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India

MDG 5: Improve Maternal Health

Target 5a: Reduce by three quarters the maternal mortality ratio

Target 5b: Achieve, by 2015, universal access to reproductive health

Disclaimer: Some of the MDG data presented in this website have been adjusted by the responsible specialized agencies to ensure international comparability, in compliance with their shared mandate to assess progress towards the MDGs at the regional and global levels.[1] 

 

Indicators (United Nations)

 

5.1 MATERNAL MORTALITY RATION (MMR):

a.    2000: 540[2]

b.    2005: 450[3]

c.    2007:

A maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes.”[4] According to the 2005 WHO/UNICEF/UNFPA maternal mortality estimates, most of the countries in the Asian region have not reduced the maternal mortality by three quarters as stated in the MDG Goal.[5] 

India records a high maternal mortality ratio of 450 per 100,000 live births in 2005.[6] National estimates of maternal mortality are reported as 254 per 100,000 live births (RGI, SRS 2004/06).

It is also important to highlight that MMR estimates at national level do not capture the large inter-state and regional variations within the countries. For example in India, in the states of Uttar Pradesh, Bihar, Jharkhand, Orissa, Madhya Pradesh and Rajasthan the MMR is much higher than the national MMR.

 

Critical indicators to comprehensively monitor maternal mortality

5.1.1 Lifetime risk of maternal death

 

The concept of adult lifetime risk of maternal death measured as the probability of dying from a maternal cause during a woman’s reproductive lifespan[7], is more holistic in comparison to maternal mortality ratio (MM Ratio) and maternal mortality rate (MM Rate). Whereas the MMRatio and the MMRate are measures of the frequency of maternal death in relation to the number of live births or to the female population of reproductive age, the lifetime risk of maternal mortality describes the cumulative loss of human life due to maternal death over the female life course. Because it is expressed in terms of the female life course, the lifetime risk is often preferred to the MMRatio or MMRate as a summary measure of the impact of maternal mortality[8].

 

The lifetime risk of maternal death is 1 in 70, as compared to 1 in 1 300 in China, which shows the extent of risk to the life and well being of Indian women in reproductive age group, which is indicative of inequity.

 

5.1.2 Maternal deaths due to unsafe abortion

 

Unsafe abortion continues to be a major factor in maternal deaths in the region. Mortality due to unsafe abortion, in South Asia, is estimated at 13%.[9]

In India, abortion was legalized in 1972; however, legalization has not ensured access to safe abortion services for Indian women. Eight percent of all maternal deaths are attributed to abortions, translating to 11,000-15,000 deaths due to unsafe abortion annually. There are no established national level mechanisms for the monitoring and evaluation of maternal mortality and morbidity resulting from unsafe abortion.[10] 

It is important to understand that providing access to safe abortion services is a critical intervention to reduce maternal deaths in these contexts and liberal laws on abortion must be backed up by safe abortion service provision

 

 

Voices from the ground:

 

Videos:

a.    In India's Orissa state, up to eight mothers die every day giving birth. This video highlights how more than two-thirds of all maternal deaths in India occur in just a handful of impoverished states, including Orissa, and the inability to get medical care in time is one of the major factors contributing to this tragedy. Watch the video 

b.    This video focuses on pregnancy in India, