.75
59
River / Pond 214 26.30 160 17.12 -- --
Other -- -- 60 6.50 -- --
Sanitation facilities Own flush toilet / -- -- 185 19.80 250 25.60

Pit toilet
Shared toilet -- -- -- - -- --
Public toilet -- -- -- - 522 54.80

No toilet facilities 814 100 750 80.20 188 19.60
Fuel used for cooking Wood 780 95.82 612 65.45 550 57.30
LPG / Electricity -- -- 114 12.19 312 32.50
Kerosene 34 4.18 58 6.21 98 10.20

Other -- -- 151 16.15 -- --
Fig - 3.10
Mushar / Nat
81.25 Chamar
100 100
Muslim Weaver
66.31
80
60
33.69 18.75
40
Muslim Weaver
20
0 Chamar
0
Electricity Mushar / Nat
Yes
No
We can notice from the above table that among Musahars/Nat none of them have electricity
facility, as they live in the temporary houses provided by the brick kin owners so they live in
such pitiable conditions while 81% Muslim Weaver and 66% Chamar have electricity
facility.
60
Fig - 3.11
Mushar / Nat
43.75
44.38 Chamar
45
38.32 Muslim Weaver
40
32.08
35
35.38 32.5
23.75
30
25
20
26.3 17.12
15
10
0 0
0
5
0 6.5 Muslim Weaver
0
Source of drinking Chamar

Tap shared
0
Hand pump / Bore
well Well Mushar / Nat
River / Pond
Other
This graph shows that 33% Nat /Musahars, 44% Chamar and 43% Muslim weavers use the
hand pump water. 26%of the Musahars/Nat brings water from ponds or river while 17%
Chamar bring water from pond.32% Chamar and Musahars/Nat are dependent on well for
their water. Musahars have to fetch the water from far distance to their place and this work is
done by girl child or female, they have to carry heavy water buckets, even during menstrual
cycle and pregnancy or after a week of pregnancy.
Fig - 3.12
100 95.82
90
57.3
80 65.45
70
60
32.5
50
40
10.2
30
12.19
20 16.15 0
6.21
10 Muslim Weaver
0 0 4.18
Chamar
Fuel used for cooking
Wood 0
LPG / Electricity Mushar / Nat
Kerosene
Other
This chart shows that 95% of the Musahars/Nat community is depended on wood fuel while
65% Chamars use wood as fuel and 57% Muslim Weaver use wood as fuel .Maximum people
from urban background Muslim weaver 33% use LPG as fuel Socioeconomic status (SES)
underlies three major determinants of health: health care, environmental exposure, and health
61
behavior. In addition, chronic stress associated with lower SES may also increase morbidity
and mortality. Reducing SES disparities in health will require policy initiatives addressing the
components of socioeconomic status (income, education, and occupation) as well as the
pathways by which these affect health. Lessons for U.S. policy approaches are taken from the
Acheson Commission in England, which was charged with reducing health disparities in that
country. Inequality in education, income, and occupation exacerbates the gaps between the
health haves and have-nots. Socioeconomic status, whether assessed by income,
education, or occupation, is linked to a wide range of health problems, including low birth
weight, cardiovascular disease, hypertension, arthritis, diabetes, and cancer.1 Lower
socioeconomic status is associated with higher mortality, and the greatest disparities occur in
middle adulthood (ages 4565).
Mushar /
100 100 Nat
90
80.2 Chamar
80
70 54.8
60
50 25.6
40
19.8 19.6
30
0
20
0
10
0 0
Muslim Weaver
0
0 0 Chamar
Sanitation
Own flush
facilities Shared Mushar / Nat
toilet / Pit Public
toilet No toilet
toilet toilet
facilities
Fig - 3.13
This graph shows that after so much work on the sanitation still the reality is very harsh. All
the Musahars/Nat community goes for open deficacy .80% Chamar also have no toilet facility
62
and 54% Muslim Weaver goes to Public toilet. This public toilet facility is not available in
rural areas.
63
Chapter 4 Data analysis of knowledge , attitude and

practice of reproductive health among women
64
Chapter 4
Data analysis of knowledge , attitude and practice of reproductive health among
women
Women's health is affected by various social economic and demographic factors such as loved
of education, social positions economic affluence, age at marriage, caste based traditions etc.
but age of marriage is the major factor which adversely affect the fertility behavior of women
.we can found in various studies that more than 90% Mushers' women get married at early age
same case is with Muslim women and Chamar women. During their illness they dont consult
the doctor until unless there is an emergency care, berider, there are a number of other factors
which directly or indirectly affect the women health & child health for example: -illiteracy,
poverty, unemployment, malnutrition and environmental factors always compel the society to
go backward. . The Maternal health care package of antenatal care, delivery care and
postnatal care is a crucial component of NRHM to reduce maternal morbidity and mortality.
The ANC package comprises of physical checks, checking position and growth of fetus and
giving Tetanus Toxic injection (TT) at periodic intervals during the time of pregnancy. At
least three check-ups are expected to complete the course of ANC to safeguard women from
pregnancy related complications and forewarn pregnant women about possible delivery
complications. Institutional delivery and post-natal care in a health facility is promoted in
NRHM through introduction of accredited social health activist (ASHA) at village level and
Janani Suraksha Yojana, a 100% centrally sponsored scheme, providing cash assistance with
delivery and post delivery care. The JSY was basically to promote demand for institutional
deliveries in high focused states to lower Maternal Mortality Ratio.
Distribution of the respondent about Hand washes Table - 4.1
Occasions of Nut / Mushar Chamar Muslim weaver

hand wash Number % Number % Number %
After toilet 525 64.4 612 64.25 425 52.21
Before food 145 17.81 152 18.87 122 14.98
With soap 25 3.07 20 2.45 42 5.15
Without soap 119 14.61 251 30.83 371 45.57
Total 814 -- 935 -- 960 --
65
Fig - 4 .1
Nut /
64.25 Mushar
70 64.4 52.21
Chamar
60
45.57
50
40
14.98 30.83
30 18.87
5.15
20
17.81
10 2.45 14.61 Muslim weaver
0 3.07
Chamar
Occasions of
hand wash After toilet
Before food Nut / Mushar
With soap
Without soap
It is clear from the above chart that among Musahar/Nat community 64.2%people wash their
hand after toilet but only 17.8% wash hand before food but only 3 percent use soap to wash
their hands. Among Chamars the condition is almost same. Among Muslim weavers use of
soap is higher than Chamar and Musahars. 45% people wash their hand with soap.
Bath taking / Nail cutting practice of respondent :-
This chart shows that Nats / Musahars don't take bath regularly .this is due to the scarcity of
water if they get water then only they take bath. Chamars and muslims take bath regulary and
even cut their nails regulary. This shows that Nats/Musahars living conditions and practices
towards health hygene is very bad and there is an urgent need for awareness programmes.
Table - 4.2
Occasions Nut / Mushar Chamar Muslim weaver

Yes No (N) Yes No Yes No
( Y) ( Y) (N) ( Y) (N)
Taking bath regularly N N -- Y N Y --
Taking bath occasionally Y -- -- Y -
Cut Nails weekly -- N --y Y --
Cut Nails occasionally Y -- -- -- N
occasionally Never --- N -- N -- N
Accessibility of Health Services to the respondent :- Table - 4.3

Place of treatment Nut / Mushar Chamar Muslim weaver Total
Number % Number % Number %
PMC / Sub-center 10 1.22 50 5.34 50 5.20 110
CHC / DH -- -- 25 2.67 90 9.37 115
Local Doctor / Private 110 13.5 140 14.97 150 16.04 400
Own home treatment 694 85.25 720 88.45 670 69.81 2084
Total 814 -- 935 -- 960 -- 2709
66
Fig - 4.2
Nut / Mushar
88.45 Chamar
90
85.25 69.81
80 Muslim
70 weaver
60
50
40 5.2 9.37 16.04

30
5.34 14.97
20 2.67
10 1.22 13.5 Muslim weaver
0 0
Chamar
Place of treatment
PMC / Sub-center
CHC / DH Nut / Mushar
Local Doctor /
Private Own home
treatment
Above table shows that very few only 1.22 % musahars/Nats 5% Chamars and 5 % Muslim
go to primary health centre or sub centre 0 .9% muslim weaver go to distict hospital for health
services a maximum of all the respondent rely on their own home made remedy Only in very
severe illness they prefer to go government hospitals.
Response towards reproductive infection Table - 4.4
Sl. No. Responses Nat/ Musahars Chamar Muslim Weavers

1. Awareness Regarding Menstruation process -- 12% 30%
2. Problems during menstrual cycle 10% 65% 70%
Interval between two Menstrual cycle
25 28 day More than it dont know
3. Prier Information Regarding Menstruation 100% 15% 12%
Yes 65% 70%
No 20% 18%
Partial
4. Hygiene practice
(a)
Homemade disposable 55% 60%
100% 35% 28%
( b) Homemade reusable
Company made branded 10% 12%

If any problem than treatment of RTT
Medical treatment 20% 10%
Home treatment 80% 10% 80%
Any other 20% 70% 30%
Awareness of Hegel Massage age(16-17) (17 -18) -- -- --
The present study shows that very few women (Age group 14-50) Have the awareness
segarding menstrual cycle 12% Chamars have Knowledge regarding menstural process. All
the Communities women suffer from som problems during meustral periods .Around 70%
female in Nats/Musahars ,suffers from it and chamars approxinas 65% women have some
67
problems during menstural cycle and approximately 70% of Muslim women suffer from
problems during periods. .Hundred percent women are not aware about the Interval between
the Menstrual cycle among Nats/Muslars. Among chamars 20% women have the knowledge
that interval of between the two Menstrual cycles 25-28days.Among Muslium women 22%
Muslim women knows about it 70% and 65% women respectively have no knowledge about
it..Knowledge regarding Period and knowledge about Menstruation cycle also shows that
Nats / Musahar women are not aware about it Although a very small proportion of Muslims
12% and Chamars 15% have knowledge regarding it.The worst part was that 100 percent
Nate /Musahars women use homemade reusable pads during their periods, In Muslims and
chamars this practice is lers, but maximum number Muslims 60% and chamars 55% use
homemade disposable pad. Only 10 %women were found to use Company based branded
pads. Regarding treatment of their health problems where do the they go .It was found that
due to economic poorness lack of knowledge and aa not of family member are not aware
about pregnancy ot 80% of the women reported that they go to local doctor. Among
muslims10% reported that they consult a medical treatment but 80% prefer home remedies ,
among Chamrs 20% respondend for local treatment .due to fear of medicine money and
doctor fee usually they dont go to hospital.
FAMILY PLANNING:-
India was the first to launch an official family planning programme in 1952 with an objective
of accelerating population stabilization process. The Family Planning division has been
formulating many interventions for increasing contraceptive choices to meet the unmet need
of contraception. The Ministry of Health and Family Welfare has been emphasizing in
provision of quality contraceptives being need-based and client-centered. The NRHM
initiatives and recent thinking in Ministry of Health and Family Welfare on repositioning the
Family Planning Programme are meant not just for achieving population stabilization but also
substantially reducing maternal mortality and infant and child mortality and morbidity. Thus,
family planning is more or less considered to be an important measure to improve maternal
health, which definitely gets influenced by more frequent and unwanted births. An important
initiative is to improve contraceptive use on voluntary basis through a comprehensive
package of improved accessibility to quality contraceptives, both temporary and permanent,
and incentive programmes to improve healthy married life and also to accelerate the
population stabilization process. Hitherto, literature suggests that family planning methods
utilization is most cost effective way of controlling population. There is enough evidence to
substantiate that usage of fertility control methods improves womens health and thus
facilitates womens empowerment too. Thus, family planning can also be adjudged as
womens health improvement measure and concomitantly accelerate the population
stabilization process in India.
68
Knowledge about family planning methods :- Table - 4.5
Sl. Methods Nat/ Chamars Muslim

No. Musahars Weavers
1 Condom 20% 42% 55%
2 Pill 8% 10%
3 IUD 10%
4 Female sterilisation 10% 60% 20%
5 Male sterilisation 10% 40% 10%
Rythm
6
7 Withdrawl
Any method they apply
Any modeun
Spacing method
Data about knowledge and use of family planning device by the respondents were collected
in the field survey. Contraception using is one reliable means to check birth .our study shows
that very very people have knowledge about their devices ,although about condoms
nats/musahars only 20% knows about condomns but never in praclve 42% chamars knows
about condoms and 55% Muslims have the knowledge about it butin practice it is very low.it
was also found during our group discussions that they have knowledge about family planning
know that there devices of family are used for spacing the pregnancy planning ,but in
practice it is very low.
It is also evident fore the study that male hardly opt for sterilization .The reason of not using
family planning methods that they are not allow to take their decision .they can't do this
without permission of their husband. Back of information about it ,barriers of socio-cultures
norms and values etc. leads towards no family planning. Information on family planning
methods used has been elicited from 7042 eligible couples from households covered under the
study. The information pertains to type of method, who motivated for the use, source of
acquiring the methods, problems during the usage, reasons for not using, etc .Almost half
(56%) of the respondents were using different family planning methods with most of them
using condom (41.5%), female sterilization (27.4%), oral pills (22.9%), and others using IUD
and other traditional methods like withdrawal, abstinence or safe period, etc. In case of these
communities 8% women were using female sterilization, none were using IUD/Copper-
T/Loop and 8% was utilizing oral pills and condoms, but in case of high focus states most of
the people were using condoms/ oral pills as contraceptives.
69
Knowledge about safe age to bear children :- Table 4.6
Sl. No. Safe age to Nat / Chamars Muslim

bear Mushars % weavers
children % %
1. 13-14 100 15 40
2. 15-19 -- 85 60
3. 20-24 -- -- --
4. 25-34 -- -- --
5. 35-39 -- -- --
Knowledge about safe age to bear children regarding this qestion knowledge of Nat/ Musahar
, hundred percent women said between 13-14 age is enough to bear child. among Chamars
85% women supported the age betwen15-19%,but none of the community go above that
.according to them 20 year is too late .During our discussions women in all the three
communities said that women should get marry till 15 to 16 years of age. About marriage age
in all the three communities maximum one third 75% women reported that the legal age of
marriage is 16 year. Althongh in our interview schedule we had no column for below 16
year.
Knowledge about safe sex :- Table - 4.7
Sl. Safe sex reported that safe sex means taking steps to avoid Nat / Chamars Muslim
No. Mushars % weavers
% %
1. STD 100 15 40
2. Pregnancy -- 85 60
3. Both STD and pregnancy -- -- --
70
Knowledge about when they were asked about safe sex 50%of Musahars women reacted that
it is to avoid pregnancy,60% of Chamars women also said same and 70% of Muslim women
reported the same answer. None of the community women knew that safe sex can also avoid
sexually transmitted disease. During our discussions it was found that they (all the three
community's dont have much knowledge about STDS.
Number of Living Children of respondent :- Table - 4.8
Number of Nut / Mushar Chamar Muslim weaver Total

children Number % Number % Number %
Between ( 0 - 2 ) 112 13.70 301 32.2 230 23.95 643
Between ( 3 - 4) 205 25.20 295 31.55 312 32.05 812
Between ( 5- 6 ) 402 49.38 290 31.01 316 32.91 1008
More than 6 95 11.62 49 5.24 102 10.6 246
Total 814 -- 935 -- 960 -- 2709
71
Fig -4.3
Nut /
Mushar
Chamar
50 49.38
Muslim
45
weaver
40 32.05 32.91
32.2
31.55
35 23.95 31.01
30
25
25.2
20
10.6
13.7
15
10
5
Muslim weaver
11.62 5.24
0
Chamar
Number of
children Between ( 0 - 2)
Between ( 3 - 4) Nut / Mushar
Between ( 5- 6 )
More than 6
Table number shows that all the three communities have a maximum number of the
respondent who have children between 3- 6 children .Among Musahars/Nats 49 percent have
5- 6 Children .Among Chamars 31 percent and even among Muslim weaver 31percent
respondent have the 5 to 6 children. So the women who conceive repetedly without much
interval impact both the mother and child SO AWARENESS PROGRAMME REGARDING
CONTRACEPTION USE HAVE BEEN STARTED BY JANMITRA NYAS IN ALL THE
THREE COMMUNITIES.
Reason for not using contraceptives of respondent:- Table - 4.9
Reason Nut / Mushar Chamar Muslim weaver
N % N % N %
Fertility related 50 6.18 110 11.76 135 11.76

Opposition to use 110 13.51 250 26.73 205 26.73
Lack of knowledge 430 52.82 312 33.36 325 33.36
Lack of access up to God 224 27.51 264 28.73 305 28.73
Total 814 100 935 100 960 100
Nut / Mushar
Chamar
60
Muslim weaver
52.82
50
33.36
26.73
40
33.36 28.73
26.73
11.76 28.73
30
11.76
20
27.51
13.51
10 6.18
Muslim weaver
0
Chamar
Reason
Fertility related
Opposition to use Nut / Mushar
Lack of knowledge
Lack of access up
to God
Fig - 4.4
72
This graph Cleary depict that maximum respondent don't use contraceptive
55%(Muasahars)and 33% Chamars and Muslim weaver beacause of the lack of knowledge.,
while other major reason is their husband oppose it , and above 25percent of the respondent
from all the communities think that this is god gift and up to god. Right now Janmitra Vyas
has conducted many programmes related to the use of contraceptive method in all the
three community.
ANTENATAL CARE:-
Antenatal Care During antenatal period, it is essential to monitor complications that could
arise during pregnancy or delivery, detect and treat the existing problems, provide advice on
the diet and about various preventive measures that should be taken during pregnancy. As per
norms, the expecting mothers should receive two doses of tetanus toxoid vaccine, adequate
amount of iron and folic acid tablets or syrup to prevent anaemia. Pregnant women are
expected to visit a health facility to have at least three antenatal check-ups for blood and urine
test and other procedures to detect pregnancy related complications. To woman questionnaire
had probed whether the pregnant women had sought any antenatal check-ups or not, and if
availed then from where, whether from public or private health care acilities.
Knowledge regarding pregnancy and antenatal care :-Table - 4.9
Sl. Knowledge regarding pregnancy Nat / Chamars Muslim

% %
1. First sign of pregnancy -- -- --
2. Missing period 10 50 100
3. Vomiting 70 100 100
4. Low BP -- -- --
If pregnant:
1. Regular ante natal care is essential - 10 12
2. Proper diet , exercise, rest is essential during pregnancy 10 60 30
Pregnant period of a women take nine months .During this period a women need more care
for her baby and herself .In this period she need health education about complication in
pregnancy .Ignorance may danger the life of a pregnant women and unborn infant .Much
early care save lives and survive the mother. She should emphasis on importance of proper
balance diet is must during our study we found that only 10% Nat/Musahars knows that
missing periods is a sign of pregnancy while50% of Muslim women and 60% of chamars
have this knowledge .But all the women for Muslims &chamars knows that vomiting is sign
of pregnancy. Nat /mushars said that they understand after 5-6 months of missing periods that
they are pregnant half of the (50%) of Muslims responded consult a doctor during their
pregnancy .One fourth 25%chamars consult a doctor during their pregnancy .none of the
women from Nats/Musahars consult any doctor running their pregnancy .Due to lack of
money, knowleged ther dont pay attention to the proper died, they even work in pregnancy
.Mushars women are habitual of (bidi)smoking .drinking even during their pregnancy
.Musahar women were also found working since mouring 4 a.m. to evening 7 a.m. during
pregnancy .There was no time and regularity in food intake .It was found that the condition of
present .Muslim women `are found more concerned towards their pregnancy again during
Nats/Musahars and Chamars that family member did not call any trained health worker for
73
delivery but among Muslim although 60% deliveries took place at home but a dais was called
when the labor pain begans 100% Musahar nats women delivered child at home and among
80% of chamars women that too without any help of trained ASHA or dais .In such cases, the
possibilities of maternal and child mortality would high from the about table we can come to
the conclusion that due to negligence of health care the condition of the health of the women
is worst in these communities. Information on utilization of antenatal care has been elicited
from pregnant women through the focus group discussion that hardly 8.8 of pregnant women
had registered within first trimester, whereas majority of pregnant women got registered
between 3-6 months (46%) and 7-9 months (45%). However, 68 percent of the pregnant
women have reported utilization of any of the antenatal care services. Majority of the
antenatal checkups are being reported to be done either at Sub-centres (SCs) or Primary
Health Centres (PHCs). Patterns of utilization seem to be similar in almost all the three
communities under the purview of the study.
Ante natal care of the respondent:-Table - 4.10
Sl. Ante natal Care Nut / Mushar Chamar Muslim weaver Total
N1 % N2 % N3 % N1+N2+N3 %
No.
1. Did you visit Dr. for Yes 70 8.60 250 26.73 285 29.68 605 22.33
health Check up?
No 744 91.40 685 73.27 675 70.32 2104 77.67
Total 814 100 935 100 960 100 2709 100
Yes
2. Women who 744 91.40 685 73.27 675 70.32 2104 77.67
received TT
No
70 8.60 250 26.73 285 29.68 605 29.33
Total 814 100 935 100 960 100 2709 100
Yes
3. Women who 250 30.71 550 58.82 515 53.65 1315 48.54
received IFA No
564 69.29 385 41.78 445 46.35 1394 51.46
Total 814 100 935 100 960 100 2709 100
Fig - 4.5
Nut / Mushar
100
Chamar
91.4
90 91.4
Muslim
73.27 weaver
80
70.32
73.27
70 53.65
53.65
58.82 58.82 69.29
60
46.35
50 29.68
40 17.32 41.78
26.73
30
30.71
20
8.6
10
0 Muslim weaver
8.6
Ante natal
Did you visit Chamar
Care
Dr. for health Women who
received TT Women who
Check up? Yes Nut / Mushar
Yes received IFA Did you visit
Yes Dr. for health Women who
Check up? No received TT Women who
No received IFA
No
This table clearly shows that maximum number of the respondent reported that they don't visit
a doctor for check up during their pregnancy(91.4% Nats/Musahars ,73%Chamars,and
74
77%Muslim weavers) .During our informal discussions they told us that due to their work
load they don't visit a doctor .But they have received TT injections from ANM . About IFA
Tablet 48% in total have received the tablets, among Musahars /Nats only 30.7% , among
Chamars 58% and 53% of the Muslim weaver rorted that they got the iron tablets from the
ANM. but in practice they dont take their medicine regularly .
Place of delivery of respondent:- Table - 4.11
Place of delivery Nut / Mushar Chamar Muslim weaver Total

N1 % N2 % N3 % N1+N2+N3 %
At Trained Dai 210 25.79 305 32.62 302 31.45 817 30.15
home Non Trained Dai 412 50.61 355 37.96 402 47.90 1169 43.15
Public / Government 100 12.28 205 21.92 206 22.03 511 18.86
Private 92 11.30 80 8.55 50 5.39 222 18.19
Total 814 100 935 100 960 100 2709 100
Fig - 4.6
Nut / Mushar
47.9 Chamar
60
31.45
50.61 Muslim weaver
50 32.62 37.96
40 22.03
30 25.79 21.92
5.39
20
8.55 Muslim
10
12.28 weaver
0 11.3
Chamar
Place of delivery
At home by trained
Dai At home by Non Nut / Mushar
trained Dai Public / Government
Private
This table shows that a maximum number of the respondent 43% of respondent gives delivery
at home by non trained staff. 30 5% of the respondent gives birth with the help of tained Dais
at home .19% of the total respondent delivered their child in government hospital while
10percent of the respondent in private hospitals But now the situation is changing ,with the
help of JANMITRA NYAS now women have been going for institutional deliveries .
75
IMMUNIZATION:-
Immunization of children :- Table - 4.12
Immunization card Nat / Chamars Muslim

Mushars % weavers
% %
1. have 25% 40% 40%
2. Does not have 75% 60% 60%
place of Immunization
1. Government yes 20% 50%
2. private -- -- 12%
3. Not given -- -- --
Immunizations status
1. fully immunized -- -- --
2. partially 25% 40%% 62%
3. unimmunized 75% -- --
4. fully immunized -- -- --
Vaccines doses
1. BCG -- 20% 62%
2. DPT 1/OPV 1 -- 20% 52%
3. DPT2/OPV2 -- -- --
4. DPT3/OPV3 -- -- --
5. Measles -- -- --
Source ANM, Family. Relatives, Neighbour, Asha, PHC
A holistic policy intervention to promote child survival comprises of new born care, both
home and facility based, proper counseling and widespread messages on proper breast feeding
practices, and food supplementation at the right time and a complete package of
immunization for children. Immunization programme being a key intervention for protection
of children from life threatening and preventable diseases predominantly facilitates reduction
in post neonatal component of infant mortality. Thus, proper breast feeding, nutritional
supplementation and complete immunization package envisages reduction in infant and child
mortality. In India, children are supposed to be vaccinated for six serious but preventable
diseases tuberculosis, diphtheria, Pertusis, tetanus, poliomyelitis and measles. The
structured schedule canvassed with the mothers having children 1-5 years were enquired
whether they got their children vaccinated for the scheduled vaccines or not, and if got
vaccinated then which ones and also the source of getting the children vaccinated, whether
private or public health facilities.
Immunizations 0f children primary health care play a vital role keep to the mother and new
bourn baby healthy and safe from infectious diseases .During this study we found that
nat/musharas 75%% children's have no immunization card and all the children are
unimmunized .Among chamar 40% childern have card from the government hospital and
among Muslims 62% children have cards 50%from government agencies and12%from
private hospitals ,but all these children are partially immunized once the mother is back from
hospital they never go again to the hospital fro further immunization so this shows the worst
condition of mother &child health.Some Children have got immunized with the help of
ASHA.
76
Reasons for not getting children Immunize :- Table - 4.13
Sl. Reasons Nat / Chamars Muslim

% %
1. Lack of knowledge regarding schedule 100% 20% 40%
2. Place/Time of Immunization known -- 60% 60%
3. Fear of side effect 100% 50% 40%
4. Unaware of Immunization YES -- --
5. Place of Immunization too far YES -- --
6 Time of immunization incorrect -- -- --
7. Vaccinator absent -- -- --
8. Chaild ill not brought -- -- 40%
9. Child ill brought but not given -- -- --
A reason for not getting children immunize .It is always better to prevent a disease then to
treat it .Vaccines prevents disease in the people who received them and protect these who
come into contact with unvaccinated individuals. If a child is not vaccinated and is expressed
to a disease germ the Childs body may not be strong enough to fight the disease. Immunizing
individual children also helps to protect the health of our community, especially these people
who are not immunized. But we found that in all the three communities' practices of
immunization is very low the reasons asked for not immunization were- Nats &Musahars
reported that they are not aware of immunization .While chamars reported that lack of
knowledge &Muslims said fear of side affect.place and time not known to them.. In surveyed
communities, information from mothers of children aged 0-5 years was elicited pertaining to
immunization of children. Almost 60% percent of the children were administered with BCG.
More than 40% children were reported to be immunized with three vaccinations for DPT and
Polio. However, immunization with vaccines of Measles was reported to be only for 20% of
the children and administration of Hepatitis was reported to quite low i.e. . Out of total
vaccinated, 40% mothers reported to be having immunization cards for the children.
Utilization of the immunization services for children has been vaccinated by ANMs.
BREASTFEEDING :-
Breast milk is the best gift a mother can give her baby. WHO recommends exclusive breast
feeding for first 4 6 months followed by addition of semisolid & solid foods to complement
breast milk till the child is gradually able to eat the normal food*1 . Breastfeeding is natures
77
way of nurturing the child, creating a strong bond between the mother and the child by
developing babys trust and sense of security. Breastfeeding is important for young child
survival, health & nutrition, Exclusive breastfeeding and longer duration of breast feeding is
known to protect the child from obesity risks, it also helps in enhancing brain development
and learning readiness. Breast feeding also serves as one of the child spacing methods , which
is especially important in developing country like ours where the awareness, acceptability &
availability of modern family planning methods are very low as per NFHS - 3 data Only 69 %
of children under two months of age are exclusively breastfed, which further drops to 51 % at
2-3 months of age and 28 % at 4-5 months of age . Although Breast feeding is universal in
India, but exclusive breast feeding & appropriate weaning practice rates are not satisfactory,
Various Socio cultural factors influence these practices, which vary from region to region*.
Beliefs like the first milk is not good or there is no secretion of milk in first three days result
in practices like discarding colostrums and promoting pre lacteal feeds, such practices
increase the risk of infections and deprive the valuable benefit of colostrum feeding to the
vulnerable neonates. This issue becomes an area of concern since large number of babies born
in India are low birth weight. Breastfeed practice exclusive breastfeeding for six months as
recommend by WHO and American Academy of pediatrics (AAP)has a number of benefits to
the growing infants .Breast milk in addition to calories and proteins contain bioactive factory
like K-careen, growth factors, gluta thione peroxide etc .Which have ant infective antioxidant
growth promoting properties. in spite of this ,breastfeeding rates in India are abysmally low
.Infant mortality in India is 47/100 live birth with 1.4 million babies dying every year due to
poor care &infant feeding practices.
Children feeding practice:- Table - 4.14
Sl. First time breast fed after birth Nat/musahars chamars Muslim weavers
No.
1. As soon after birth Nil Nil Nil
2. Within Six month -- -- 15%
3. Within 24 hour but after 6 hour 20% 15%
4. After 48 hour 100% 80% 85%
5. On three days Nil Nil Nil
Type of first feed
1. Breast feed
2. Honey 100% 100% 100%
3. Sugar water Yes Yes Yes
4. Artificial feeding Sometimes Sometimes Sometimes
5. Cows milk 40% 50% 55%
6. Buffalos milk No No No
Breast feed
1. No. of times breast fed /day Don't know Don't know Don't know
2. As and when baby cry fix timing Yes Yes Yes
3. Semi +demand Nil Nil Nil
(Fixed demand + when babycared)
78
Our study shows that soon after the birth in all the three communities they either give
only honey or sugar water they dont know anything about colostrums.They start
giving their milk after 2nd day only very few respondent 20% from Chamars and 15%
Muslims start breast fed within 24 hour, but except a few all mother were found
breastfeed after 48 hours .Very few start giving cow's milk that too after six
months(40% Muslims ,50% chamars 60%,musahar ) .So we found till six months all
the respondent reported they prefer breastfeeding when they wear asked how many
times they feed their children they said there are no fixed time depend where their
baby cry. The main reasons for stopping breastfeeding wasthey breast feed till next
pregnancy in 60%of the cases .
Distribution of children by duration of breastfeeding reveals that around 20 percent of
children were put on exclusive breast feeding for initial four months, another 54
percent up till six months and another 27 percent for period extending beyond six
months. Breast feeding in almost universal as 99 percent of the children were breast
fed and as norms we find around 80 percent of children in rural areas are breast fed
for six months after their birth.
Dietary practice of Lactating mother:- Table - 4.15
Sl.No. Dietary Fast Nat / Musahar Chamar Muslim Weaver

1. Do they Fast No No No
2. Takefood along with family No No No
3. Take food (previous day) Yes Yes Yes
4. How many times do they take food -- -- --
5. Breakfast 100 Yes Yes
6. Lunch No No No
7. Dinner Yes Yes Yes
Dietary practice of Lactating mother.if a mother is lactating she need a sufficient and such
diet because she is also feeding her baby but our data shows that in their breakfast they
generally eat left over previous day food (Musahares 100%) same condition is of chamar
women Muslim women 20% take proper breakfast. But it was also found that they take their
breakfast at 11a.m.So most of the women in all the there community dont take lunch. they
dont have money to drink milk or tea. they dont have knowledge how much they proteins
,calcium or food they should taken during lactating the dietary practice are worst among
Muslims/nat they only eat rice & no proper diet very un hygienically cooked food. Most of
the women are malnourished and in turn at a greater risk of poor general health and more
vulnerable to infections, infact the whole Musahars community is surrounded by food
insufficiency problem. Somehow the same condition is of Muslim weaver women
&community.
79
Knowledge towards breast feeding:-

Table - 4.16
SL. Knowledge towards breast feeding Nat/ Musahar Chamar Muslim weaver
No.
1. Colostrums is first breast milk Don't know Don't know Don't know
2. Colostrums is important for the baby to maintain immunity don't know don't know don't know
3. Burping should be done after each feed know know know
4. Breast feeding should be continued up to two year don't know don't know don't know
5. Lactating mother should take healthy food for proper secretion of milk know know know
6. During Breast feeding the mother should sit comfortable don't know don't know don't know
7. During Breast feeding the mother should maintain eye to eye contact and don't know don't know don't know
talk with he baby
8. Wash each breast with warm water before breast feeding don't know don't know don't know
9. Awaking the baby while breast feeding No No No
10. Breast feeding help in mother and child boundary don't know don't know don't know
11 Stop Breast feeding when you start weaning No No No
This table shows that maximum women know that breastfeeding is good for babies health .
They also have the knowledge that lactating mother should take healthy diet and they should
burp their child after feeding . In practice they follow breast feeding due to poverty they are
not able to take a healthy diet, while they don't have any knowledge about the other things
related to breast feeding .
Practice abortion:-
Table - 4.17actice of a bortion
Variable Nat/Musahars Chamar Muslim weaver
Have you ever practice Yes 68% 72% 63%
abortion No 32% 28% 36%
Where did you attend Health center 10% 25% 20%
Private clinic 5% 15% 24%
Doctor 12% 7%
Other health 85% 48% 49%
professional
What was the duration of 0-3month 44% 78% 77%
induced abortion 3-6month 66% 30% 29%
6-7month 2% 4%
What was the reason for attending abortion -- -- --
Natural problem 52% 48% 51%
Spacing between the children 48% 52% 49%
Was there any problem after Yes yes yes yes
abortion No -- -- ---
This table shows that all that a maximum number of the women have face abortion . Among
the female who have practice abortion 85% of the musahars women practice unsafe abortion
with the local professional dais while 48% muslim and Chamar practice it . We can also
observe that 66% of the Musahars /Nats have induced abortion between 3 to 6 month which is
very dangerous ,while among Chamars 30 % and 29% also get done their abortion during 3 to
6 months. Very few respondent got their abortion after six months because of some natural
abortion . what type of problems do they face after abortion female complaints various
problems like itches over valve, white discharge, lower abdomen pain , puring intercourse ,
bleeding after intercourse .
KNOWLEDGE ABOUT ASHA, NRHM, VHND AND VHSC:-
Data collected through field surveys indicate the extent of respondents knowledge regarding
NRHM, ASHA, Village Health and Nutrition Day (VHND) and VHSC. The data shows that
overall two-third of the respondents have heard about NRHM but when we go through the
communities separately, the highest percentage was in Chamar community (46%) and lowest
80
in Nats /Musahars(29.4%) and most of them by ASHA/ANM (62%) but in case of Chamars it
was Asha followed by radio/televisions. On another Muslim community 55% of the known to
ANMs and mostly ANMs visits monthly in the Chamars village, overall only one-fourth
respondent has reported about weekly visit of ASHA in the village. On average 76% ASHAs
having kits and in 81% cases they provide common medicines to people as reported by the
surveyed people.. Janani Suraksha Yojana (JSY) under NRHM is to promote institutional
deliveries among poor pregnant women. In availing institutional delivery services the client is
usually escorted, will be requiring transport to reach the institution and in case of
complications, referral services will be required. The scheme has considered all these
elements and has made provision for transport including referral and escort under the NRHM
Programme.
Benefit of JSY to respondent:-
Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural
Health Mission (NHM). It is being implemented with the objective of reducing maternal and
neonatal mortality by promoting institutional delivery among poor pregnant women. The
scheme is under implementation in all states and Union Territories (UTs), with a special focus
on Low Performing States (LPS). Janani Suraksha Yojana was launched in April 2005 by
modifying the National Maternity Benefit Scheme (NMBS). The NMBS came into effect in
August 1995 as one of the components of the National Social Assistance Programme (NSAP).
The scheme was transferred from the Ministry of Rural Development to the Department of
Health & Family Welfare during the year 2001-02. The NMBS provides for financial
assistance of Rs. 500/- per birth up to two live births to the pregnant women who have
attained 19 years of age and belong to the below poverty line (BPL) households. When JSY
was launched the financial assistance of Rs. 500/- , which was available uniformly throughout
the country to BPL pregnant women under NMBS, was replaced by graded scale of assistance
based on the categorization of States as well as whether beneficiary was from rural/urban
area. States were classified into Low Performing States and High Performing States on the
basis of institutional delivery rate i.e. states having institutional delivery 25% or less were
termed as Low Performing States (LPS) and those which have institutional delivery rate more
than 25% were classified as High Performing States (HPS). Accordingly, eight erstwhile
EAG states namely Uttar Pradesh, Uttarakhand, Madhya Pradesh, Chhattisgarh, Bihar,
Jharkhand, Rajasthan, Odisha and the states of Assam & Jammu & Kashmir were classified
as Low Performing States. The remaining States were grouped into High Performing States.
81
Fig - 4.7
Yes
Benefit of JSY to respondent
No
38.15
61.75
During our visit we found that 61.75 % of the respondent got the benefit of JSY , however the
deliveries' were done at home but somehow with the help of ASHA they manage to got the
benefits, while rest 30.15% of the respondent did not get any benefit.
Accomodation Fees paid for Institiutional deliveries:- .
However, they further related that there were costs associated with government hospitals,
such as bribes and costs for medicines and equipment (e.g., needles and sutures). Families
often purchased equipment prior to the delivery and brought the items with them to the
hospital.
Earlier they [government hospitals] were providing treatment at free cost. Nowadays, they
too collect money for providing treatment. (New mother in bajatdiah urban slum)
Receipt of government incentives was not uniform across districts; some benefits were not
received despite families meeting government requirements.
Interestingly, some women who did receive incentives from either scheme indicated that they
would prefer home deliveries if they received incentives at those sites.
Fig - 4.8
Yes
Accomodation Fees paid for Institiutional deliveries
No
40.44
59.56
Above chart shows that 59.56 % of the respondent have to pay in any form even during
institutional deliveries. While 46.43% did not pay during institutional deliveries'.
82
Nutrition's provided to pregnant women by AWCs: - A third of women of reproductive

age in India are undernourished, with a body mass index (BMI) of less than 18.5 kg/m2. It is
well known that an undernourished mother inevitably gives birth to an undernourished baby,
perpetuating an intergenerational cycle of under nutrition. he major reason for stagnant levels
of undernutrition among Indian children is because of a failure so far to adequately prevent
undernutrition when it happens the maximum i.e., in the womb - caused by poor nutrition of
women before and during pregnancy. Given this, womens nutrition before, during and
after pregnancy has now been included as a special focus area in UNICEF Indias nutrition
programming. The organization now aims to give added focus to universalize the coverage
of five essential nutrition interventions for women which have been arrived at based on global
and national consensus.
Fig - 4.9
Yes
Nutritions provided to pregnant women by AWCs
No
60.50
39.50
Our study data shows that only 39.50 % of the respondent reported that they are getting the
regular nutrition by the Aaganwadi workers, while 60. 50 % of the respondents are not getting
any nutrition by the AWCs worker.
83
BCG Vaccinations given to infant during Institutional deliveries: - BCG) vaccine is

a vaccine primarily used against tuberculosis. In countries where tuberculosis is common one
dose is recommended in healthy babies as close to the time of birth as possible.
Fig - 4.10
Yes
BCG Vacination given to infant during Institutional deliveries
No
26.64
73.35
This is clear from our study that the women who had institutional deliveries among them only
one third of the neonatal were given BCG vaccine while 26.64% were not given BCG
vaccine.
Visit of ANM within 42 days after birth of Neonatal: - Providing basic care to newborns at
home has been identified as a critical intervention that helps in preventing newborn deaths.
However, postnatal care has not received adequate attention until recently and NFHS-III
records only a small percentage of women or children being visited by a health worker during
the first month of life. NRHM includes a comprehensive package of newborn and child health
interventions for implementation, the aim being a decisive breakthrough in neonatal, infant
and child mortality. The strategy encompasses home, community and facility level care to
reflect a "continuum of care".
WHAT ASHA DOES DURING HOME VISITS During these visits, ASHA examines the
baby, ensures warmth by wrapping the baby properly, cord care, skin care, assists in starting
breastfeeding, identifies problems if any and guides accordingly, counsels about nutrition and
rest for the mother, guides about the immunization schedule, VHND and family planning.
During each of these visits ASHA records her findings in a postnatal card. Day wise tasks
mentioned in the next table The package covers one month before expected delivery and
builds on the ANC facilitated by ASHA under JSY norms. The 8th month visit is used for
preparing the family for the birth, establishing a mutually agreeable birth plan and motivating
the mother and family members for institutional delivery. The month after birth is the critical
period for the newborn and for the mother after delivery (it is not must for ASHA to be
present during the delivery) ASHA will undertake 6-7 home visits.
HOME VISIT SCHEDULE: 1st visit (Day 1- Day of birth) 2nd visit (Day 2-3 after birth) 3rd
visit (Day 5-7 after birth) 4th visit (Day 14-17 after birth) 5th visit (Day 23-28 after birth) 6th
visit (42-45 days after birth)
84
Fig - 4.11
Visit of ANM within 42 days after birth of NeoNatal
60
40
56.73
13.79
20 4.07 10.03
7.24
0 5.64
1 Time 0.94
2 Times 1.56
3 Times
4 Times
5 Times
6 Times
7 -12 Times
Never
Visit of ANM within 42 days after birth of NeoNatal
Above graph shows that after the birth of neonatal within a gap of 42 days ASHA visited only
1 time in 4.07% families, two times in 13.79% families, 3 times in 10.03% families, four
times in7.24% families, 5 times in 5.64% families, 6 times in 0, 94 families and 12 times in
1.56 % families whereas ASHA never visited even a single time in 56.43% of the families.
First time bath to Neo-Natal: - The AWHONN Neonatal Skin Care guideline
[8]
recommends that the first bath be given between 2 and 4 h of age, after the vital signs and
temperature are stable. The World Health Organization (WHO) recommends delaying the
first bath until 6 h of age. This allows time for the infant to transition to extrauterine life with
emphasis on maternalinfant bonding and early breastfeeding.
Fig - 4.12
First time bath to Neo-Natal

74.92
80
60
44
40
11.28
20
0
First time bath to Neo-Natal
1- 5 Days
On 6 th Days
After 7 th Days
It is clear from the table that neonatal were given bath for the first time between 1- 5 days
(11.28%) while because of the customary practice maximum number of the neonatal were
given bath on sixth day -74.92% and 13. 79% of the neonatal were given bath after 7 day.
ASSESMENT OF ANMs: - Auxiliary nurse midwife, commonly known as ANM, is a

village-level female health worker in India who is known as the first contact person between
the community and the health services. ANMs are regarded as the grass-roots workers in the
health organization pyramid. Their services are considered important to provide safe and
effective care to village communities. The role may help communities achieve the targets of
national health programmes.
85
Role of the ANM: - ANMs works at health sub-centers. The sub-centre is a small village-
level institution that provides primary health care to the community. The sub-centre works
under the Primary Health Centre (PHC). Each PHC usually has around six such sub-centers.
Before the launch of the NRHM in 2005, there was provision of one ANM per sub-centre.
Later it was found that one ANM was not adequate to fulfill the health care requirements of a
village. In 2005 NRHM made provision of two ANMs (one permanent and one contractual)
for each sub-centre. The ANM is usually selected from the local village to increase
accountability. As per the Rural Health Statistics Bulletin of 2010, there were 147,069 sub-
centers functioning in India, which were increased to 152,326 in March 2014. As per recent
norms, there should be one sub-centre for population of 5,000 while in tribal and hilly area
population allotted for each sub-centre is 3,000. Under NRHM, each sub-centre gets an untied
fund of Rs 10,000 for expenditure. The ANM has a joint bank account with the Sarpanch
(head) of the village to get such funds. ANMs use untied fund for buying items needed for
sub-centre, such as blood pressure equipment, weighing machine, scales and for cleaning. The
rate of deliveries at the sub-centre level has been increased since the grant of untied funds via
NRHM.[1] ANMs are expected to be multi-purpose health workers. ANM-related work
includes maternal and child health along with family planning services, health and nutrition
education, efforts for maintaining environmental sanitation, immunization for the control of
communicable diseases, treatment of minor injuries, and first aid in emergencies and disaster
In remote areas, such as hilly and tribal areas where transport facility is likely to be poor,
ANMs are required to conduct home deliveries for women.
Relationship with ASHA:-The Accredited Social Health Activist (ASHA) is a community

health worker. Depending on the area covered by the sub-centre, each ANM is supported by
four or five ASHAs. ANMs are supposed to take weekly or fortnightly meeting with ASHAs
to review work done the last week or fortnight. ANM guides ASHAs on aspects of health
care. With the Aaganwadi Worker (AWW), the ANM acts as a resource person for the
training of ASHAs. The ANM motivates ASHAs to bring beneficiaries to the institution. The
ASHA brings pregnant women to the ANM for check-ups. She also brings married couples to
the ANM for counseling on the family planning. The ASHA brings children to immunization
sessions held by the ANM. The ASHA act as bridge between the ANM and the village the
work of the ANMs was assessed in the four blocks and one urban slum area chosen for our
study. Total 11 ANMs were found in these the selected area. Five ANMs have 5 to 7 villages,
while six ANMs have 3- 4 villages. 10 ANMs are working with 5000 to 7000 population and
one ANM is working with 5000 population. It shows that they have a large coverage. It was
found that the ANMs are over burdened and not well paid according to their workload.
At last we can say that poor socio -economic status really affects a lot o n the health
practices. Knowledge regarding the health, hygiene, periods, contraceptive and breast feeding
is very poor among this most vulnerable section of the society. Their practice habits were also
found very low.
86
CHAPTER 5 DATA ANALYSIS OF THE AAGANWADI CENTRES OF THE

STUDY
87
CHAPTER 5
DATA ANALYSIS OF THE AAGANWADI CENTRES OF THE STUDY
India is home to the largest child population in the world. According to the 2011
census, India has around 164.5 million children below the age of 6 years, constituting
13.6% of the population. Forty three percent children under 5 years of age in India are
underweight. The ICDS Scheme was launched by the Government of India in 1975, in
response to the challenge of providing pre-school education on one hand and breaking
the vicious cycle of malnutrition, morbidity and mortality on the other hand. ICDS
provides opportunities for holistic development of children and child bearing women
from vulnerable backgrounds. Even after 35 years of implementation, the success of
ICDS in tackling childhood and maternal problems remains a matter of concern. In
thepresent chapter we assess the functioning of the ICDS Programme with regard to
the services provided, in anganwadis running in the Musahars /Nats ,Chamars
community and muslim weaver community. There are total 34 Centrs in the
communities taken for our study .
PRIMARY INFORMATION ABOUT THE AAGANWADI CENTRES :-
There are total 34 centres in four blocks Harhaua ,Arajiline,Pindra ,Baragaon and in
one urban slum area Bajardiah.
Table - 5.1
Total no. of Children age 7- 36 3- 6 years Adoloscent Pregnant Lactating Mal nutrition
aganwadid centres group 0-6 months children women mothers children
month children
34 385 1729 1591 2399 313 375 299
88
Registration and Attendance of Beneficiaries:- While 3,705 children 0-6 years old were
registered in the 34 AWCs, only 11.3% were found to be attending the Center. Attendance of
the 0-1 year old was 3.4%, of the 1-3 years old 8.4% and of the 3-6 years old 15.9%. The total
number of pregnant women, lactating mothers was 688 and adolescent girls registered were ,
2399, respectively, but none of them were found present in any of the AWCs.
Infrastructure:- Out of 34 AWCs studied, all are in scarcity of resources.Out of 34 AWCs 7
are functioning in rented rooms and 1 in a school building 4 centers are running in Panchayat
Bhawan and 8 centers are running in open place .How can these centers work in adverse
weather like cold and rainy season.
Fig -5.1
10 8
7 AWCs Operational Place
1 1 7
2 4
0 1 1 2
SITTING AARRANGEMENT OF CHILDREN IN AWCs :-

We saw during our study that in 28 centres children sit on the grain bags, which is the worst
condition . In three centres children sit on the mats provided by the department while children
sit on table chair in ayar khas harhaua block which is adopted by the District Magistrate.
Children in musahar ayar community also sit on table chair given by PVCHR.
Fig - 5.2
Sitting arrangment for

28 children in 34 AWCs
30
25
20
15
10
5 3
3
0
Sitting on
Sitting on
Grains Bag Tables &
Jute Mats
Chairs
UTENSILS FOR HOT COOK IN THE AAGANWADI CENTRE :- Among 34 centres

only 9 centres have utensils to cook while rest 25 centres dont have any arrangement for hot
cook.The workers told us that either they cook at their home and bring it with them or bring
heuntelsis from home.they reorted that they have not got any utensils for hot cook.
89
Fig - 5.3
Availabilty of Utensil to cook hot food
30 25
20
9
10
Utensil available
Utensil not
available
List of the centers who dont have utensils for hot cook :-
Block Village Worker's name

Badagaon Lakhmipur Seema Devi
Badagaon Kuwar Sushila Devi
Badagaon Chiria Sanju Devi
Badagaon Chiria Sanju Devi
Pindra Rajetara Reena Devi
Pindra Dallipur Reeta Devi
Pindra Ramaipur Raj Kumari
Pindra Saraimughal Premlata
Pindra Ramaipatti Gayatri Devi
Pindra Raitara Anita Devi
Pindra Kharuapar Vijay Laksmi
Pindra Mirashah Meena Kumari
Pindra Aayar Urmila Singh
Pindra Aayar Urmila Singh
Pindra Maithauli Shipra Singh
Pindra Puarikhurd Meera Srivatava
Pindra Puarikhurd Anju Prabha
Pindra Puarikhurd Urmila Pandey
Pindra Puarikhurd Durgawati Devi
Bajardiah Bajardiah Hansa Devi
Bajardiah Bajardiah Jyoti Mishra
Bajardiah Bajardiah Mamta mishra
Harhaua Puarikala Pushpa Singh
Harhaua Puarikala Mansa Devi
Harhaua Puarikala Sheela Devi
AVAILABILITY OF PLATES /BOWL TO EAT SUPPLIMENTARY NUTRITION:-

Eleven centers dont have any facility of plates or bowl to eat hot cook nutrients by the
children. Another 23 centers have Tiffin's but they are not in sufficient numbers so they are
not used by the workers .In all the centers children bring their plates or bowl from their home
to eat hot cook. Those centers are who dont avail this facility are
Badagaon Lakhmipur Seema devi
Badagaon Kuwar Sushila devi
Badagaon Chiria Sanju devi
Pindra Aayar Poonam jaiswal
Pindra Aayar Urmila singh
Pindra Maithauli Urmial singh
Harhaua Puarikala Shipra singh
Harhaua Puarikala Anju prabha
Bajardiah Bajardiah Hansa devi
90
Fig - 5.4
23 Plates / Bowl for children
25
20
11
15
10
Plates avaliable for children
Plates not avaliable for children
SAFE DRINKING WATER FACILITY :-

There is no availability of safe drinking water in the centers .only two centers have
RO water the machine is donated by HDFC bank. In 26 centers children drink water
from nearby hand pump. On one centre well water is used to drink water. There is no
facility of drinking water in harhaua blocks kakhari and khasera centers in a Chamar
community.
Fig - 5.5
40
26
Drinking water facilties in AWCs
20
2
0 2
0 2
1
WEIGHING MACHINE :-
On 20 centre the machine is available and in working conditions rest of the centers dont have
weighing machine. So how do the workers weigh the children it is a matter of concern.
Centers where weighing machine is not available.
91
Fig - 5.6
20
Weighing Machine availabilty
20
14
15
10
Yes
No
Block Village Worker's

name
Badagaon Lakhmipur Sona devi
Badagaon Ramaipatti Sanju devi
Badagaon Ramaipatti Usha devi
Badagaon Aayar Gayatri devi
Badagaon Aayar Poonam
jaiswal
Badagaon Aayar Urmila singh
Badagaon Maithauli Shipra singh
Badagaon Puarikala Shruti
Badagaon Puarikala Hansa devi
Bajardiah Bajardiah Pushpa singh
Harhaua Puarikala Mansa devi
Harhaua Puarikala Sheela singh
Harhaua Puarikala Sona devi
Pindra Sobrana nat Sanju devi
basti
Pindra Kuwar Sanju devi
priti sharma
Pindra Sajoi Priti sharma
Pindra Parmanandpur Geeta devi
GOWTH CHART
There were positive remarks here, 30 of the centers have growth charts but the records and registers
were not regularly maintained in any AWC. Only four centers dont have growth charts .
Fig - 5.7
Avialablity of growth chart & Measuring tape
30
30
25
20
15
10 4
5
0
Yes
No
92
Centers who dont have growth chart :-

Badagaon Lakhmipur Sona devi
Badagaon Sobernanat Priti sharma
basti
None of the AWCs were monitoring the growth of the children. The AWCs did not have
Salters scales and the AWWs did not know how to weigh children using this scale. Only
55.6% knew how to plot the weight on the growth chart. The growth chart registers were
available in some AWCs but they were not maintained here the condition is reverse only 4
centers have measuring tape to measure the height of the children. It is really a matter to
discuss this issue that how the worker see the weight height and growth of the children
without use of these measuring tape and weighing machine.
REFFERAL SLIP
ONLY 13 of the AWCs had referral slips and rest of the centers dont have referral slip.
Fig - 5.8
Referal Slip / Yellow parchi
30
21
20 13
10
0
Yes
No
MEDICINE KIT
Only 2 AWCs dont have complete medicine kits. In all the AWCs the nutrition and health education training
material was available but used only in four AWCs. None of the AWCs had Salters scales. Consequently, while
all the AWCs had Growth Chart Registers, none of them maintained growth monitoring of the children. All the
AWCs had playing kits for the children. Supplementary nutrition was provided to the children for 24 days (average
for all 34AWCs studied) in the last one month in which it was given. Monthly medical check-up was done in 4
AWCs (44.4%) by the Auxiliary Nurse Midwives (ANMs) of the nearby health Centers .
93
Fig - 5.9
Medicine Kit
Iron pills / Worm pills
Use of Towel/ soap / Mirror
30 Toilet facilties
26
26
35 33 Kichen
32 31 33
30
30 Pre primary kit
Nutrition & Health education kit

25
Nutrition & Health education kit
20
15 8
8
4
10
4
1
5 1
3
0
Yes 2
No
Nutritional Status:- The Growth Chart used for growth monitoring in the ICDS
Programme is till 5 years of age. Because of this limitation, the nutritional status of 4 children
aged 5-6 years present in the AWCs could not be assessed. Only 28.1% of the children were
in the green zone (road-to-health), 30.3% in the yellow zone and 41.6% in the orange zone
(severe malnutrition). 26.8% of the boys and 29.2% of the girls were in the green zone; 26.8%
of the boys and 33.3% of the girls were in the yellow zone; 46.4% of the boys and 37.5% of
the girls were in the orange zone (p = 0.681). All 4 infants attending the AWC were in the
orange zone. In the 12-35 months old, 51.9% were in the green zone, 29.6% in the yellow
zone and 18.5% in the orange zone. In the >35 months old, 18.9% were in the green zone,
32.8% in the yellow zone and 48.3% in the orange zone (p = 0.002).
Supplementary Nutrition:- The ration for the supplementary nutrition was provided to the
AWCs by the supervisor of that area, who did not have any criteria to select the beneficiaries.
The present studyshows that no standard measure was used to distribute the food to the
children. In some AWCs due to lack of sufficient utensils, the AWW had to prepare the food
at her house and then bring it to the center. Double diet is to be provided to the malnourished
children according to the Programme guidelines, but this was not practised in the AWCs
under study.
Health Services:- None of the AWCs had any record of the immunization status of the
children. The children of 3 1out of the 34 AWCs were dewormed and provided Iron-folate
tablets, but none of the AWCs provided vitamin-A supplements to the children because of
lack of supply. Regular monthly health check-up of the children was done in 14 AWCs by the
ANMs of the nearby dispensary/health center. However, referral forms were not available.
94
Health Education:- Only 4 out of 34 AWCs organized meetings with mothers and pregnant
women of their AWC area but not on a regular basis. Immunization and antenatal care were
usually the topics of discussion.
Pre-school education:- Most of the AWCs had pre-school timetable but none of them
followed it. They had charts and pre-school education materials like slate and books but none
of them made any use of them. In some AWCs, the AWWs taught alphabets and rhymes but
most of the time the children were kept engaged with the toys and no pre-school education
was imparted. The knowledge of workers regarding child care components was minimal.
None of the AWWs knew about the calorie and protein requirement of children, and to whom
the therapeutic diet should be given. Seventy-five percent knew that exclusive breast feeding
should be given till 6 months of age.
So this is a matter of concern when the workers themselves dont have knowledge about
reproductive health, nutrition, protein then how they will provide good health services to the
exceptionally marginalized Communities
95
CHAPTER 6 FOCUS GROUP DISCUSSION AND CASE

STUDY
96
CHAPTER 6
FOCUS GROUP DISCUSSION AND CASE STUDY
To support and supplement data generated through secondary sources and questionnaire for
the purpose of our study the Research Team organized Focus Group Discussion with selected
members of the community . The intention was to bring out qualitative information that
cannot be fully reflected through interview schedule is not adequately deal with the available
secondary literature a Focus Group Discussion was conducted in each catchment area of those
communities which were selected for the study the question wwhich were included in the
FGD( Focus Group Disscussion) .
1. What does Healthy mean?
What does health mean to you?
What (if any) is the difference between looking healthy and being healthy? What would you
tell someone else about being healthy or staying healthy?
2. Preventative Health Behaviors
What things do you know you should do to stay healthy? [Make a list on flipchart
{sometimes dental health is overlooked}]
What are some things you know you should do to stay healthy but you dont?
What would motivate you to practice some of those healthier behaviors?
3 Preventative Health Care Services
How often/when should people go to the doctor?
What makes you go to the clinic/doctor? [Probe: ask about well visits]
What things prevent you from going to a doctor? [Probes: money, transportation, fear,
communication problems, lack of respect from doctor/nurses/staff, family members,
motivation, feelings, etc.]
4 Family, Friends and Relationships
How do your relationships influence or affect your health? [probe: domestic violence]
5 Pregnancy and Reproductive Health what does the term healthy pregnancy mean to
you?
NUMBER OF PARTICIPANTS AND BLOCKS IN FOCUS GROUP
DISCUSSION:
SUMMARY OF TOPICS AND FINDINGS WHAT DOES HEALTHY MEAN
What does health mean to you?
Most groups had similar ideas of what healthy meant to them.
Many groups talked about being healthy in mmean sonly, physical, well being . They said
when they get ill or deliver a child that is only health. None of the group was aware of
physical mental and social well being.
What would you tell someone else about being healthy or staying healthy?
97
Health advice varied among the groups. However, there were a few pieces of advice that
groups agreed upon. Consensus from across several groups included: stop (or do not start)
smoking, eat right, and the overal l importance of becoming or staying healthy.
One group was very focused on food and health and making sure people knew about the
importance of good food . They said ACCHA KHAYO, HAME SAWASTHYA REHNA
ZARURI HAI WARNA KAAM KAISE KARENGE
PREVENTIVE HEALTH BEHAVIORS:-
What things do you know you should do to stay healthy?
The overwhelming majority of groups stated that eating right and as well as brushing your
teeth.
Some focus group members also mentioned washing your hands, taking prescription
medicines
What would motivate you to practice some of those healthier behaviors?
Time constraints, lack of money or health insurance, and outside stressors were barriers for all
women, both with and without children. For women with children, being an example for their
children was an important motivator, but again the issue of the cost of healthy living, no day
care, no money. grandmothers included drinking water, drinking milk, taking care of your
body, and practicing safe sex.
HEALTH INFORMATION AND ADVICE: -
Who do you rely on for advice about your health?
In several groups, many women indicated that they look to their husband or significant other
for advice or information about health or health care. Most groups also mentioned personally
(their mom or grandma, other family, friends, one participant stated they were more likely to
talk to family first because they were afraid the doctor doesnt really listen
PREVENTIVE HEALTH CARE SERVICES:-
Where do you get your health care? when they were asked where do they go for health check
up most of the women said that they don't go anywhere in Musahar community they prefer
homemade remedy or go for jhaad phunk Chamar women prefer to go local doctor of their
community, In several groups women stated that their providers dont listen to them, dont
spend enough time with them, and create an assembly line feeling. The issue of no
continuity of care (no medical home) also came up in one group of low income mothers,
which was frustrating to them and contributed to their feelings of not being listened to and not
being respected. There were some women across several groups who said nothing.Women
also said that they spend a huge amount of their earning on health problems.
Do they go to PHC OR CHC OR SUBCENTRES?
Some women from the group said that they have visited a PHC or health sub centre from
the Chamar community but our discussion from Musahar community came to the conclusion
that they never visit to any health sub centre or PHC. Among Muslim weaver they prefer to
visit a local doctor because there is any doctor available in the sub centre.
FAMILY, FRIENDS, AND RELATIONSHIPS:-
How do your relationships influence or affect your health?
98
The majority of the groups discussed the negative impact family, friends, and other
relationships have on your health. A few groups and some individual women in more negative
groups were positive about the impact of relationships on their health or mentioned positive
examples, as well as, negative. However, the overwhelming response to this question was
negative.
Domestic violence was mentioned in some groups as part of a relationship that negatively
impacts your health; one woman said a stressful relationship made my chest hurt. Among
those positive responses to the question, women mentioned family or spousal support to stay
healthy or fit, motivation that 11 can come from a supportive relationship to care for your
health, and that if your relationships are good then it reflects good on my health. IN
maximum of the cases women are victim of domestic violence and no one from family or
neighborhood come to save them. So they don't believe on relationships
When asked why women generally do not report any type of violence by their husband to the
authorities, one woman from a Dalit community said We are scared that if we go to the
police, our husbands will leave us. Mamta, who had suffered abuse from her husband,
explained the difficulty of going to the police: I would prefer not to cause a scandal by
reporting to the police. I have so many kids. I could go to the police but only if I leave my
husband and my kids.Women human rights defenders working to assist survivors of violence
have also faced threats, harassment and violence because of their work and an ineffective
response from the police.
PREGNANCY AND REPRODUCTIVE HEALTH:-
What does the term healthy pregnancy mean to you?
Among the groups of younger women , the most common response was unknown about
pregnancy - scared to admit I was pregnant, not knowing about pregnancy until several
months after conception, and then after that nothing. For other women in the focus groups,
the issue of health care and money for care.In all the groups none of the female know what is
a healthy pregnancy , neither they take care during pregnancy. Although they know how to
take care during pregnancy still because of low economic condition they have to work during
pregnancy and don't have money for proper treatment
. My father-in-law and mother-in-law eat first. Then all the other male family members eat
and then the women eat last.
Did pregnancy make you think differently about your health?

In all the groups women said they know they are bearing a child but they can't think
differently and take pregnancy as no difference in their diet or habits or work. Pregnancy is a
routine work for them.
DID THEY VISIT TO THE DOCTOR DURING PREGNANCY?
Some women from Chamar and Muslim community visit the local doctor during pregnancy.
MUSHAR group female never visit to any doctor. Groups from Muslim community and
Musahars said that no ANM or ASHA ever visited them during pregnancy. Some women
brought up the issue of un touch ability and religious feeling .Some women during group
discussion said that they had a BP test and weight check during pregnancy but majority
99
women have no idea about it. Some of the women had tetanus vaccine during pregnancy
while majority of the groups don't know about it. One group women talked about the Folic
acid tablets. But maximum women don't know about it
Women participating in focus group discussions told Amnesty PVCHR that the majority of
women they know give birth at home with untrained helpers (usually Traditional Birth
Attendants or older women from the local area). Although government data over a period of
time shows that increasing numbers of Indian women give birth in health facilities (hospital
or birthing centre) assisted by skilled birth attendants butmore than half of Indian women
still do not give birth with a skilled assistant.The Dalit women participating in the focus group
discussion in harhaua told pvchr that most of them had given birth to their children in the
insanitary conditions of the cowshed without a skilled birth attendant although a few had gone
to the district hospital with the help of ASHA..
How long should women wait before having another baby? Why?
The majority of groups had no consensus about the length of time to wait before having
another baby. Only one woman stated a shorter interval 6 weeks, and one woman said 1-2
years. Among Muslim weavers two women brought up the issue of being able to afford
another child as a motivation to space children. But maximum women believe that they can't
take decision in this issue. In some group women said ye to bhagwaan ki den hain how can
we tell you Women often do not have control over the amount of time between when they
give birth and when they have sexual intercourse with their husband. A woman living in
Muslim district who spoke to PVCHR about her experience of uunwanted pregnancy said
that after the birth of each of her children, the amount of time before she resumed sexual
relations with her husband varied between one week (when her husband was at home) and
one month (when he was away). Dalit women from the Mushahar community in arajiline told
JANMITRA NYAS that it was very common for husbands to beat their wives. They said
husbands insisting on sex was the reason behind the violence in our community;
husbands force us to have sex and women were beaten by their husbands if they tried to
refuse.
USE OF CONTRACEPTIVE METHODS:-
The majority of the women interviewed both in focus group discussions and individually, said
that they and their husbands had never used any form of contraception. The younger women
who participated in focus group discussions were more likely to be using contraception or
have used it at some point in the past than the older women. Laxmi Tamang, the coordinator
of a network of mothers groups in Ramechhap district said Earlier women had many
children (6-12), but now things have changed. Mothers groups and Female Community
Health Volunteers have increased awareness and women now use contraceptives. So women
in their 30s and 40s now have smaller families.
100
INFANT HEALTH:-
About breastfeeding
although most women felt it was healthy for the child. Some women reported hearing it was
painful ALL the women in all group discussions do breastfeeding but they are not much
aware about its benefit like spacing in the two birth . They even don't know the how to take
proper care of the children. Some women have knowledge about the right position to feed the
child. Some women raise the issue of Weaning.
DO THEY IMMUNIZE THEIR CHILDREN REGULARY?

Among the entire group women raise the issue that they don't know the importance of
immunization, they don't have time to take their children to get immunize, some women think
that immunization have side effect on the children.
WORK AFTER DELIVERY:-
They told they have to go to work immediately after delivery to the work. Musahar and Nat
women told that they never follow the 40 days post delivery period .They go to back work
immediately within a week to work .But in Muslims and some Chamar follow this 40 days
period. Musahar women group said they face lots of problem due to this they even have to
carry heavy loads soon after pregnancy. Due to this they have lots of reproductive tract
diseases but feel shy to discuss these with someone some women said they even face
domestic violence soon within a week of delivery. But now they feel they can discuss this
with some NGOs people and they can help them. Lifting heavy objects and carrying heavy
loads can strain the pelvic muscles particularly during pregnancy and soon after women give
birth.
101
DID THEY FACE ABORTION?

During the discussion women discussed that they face abortions. But maximum women get it
done through some of their own community untrained Dais. They rely more on their local
traditional methods and people, as one 30 year old woman narrated .After three girl
children, when I conceived again I was afraid that this might also be a girl. Even that did not
bother me as much as my husbands obscene remarks about my sexuality. For this reason,
every time I got pregnant I tried to commit suicide. But this time I decided to abort the foetus.
But ther Dai advised me against the abortion, as it was too late to have it. So, I threatened the
her saying that I would commit suicide right inside her , if she did not perform the abortion.
I also requested her lot .Only then she agreed and aborted the foetus. But it turned out to be a
male child. Still there was a pleasure in the abortion, as this time my husband could not
suspect the child and me.
All the women reported that they faces lots of problems like vaginal pain during urination,
abdomen pain , irregular periods , heavy bleeding , but they never take it serious and take it
as a matter of women health.
According to the World Health Organization (WHO), every 8 minutes a woman in a
developing nation will die of complications arising from an unsafe abortion. An unsafe
abortion is defined as a procedure for terminating an unintended pregnancy carried out either
by persons lacking the necessary skills or in an environment that does not conform to minimal
medical standards, or both.1 The fifth United Nations Millennium Development Goal
recommends a 75% reduction in maternal mortality by 2015. WHO deems unsafe abortion
one of the easiest preventable causes of maternal mortality and a staggering public health
issue.
SEXUAL EXPLOITATION OF THE WOMEN

During the discussion women from Musahars community even discuss in group that they get
physically exploited by the brick kin contractor, their husband even knows about it but they
never help their women due to the fear of losing home and work. They were not aware about
RTI through unsafe sex and multiple sex partners.
Position of Aaganwadi centre
WHILE DISCUSSING ABOUT THE CHILDREN HEALTH AND AAGANWADI CENTRE
ALL THE WOMEN SAID THERE IS LACK OF RESOURCES IN THE CENTRES.
AAGANWADI WORKERS ARE ALSO NOT SERIOUS ABOUT THEIR WORK.
WOMEN SAID CHILDREN DONT GET NUTRITION FOOD AT TIME; THERE IS NO
AVAILABILITY OF SAFE DRINKING WATER. SOME WOMEN RAISE THE ISSUE OF
NON AVAILABILITY OF MEDICINE KIT IN THE CENTRES.
I gave birth to my first daughter and after six days, I went to bring millet from the farm. I
was carrying the load of millet and I felt that something was coming out [of my vagina] My
husband treated me indifferently. He used to say: I am not satisfied with you, I will bring
another wife .
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Case study of Mal-Nutrition child
Date of survey 28-08-2016 Name of child Deepak

Post Ramaipur, musahars basti Sex Male
Gram panchayat Pindra vikas khand pindra Dob 18-11-14
District Varanasi State UP
Nutrition mapping of child

Month /year Nutrition Age Weight Grade
Mapping date Year Kg
June 2016 20-06-16 1 7.500 Serious
July 2016 06-07-16 1.8 7.200 Serious
August 2016 23-08-16 1.9 7.00 Serious
Name of father Rinku Name of Mother Geeta

Age 22 year Age 22 year
Caste Mushar Dob 18-11-14
Age at the time of 15 year Age at the time of 14year

marriage marriage
Name of alive child 1. Govind Age of children (1) 4 year
2. Deepak (2) 1.9 year
Service provided By ICDS: only sometimes helper come in the village and when she
comes all children go there. Deepak is malnutrition for few months but ICDS employs never
visit their home for their regular survey and they did not give any suggestions for the
nutrition. Deepak get their nutrition only two times in a months.
Vaccination:-
Date of Vaccination Name of vaccine
19-11-14 BCG Hepatitis BO polio O

01-07-15 DPT 1 hepatitis B polio 1
02-09-15 DPT 2 Hepatitis B2 polio 2
01-10-15 DPT 3 Hepatitis B3 polio3
07-10-15 Kashara
07-10-15 vitaminA
Rashan card:- They have patra cinshiti card in which 3 units are mentioned and 15 kg grains
are given by authority .There are 4 unit and 1unit are left. This amount of ration is insufficient
for the family.
MANREGA job card- since last 8month they are working in bricking they got their salary
from the place where they work. After that they work as a labour for 4 month it they dont it
have work they sit at home. They get less then 100rs for per day and their monthly income in
2000rs. Whole family helps in their husbands work.
Symptoms of Mal nutrition in child:-
1. Hairs are brown
2. Stomach has come outside
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3. Generally the weight and height is not according to the age.

Pension in family: in the family there is no sources of ppension
Housing in family:-- They lives in very poor conditions during the rainy season rain drops
come from the roof.. They cover the boundaries of their hut with bunches and the door of the
hut is made by the curtains. There living conditions are very inhuman and unhygienic.
Name of the surveyor Name of responding

Vinod kumar Geeta
Case study of Mal-Nutrition child

Date of survey 28-08-2016 Name of child Durga
Post tola- khruapur mushar basti Sex Female
Gram panchayat panchayat or vikas khand Dob 30-09 -2014
pindra
District Varanasi State UP
Nutrition mapping of child
Month /year Nutrition Mapping Age Weight Grade
date Year Kg
June 2016 23-06-2016 1.8 6.200 Serious
July 2016 05 -07-2016 1.9 6.400 Serious
August 2016 26-08-2016 1.10 6.800 Serious
Name of father Gabber Name of Mother Meena devi

Age 37 year Age 35 year
Caste Mushar Dob 30-09 -2014
Age at the time of 16 year Age at the time of 15year
marriage marriage
Name of alive child 1. Vijaya Kumar Age of children (1) 17 year
2. Nandani (2) 4 year
3. Durga (3) 1.1 year
Real service given by Aganwadi:- Durga is admitted in aganwadi centre she here full
nutrition food in one month. Aganwadi employer didt visit home regularly and neither
gives the suggestion related to nutrition They give the food items but dint get proper
Nutrition They give the food items but never gives the suggestion how to eat that food
materials
Vaccinations :-
Date of vaccination Name of vaccination

22-10-2014 B.C.G.
06-06-2015 D.P.T.1
04-07-2015 D.P.T.2
RASHAN CARD:-- Antodaya rashan card is in the family in which 4unit is present and in
family, there are 5 unit . rashan is given on rashan card which is not sufficient for one month.
Manarega job card:- In family making in job card is due to MANREGA job in which total
working days is 11 in month of July and august the salary has not been distributed till now
Condition of income in family:- -since last 8 month family is doing the work of bricking
and in month of july they come at home . During this period which they got dihadi majduri
and in one month their income is from 1200 -2000 Rs. which is too low.
SYMPTOMS OF MAL NUTRITION CHILD :-
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1- CHILD IS LAZY
2- SIZE OF CHILD HAND AND LEG ARE THIN
3- CHILD OF STOMACH HAS COME OUTSIDE
4- HAIR ARE THIN AND BROWN
Pension get by the FAMILY- s amajwadi pension is given in family
Housing of the family gabber made his own hut and live in this hut with his children. He
didnt get any profit from Aawas yojana or any other yojna by the government.
Name of surveyor respondent

Sanjay kumar Gabber
CASE STUDY
Abdul Khaliq was a master in the art of weaving the famous Banarasi Sari. He was living
with his family in a rented house in Jakhwa Uncha mohalla in the same Bazardiha region.
Abdul Khaliq has a family of six members including his wife Nazra Khatoon (35 years)
with daughters; eldest one Nasira Parveen, age 18 years, Nazia Parveen age 16 years,
Shamina Parveen age 14 years, Shahina Parveen age 12 years, Shaba Parveen age 7 years
and the only son Mohammad Murtaza age 3.5 years. Of late two years back, 7 year old
Shaba Parveen was the first daughter who died. After that Abdul Khaliq died 10 months
back and now on 9th May, 2013 on the mid night around 2 a.m Mohammad Murtaza had
his last breath and the very next day morning around 10 am, 14 year old Shahina Parveen
died due to insufficient food.
Abdul Khaliq barely managed to earn 40 to 50 rupees after putting his hard labour in
weaving work. His wife Nazra Khatoon and eldest daughter Nasira Khatoon used to earn a
little bit by doing aari and sari cutting work. It was a period of economic decline but
somehow the family managed to survive. But after the death of Abdul Khaliq, the sole
bread winner of the family, the hopes of the whole family were broken. The family once
had an above poverty line only and never got any benefits of any government schemes. The
family neither had a weaver identity card nor had the health insurance card under the
Lombard Scheme being run for the health of the weaving community. Young children of
the family were not associated with the Integrated Child Development Scheme (ICDS).
Even after the untimely death of the sole family bread winner, Nazra Khatoon, widow of
the deceased did not get any help from National Family Help scheme. She even did not
receive any benefit under the widow pension scheme.
After the death of her husband and three children within a span of two years, Nazara
Khatoons world is totally broken and she is left with no physical and mental strength to be
able to speak to anyone about it. Her eldest daughter Nasira Parveen, who is married now,
narrated her story to us, Our family is very poor. My father used to work hard and was
105
able to earn 40 to 50 rupees and sometimes 100 rupees. Till I was not married, I and my
mother used to do sari cutting and other artisan work and we were able to earn 10 to 20
rupees. But after my marriage and death of my father 10 months back, the conditions in the
family further deteriorated. We never had a chance to eat full meal with such a meager
earning. If we eat in day time, we could not eat during the night and if we ate in the night
then we never had food in day time. I do not remember a time when our family had a full
proper meal. My father, my two sisters and my only brother, all died due to insufficient food
and acute hunger. When we do not eat, we will naturally be weak and sick. If there is no
food in the stomach, how is the medicine going to affect? My father often used to fall sick
and he was not able to earn enough. When my father was alive, many people told us to get
below poverty line card (Antyodaya Card) and health insurance card for medical treatment,
we went to many places for that but no one came to help us. As a result he could not get his
card and he did get any help from the government. We do not have our own house. We live
in a rented house for which we have to pay 600 rupees as rent. We have not been able to
pay the rent for the last 6 months. Here we neither have Aaganwadi facilities for the young
children nor do we have any medical facilities. My mother does the work of making
mattresses by taking old clothes in the neighborhood localities. She gets 50 to 100 rupees by
making the mattresses. It takes 4 to 5 days to prepare the mattress. We know artisan work
but after the death of my father it is very difficult to get work from outside. Whatever little
work we got, my mother and sisters were managing their lives with that. This had gradually
put a negative impact on their health and their bodies began to deteriorate slowly. They
became weak and often started falling sick. Because of physical weakness, they found it
difficult to work properly. My brother Murtaza and sister Shamina Parveen had been sick
for the last many days. Their intestines were getting dried up due to insufficient food, they
had lost all their body flesh and they were looking as if their skeletons had been covered
with layers of skin. If we were not able to earn anything any day, we used to look for others
to give us something to eat. Mother Nazra got my sick brother admitted in Kaudia Hospital
(Ram Krishna Mission Trust Hospital) for treatment but he was not given proper treatment
there. In the hospital the family was not treated well and they did not give any advice for
the treatment. We were referred to go to BHU for treatment but we did not have money to
go there so we came back to our house. Whatever little money we could arrange from
others, we had spent in this period. We were in no position to ask further monetary help.
Moreover, our neighbours were not rich enough to help us all the time as they had to run
their families with their little earnings.
After the painful deaths of two children in the family, the SDM reached the spot only after
4 pm in the evening to assess the situation. In the morning regional officer of the Epidemic
Cell, Mr.Gulam Shabbir visited the house and gave some medicines for the prevention of
infection from water, stomach pain and some chlorine tablets. While one member of the
family, Nazia Parveen had high fever at that time but they did not consider it important to
give medicine to get relief. When the regional officer was contacted on phone by a member
of PVCHR in this regard, he replied that while coming from CMOs office, he would
deliver the medicines. After 2 pm in the afternoon, the social activists of PVCHR took
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Nazia to a private hospital nearby for the treatment where on the advice of the doctor, X-
Ray and blood tests of Nazia were done. Nazia had been complaining of high fever and
cough. On the basis of doctors prescription Nazia was given paracetamol, anti-biotic and
energy related medicines.
Despite the existence of various government schemes to help the poor, the district
administration acted so late. By 14th of May, widow of Abdul Khaliq, Nazra Khatoon was
provided a BPL card (Antyodaya ration card), Weaver Card, House under Kashi Ram
Aawas scheme, one quintal wheat, one quintal of rice and 25 liters of Kerosine. The
tragedy is that Nazia Khatoon got all this when she had already lost her husband and three
children forever.
At first I didnt tell anyone. But later, I started to attend trainings and meetings
[run by NGOs]. I came to know that I can share my experiences and pain with
other women. So after that I told someone about my problem.
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CHAPTER 7 Conclusion & Suggestion and Further Plan
109
CHAPTER 7
Conclusion & Suggestion and Further Plan
State governments has designed and implemented many maternal health interventions in a
very good way but due to lack of proper monitoring expected results have not been achieved.
ASHA, AWW & ANM, the three field based facilitators, are working in the same
geographical area but many times their mutual coordination is not good and that is why
quality of services comes down sometimes. To improve IMR and MMR in up, first step
should be to establish better coordination among these field staffs and it is very sure, if they
start working as a team many problem and barriers can be removed very easily. This research
find the awareness is a major issue in low performing districts and efforts should be there to
start a massive campaign through electronic media, print media, folk songs and debates in
schools and panchayat meetings . It is clear from the study that Gender has played a lead role
during specific situation such as decision making for place of delivery, behavior of patient,
knowledge of husbands of pregnant women about health of her wife and others. It is
recommended to focus more on husband and mother in laws of pregnant women during
designing BCC campaigns. Government is providing all facilities free of cost and gender
barriers should not come in way of availing these facilities. In South Africa, involving men as
partners in maternity care and in couples counseling resulted in greater numbers of men
assisting their partners in emergency situations. Communication between couples on topics
such as sexually transmitted infections and sexual relations also improved. Under NRHM it is
mandated that association of PRI members through Village health Sanitation and nutrition
committee will participate in health intervention at grassroots level but due to lack of
monitoring by authorities this committee is also not working properly. Vision of NRHM is to
empower the PRIs at each level i.e. Gram Panchayat, Panchayat Samiti (Block) and Zilla
Parishad (District) to take leadership to control and manage the public health infrastructure at
district and sub district levels. This is actually not happening in UP currently still provisions
are there but only formalities are being completed at every level. To build awareness among
men regarding womens health issues effective PRI support is very much needed. Research
showed High performing d districts have performed better mainly because of good awareness
campaigns So UP government should think about ways and means to increase awareness in
remote districts for decreasing the IMR and MMR ratio to achieve the 4&5 MDGs in given
time period. Some below mentioned aspects also have major importance and have been
discussed with reference of study conducted in field.
1. Increasing Awareness age of marriage:-

Age at marriage in low performing districts and high performing districts is almost in similar
trend. Pregnancy in low age is itself a danger sign. Under age pregnancy causes maternal
death and infant death. Its suggested that in revised strategy NRHM should also focus on this
issue and under BCC activity they should plan different type of spots on spreading this
message. This issue is very serious and critical because though we have all facility for safe
delivery in institutions but if mother happens to be weak and under age, risk of maternal death
is always there.
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2. Advice of ANC & PNC:-

ASHA workers are working in efficient way in taking pregnant women to institutional
delivery only. Community linkage and Care during pregnancy and after delivery is not done
properly. We cannot achieve our aim to reduce IMR and MMR without this and it is
suggested that ASHA should more emphasis on antenatal and post natal care. ASHA worker
if focus on first ANC and give all messages, full ANC done scenario can be achieved. When a
pregnant women comes at session site for first ANC service providers should convince her for
coming twice and thrice visits. After delivery ASHA worker have to visit again to new born
in first week for PNC and suggest for new born care. It has been found that very few health
workers are going to respondents home after delivery of babies. ASHA worker should be
sensitized on this aspect and asked to visit respondents home for providing suggestions on
PNC and new born care.
3. Awareness on TT Vaccination & IFA consumption in low performing Districts:-

TT vaccination and IFA consumption are very low in low performing districts. This shows
that awareness among people living in high performing districts is good enough and
respondents know the importance of TT vaccination. Research suggests that we must do some
special efforts in low performing districts for spreading awareness on this issue. If people are
aware about importance of vaccination they will come forward and load of ASHA workers
and other service providers will be reduced.
4. Effective logistic support:-

There are enormous logistic problem like perennial shortage of medicine, non-availability of
proper equipments, storage facilities at sub Centre. At the time of emergency in pregnancy
people rush to nearby facilities. It observed in low performing districts they taken pregnant
women to quack in emergency situation. They increase problems and charge too much from
rural people. Respondents rush to quack in emergency situation because they dont have faith
in government health services and also due to non-availability of services in sub centers.
Effective logistic support will enable the building of community confidence in health
services.
5. Effective Monitoring system:-

Supervision of MPW/LHV needs to be strengthened as supervision is considered the
connection between PHC and the grass-root workers. Actually current supervision system has
many loopholes. At VHND day Supervision done in two way, first relates with vaccine
carrier drop and pickup work done one person at session site who ensure delivery of vaccine
carrier to ANM and LHV/MPW and second health staff visits village during VHND day. Due
to distance and having more official work, senior officers have not done supervisory visit on
that day. They only have completed the formalities by visiting road side and nearby sub
centers from the hospitals. Mostly vaccine carrier received by ASHA worker will be
deposited with report at the end of day. Monitoring system should be revised and a software
system will include who also showed the option for field visits plan for senior supervisors and
MPW/LHV should monitor by village head and VHSC members .MPW/LHV will submit
their report signed by at least two beneficiaries along with village head and VHSC members.
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6. Transport Facilities for beneficiary: - Most of the time villagers rush to PHC/CHC at the
last stage of pregnancy in emergency situation. When lower pain started only then villagers
rush to the hospitals. Most of the time villages not having public transport system and in this
case arranging a transport facility takes a lot time which is very crucial for pregnant women.
If some Transport facilities remain available at the nearby hospitals to be used in this
situation, it will save the life of mother and will increase institutional delivery also. State of
Madhya Pradesh have introduced the facility of Janani express under which private vehicles
remain available within hospitals and on beneficiary request hospital sent vehicles in the
particular village and all expenditure is borne under provision of JSY. This is such a good
scheme and by this scheme safe delivery percentage has increased in MP. This type of
scheme should be introduced in UP also.
7. Linkage between Community and PHC: -

There are very poor linkages between the PHC and the Community. Research has proved that
hospital staff including Doctors behavior is not good towards the beneficiary. The staff rarely
fined any time to visit the community and diagnose its problems to ascertain their needs. To
build linkage between communities to PHC, it is suggested that the PHC staff must visit
community once a week to provide health education through well-arranged lectures in school
building / panchayat ghars or exhibitions. If Hospital staff starts visiting villages they will
understand problems and also can solve this as per need of villagers. This is a need of
courteous behaviors with the patients who are already troubled with their sufferings. Village
Health and sanitation committee is also non-functional and actually many of villagers dont
know this committee. Only village head and ASHA completes formality of this meeting or in
other words it runs on paper. If used properly, it can be a platform between community and
PHC.
8. Building Confidence and Motivation of AHSA, ANM & Field workers: -

The direct causes of maternal mortality like hemorrhage, pre-eclampsia / eclampsia, sepsis,
obstructed labor can be taken care of by skilled birth attendance and quality maternal health
services. Building Confidence of these workers gives respect of work and gives positive
energy of work. It is a self-stimulating incentive within the minds and hearts of the
multipurpose workers. A whole some morale stimulates loyalty generates co-operation and
encourage team work. All these are essential for the achievement of the goals of sub Centre
and primary health care system. A beginning can be made by developing a system of
rewarding on good performance. ASHA bahu sammelan gives a pride to ASHA workers and
others. It will be more beneficial if it is covered by media houses and work recognized by
district authorities.
9. Coordination with Development Agencies: -

There are a large number of development agencies working at block level and villages under
jurisdiction of PHC, but there is no coordination among these agencies. State of Bihar and
Madhya Pradesh and several other states are running health reforms projects and they linked
with development partner for technical assistance and monitoring of community worker by
two ways gives better results. It is suggested that all the development agencies in a particular
area must promote the problems of developments simultaneously to produce sustained impact
on population inhabiting these areas.
10. Community Participation and BCC: -
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For improvement in delivery of health services, and its application to the community, it is
necessary to involve community members .Community participation has been a successful
method for delivery of health care. For effective community participation it is very necessary
to motivate people for a positive change in behavior, this can be done through Behavior
change communication strategy (BCC), education communication (IEC).Here numerous
modes such persons to persons contact use of print and electronic media, sensitization
workshops, nukkad nataks, haat shows etc. are used for awareness building among the
community regarding health issues which facilitates community participation.
11. Strengthening of Village health and sanitation Committee:-

The active involvement of PRI in VHSC is making people aware about their rights to health
services through panchayat meetings, demanding for quality of services and getting a role in
local management and delivery of health services. So the active participation of PRI must be
encouraged through VHSC. Strengthening of Village health and sanitation committee can
prevent village from many diseases .VHSC have funds for cleaning village nalli (drainage
facility) and make arrangement of many other things for safety of village in health regards.
Root causes can be addressed through community-level interventions as well as making
maternal health a political issue, which is of concern for society at large.
12. Strengthening of Village health and Nutrition Day:-

Under Strategic Communication Plan for VHND a logo can be developed for branding
VHND. Micro Planning template, monitoring formats, reporting formats should be there for
facilitating better implementation. District level capacity building workshops should be
conducted in all the districts and capacity building of frontline workers (ASHA, ANM and
AWW) and VHNSC members should be focused a lot. To make VHND a successful
programme, a common platform for convergence - be it inter-sectoral or inter-departmental -
is required. At the village level, it calls for convergence amongst service providers of health;
Integrated Child Development Services (ICDS); Panchayati Raj Institutions (PRIs), and the
community. For instance, Accredited Social Health Activists (ASHAs) along with Anganwadi
Workers (AWWs) are responsible for mobilizing the community for VHNDs (and holding
health education sessions), with support from PRIs. Auxiliary Nurse Midwives (ANMs)
provide maternal, new-born and child health services such as antenatal care (ANC) and
routine immunizations.
District and Block Level Coordination Committees can be established for Inter-sectoral
convergence and better implementation. Representatives of Panchayati Raj Institutions are
also been included as members of these committees. VHND Micro planning and Session
Monitoring template and data entry tool can be developed by the state with technical
assistance from development partners and Micro planning exercise should be jointly carried
out by ANM, AWW and ASHA.
13. Sensitization of service providers on Gender Issue:-

Strategy to limit Gender bias is also necessary to reduce MMR and IMR. Many times, service
providers are not behaving well with pregnant women. They treat them badly and this
behavior creates distance between patient and health service providers. ANM & ASHA
worker are also not behaving well with female clients they were not given appropriate
information if any pregnant women asked, if same information asked by husbands they
provide the information. Doctors and MPW are also not well behaving especially with women
as in her mentality women is inferior in comparison to Men. Comprehensive interventions
including gender sensitization initiatives are required to bring down maternal mortality ratios.
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Gender-accommodating approaches typically do not seek to change norms and inequities, but
endeavor within existing normative structure to improve outcomes for women. This approach
is strategically necessary as a first step in womens health related programs in our
conservative society.
14. Behave respectfully towards patients:-

All staff should be oriented to behave respectfully towards patients. Every one working in the
facility should behave respectfully with patients since their arrival and until their departure.
Aspects of respectful care include timely response to patients in labor, fully answering to
patient questions, not scolding women for yelling or seeking more comfortable positions
when they are in pain, allowing a trusted person to comfort them in the delivery, encouraging
cooperation with clinical procedures in a caring and calm manner, not seeking gifts or
illegal payment for standard delivery practices or postpartum care. Facility managers should
consult with community health workers to determine if abuse of patients is being reported in
the community and take appropriate action to investigate and respond to any such reports.
Staff should be encouraged to participate in Village Health and Nutrition Days to answer
questions about the ANC & institutional deliveries.
15. Biometric attendance is made compulsory:-

It is a common problem to see that doctors are missing or come only for a few hours or few
days in a month. It is suggested that the entire NRHM attendance moves paperless (biometric
attendance be made compulsory). With this, the problem of absenteeism will certainly come
to an end and service delivery will be smooth.
16. Paper less reporting for productive time of the health workers:-
Preparing reports and paper work takes most of the productive time of the health workers.
With the advent of low cost tablet PCs & low price 3G enabled phones; it might be worth
considering giving these devices to health workers like ASHAs. Also, if these mobiles /
tablets have a GPRS connection, it can mean live data updates, thereby, reducing the three
month gap between the village data entry and the central review points at Delhi. Digitizing
the records through mobile phones would be great as the data will be updated live and the
impact will also be significant with no chances of multiple entry and errors. Real time actions
can happen through SMS based follow up and care.
17. Community Radio:-

Community radio is a very new concept and it will create significant awareness among
villagers. Through this villagers may know provision of VHSC and other public interest
scheme running under NRHM. Similar services can be started in villages to drive healthy
behaviors. Simple awareness campaign (pictorial & through songs in local dialect) can
reduced the maternal mortality effectively. The expenses in this project will not be more than
Rs.5000.00 per village. Such models need to be adopted as soon as possible in as many areas.
18. Mobile Sub centers:-

Sub centers are built at a cost of Rs.8.5 13.5+ Laces. It might be worth considering to set-up
mobile sub centers (Mobile Vans) that can go across to the remotest areas and conduct
outreach programmes. So the cost of operating the sub center ( rental , electricity etc ) gets
consumed in the form of fuel expenses for the mobile health center and also, these sub centers
can be used as an ambulance in case of medical emergencies. Thus it would save Rs.300 that
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is given for transferring patients to the referral center. The cost of mobile center is expected to
be much lower than the cost of a physical center. 19. Incentive to health workers: - It is
expected that since ASHAs and ANMs are incentivized for institutional deliveries, referral
etc. The incentive might also make them turn to private practitioners over a period of time, as
the lure of money will drive them to recommend private gynecologists & give less focus to
home visits and counseling, and this might be happening even today as well. It is suggested
that the ASHAs & ANMs must be incentivized for counseling, home visits, immunization &
preventive checks as a routine part of their job and the incentive must be paid for each home
visit ( even Rs. 2 to Rs.3 per visit is good enough). This will lead to a fixed remuneration to
ASHAS & ANMs. Certain Evaluation parameters for the success of an ASHA must be
established like how many households are aware of sanitation, hygiene, preventive health and
healthy lifestyle. ASHA is not paid a salary but is paid incentive for institutional deliveries
(Rs.100), DOT treatment (Rs.250), meetings for once a month (Rs.150, out of which Rs. 100
is for travel and Rs.50 for refreshments).
20. Role model & Case study publication:-

People believe in facts, and the case studies & success stories of ASHA & ANMs must be
shared state wide to make the acceptance more impactful for behavioral change. Cases of
good pregnancy can be shared with print media and electronic media. Case study should be
covering ANC & PNC visits by ASHA and their experiences, new born care. Issues and
danger sign during pregnancy.
After understanding the knowledge, attitude and practices of all these very exceptionally
marginalized community, now we are working on the proposed plan which is given below.
It is expected that since ASHAs and ANMs are incentivized for institutional deliveries,
referral etc. The incentive might also make them turn to private practitioners over a period of
time, as the lure of money will drive them to recommend private gynecologists & give less
focus to home visits and counseling, and this might be happening even today as well. It is
suggested that the ASHAs & ANMs must be incentivized for counseling, home visits,
immunization & preventive checks as a routine part of their job and the incentive must be
paid for each home visit ( even Rs. 2 to Rs.3 per visit is good enough). This will lead to a
fixed remuneration to ASHAS & ANMs. Certain Evaluation parameters for the success of
an ASHA must be established like how many households are aware of sanitation, hygiene,
preventive health and healthy lifestyle. ASHA is not paid a salary but is paid incentive for
institutional deliveries (Rs.100), DOT treatment (Rs.250), meetings for once a month (Rs.150,
out of which Rs. 100 is for travel and Rs.50 for refreshments).
20. Role model & Case study publication:-

People believe in facts, and the case studies & success stories of ASHA & ANMs must be
shared state wide to make the acceptance more impactful for behavioral change. Cases of
good pregnancy can be shared with print media and electronic media. Case study should be
covering ANC & PNC visits by ASHA and their experiences, new born care. Issues and
danger sign during pregnancy.
After understanding the knowledge, attitude and practices of all these very exceptionally
marginalized community, now we are working on the proposed plan which is given below.
Location of PHCs & Sub Health Centers is mostly around a few Kms from the residential
areas and this fault line needs to be corrected through provision of such mobile health center.
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116
KRA 1 Sensitization of the community on the appropriate mother and child care practices and the related health seeking behavior
Outcome Activities Indicators
Yr 1 Yr 1
In-depth understanding and analysis of Assessment of the behavior and A status report will be developed on the existing beliefs and practices and superstitious myths on varied
the behavior, practices , existing myths KAP of different communities- issues of different communities.
and superstitious beliefs of different Musahars, Chamars, weavers etc
varied communities on the existing will be observed and studied in the
mother and child care rearing practices first three quarters.
and their related health seeking behavior.
The study will include issues such as

health and hygiene practices, ANC
and PNC, immunization, importance
of breast feeding within one hour of
delivery, exclusive breast feeding,
supplementary nutrition after six
months, interval between births,
health seeking behavior, safe
delivery, fooding habits and patterns,
cleanliness, gender bias and other
related issues.
The process of formation of Number of adolescent groups which will be formed. Number of meetings in each group
adolescent groups will be initiated in
the intervention area. Small
interfaces will be initiated with the A group of around 25 girls and women team activists will be trained
girls as an initiation of the
preventive approach
KRA 2 To facilitate safe deliveries and ensure effective administration of ANC and PNC care programs in all the villages.
Yr 1 Yr 1
Increased sensitization on the health of Ensuring tracking of PW and registration in ICDS Number of PW women registered in the ICDS vis a vis the total Number of PW
PW and increased use of ambulance centre.
services.
Ensuring MCH card is given to all the PW. Number of women who receive the MCH cards
Sensitization on importance of immunization of Number of PW who would receive both the immunization
pregnant women. Immunization, check-up and IFA
distribution to the pregnant women.
Sensitization on the importance of safe delivery. Number of PW who would use the Ambulance
Preparing them for the delivery and their sensitization
for usage of Ambulance 102 and 108.
Awareness about the JSY scheme and opening of their Number of women who would receive JSY benefit
bank accounts
Sensitized people on post delivery care Keeping regular track of nursing mothers for importance Number of women who breast feed Colostrums to the infants
and requirement of nutritious food. of breast feeding within one hour and breast feeding
practices.
Linkage to ICDS All LM will be linked to ICDS Number of LM linked to ICDS
centers. Sensitization on judicial use of the nutrition
received.
117
KRA3 The children in 0-5 years of age access the appropriate services entitled for them in health and nutrition
Yr 1 Yr 1
Increased awareness and Response for Child wise tracking will be undertaken. The frequency Standardized frequency for growth monitoring. Frequency of tracking during the year
the malnourished children and their of tracking would be once in a month for SAM children,
families once in two months for MAM and once in three months
for normal children. The existing gaps in terms of
frequency, timelines, and uniformity need to be
streamlined.
Child wise tracking will be undertaken. The frequency Standardized frequency for growth monitoring. Frequency of tracking during the year
of tracking would be once in a month for SAM children,
once in two months for MAM and once in three months
frequency, timelines, uniformity need to be streamlined
streamlined.
streamlined.
streamlined.
streamlined.
hild wise tracking will be undertaken. The frequency of Standardized frequency for growth monitoring. Frequency of tracking during the year
tracking would be once in a month for SAM children,
streamlined.
streamlined.
streamlined.
To establish the issue of identity and To ensure birth registration of all the children born. The 90% new born children will have possession of birth certificates and the remaining
facilities registration certificates for the correct date of birth forms the basis of growth children.
118
children monitoring for children.
A fresh assessment of children devoid of birth A fresh assessment in place.

certificates or children in the age group 1-5 years.
Sharing with appropriate authorities and NCPCR for
further advocacy.
Initiation of Immunizations and its follow up till nine Number of children with complete immunization Number of children who did not
months of age. administer any vaccine
To ensure effective functioning of health and nutrition services related institutions and ensure facilities for the community from village to
KRA 4
district level
Yr 1 Yr 1
The status of the functioning of service A mapping of the existing situation of ICDS centers, A status report to be in place by second quarter.
institutions -ICDS, SC, PHC, CHC, Sub centers, PHC, CHC, NRC , district hospital to be
NRC , District hospital to be in place and studied, analyzed and documented.
demands raised as per shortfalls.
A mapping of the existing situation of ICDS centers, Target setting to be done based on the assessment.
Sub centers, PHC, CHC, NRC , district hospital to be
studied, analyzed and documented.
A mapping of the existing situation of ICDS centers, Preparations of document and the interfaces organized
A mapping of the existing situation of ICDS centers,
A mapping of the existing situation of ICDS centers, Number of representations and meetings
A mapping of the existing situation of ICDS centers, Clear status on the availability of ANM and the existing shortfalls and their work profiles
Sub centers, PHC, CHC, NRC , district hospital to be would be available.
A mapping of the existing situation of ICDS centers, Number of representations sent and the meetings conducted with the stakeholders
A mapping of the existing situation of ICDS centers, Report to be in place
A mapping of the existing situation of ICDS centers, Number of meetings conducted
To analyze the causes and reasons for In case of any death, verbal autopsy to be conducted and Case studies created and verbal autopsies undertaken for all the deaths
death case studies to be documented.
Detailed audit to be conducted to arrive at the root cause Cases to be documented
of death and thereby taking up the cases for advocacy
home district to national level.
Social audit of MMR and IMR and its causes then
sharing with administration, health department and
health ministry at state and central level.
Death registration to be facilitated for the deceased. Number of death registrations facilitated vis a vis the number of deaths
To file RTI's for comparison of deaths with primary data Number of RTI's filed and the number of responses received
119
To initiate the mapping of facilities at the delivery

centers to gauge the specific reasons for MMR and
IMR.
120
APPENDIX :BIBLIOGRAPHY ,INTERVIEW SCHEDULE
121
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KAP Report On Child and Maternal Health

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KAP Report On Child and Maternal Health

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A STUDY OF KNOWLEDGE, ATTITUDE AND PRACTICE OF CHAMARS, NAT / MUSAHAR

AND MUSLIMS TOWARDS REPRODUCTIVE AND CHILD HEALTH

PREPARED BY DR. SHAILA PARVEEN

SUPPORTED BY CHILD RIGHTS AND YOU

Dr. Shaila Parvven

Chapters Page Number

2. Research methodology 37-48

3. Demographical profile of the respondent 49--62

4. Data Analysis. (Knowledge ,attitude and practice ) 63-85

5. Assessment of the Aganwadi Centre 86-94

6. Focus Group discussion and Case Study 108-112

7 Conclusion ,Suggestion and action plan 112-117

2. Interview Schedule 128-135

Sl. Table Name of table Page

Sl. No. List of Figures Fig No Page No.

1. Causes of maternal health 1.1 11

2. Age wise distribution of the respondnet 3.1 51

3. Education wise distribution of the respondnet 3.2 52

4. Income wise distribution of the respondnet 3.3 52

5. Residence wise distribution of the respondnet 3.4 53

6. House wise distribution of the respondnet 3.5 54

7. Land wise distribution of the respondnet 3.6 55

8. Family wise distribution of the respondnet 3.7 56

9. Marital wise distribution of the respondnet 3.8 57

10. Occupation wise distribution of the respondnet 3.9 58

11. Electricity wise distribution of the respondnet 3.10 59

12. Source of drinking water 3.11 60

13. Fuel used for cooking 3.12 60

14. Use of toilet 3.13 61

15. Hand wash practice 4.1 65

16. Accessibility of health services 4.2 66

17. No. of living Children 4.3 71

18. Reasons for not using contaceptive 4.4 71

19. Ante natal care knowledge 4.5 73

20. Place of deleivery 4.6 74

21. Benefits of JSY to the mothers 4.7 81

22. Accomodation fees paid for the institutional delevery 4.8 81

23. Nutrition provided to pregnant women 4.9 82

24. BCG vaccine given to the children after birth 4.10 83

25. Visit of ANM within 42 days of birth 4.11 84

26. First time bath to the neonatal 4.12 84

27. Operational place of AWCs 5.1 88

28. Sitting arrangement of Children at AWCs 5.2 88

29. Availability of Utensils to cook hot food 5.3 89

30. Availability of Plates /Bowls for children 5.4 90

31. Drinking water facility at AWCs 5.5 90

32. Weighing machine at AWCs 5.6 91

33. Availability of growth chart 5.7 91

34. Availability of referral services 5.8 92

35. Facilities in AWCs 5.9 92

Causes of maternal deaths in India (19972003)

Causes of maternal deaths in India (19972003) :-

schemes and programmes. Consequently, the Muslim community remains in deplorable

.Ayurveda Hospitals 07 .Homeopathic Hospitals 03 .Medical Colleges 02 .ANM Training

Comparative detail of district wise on Institutional delivery, underweight

Comparative detail on Mother mortality rate in division in year 2011.12 and

Name of No. ICDS/MMR in district

Name of Sex ration from Child marriage Children labour

Detail of Varanasi district on Institutional delivery, underweight

Varanasi data of complete immunization of children between age group 12 23 months

Balasubramanian K. (1984), Hindu-Muslim differentials in fertility and population

Dasgupta S. (2004, Sept 13). India as an Ostrich. Rediff News, Rediff.com.

Government of India. 2008. Development Challenges in Extremist Affected Areas: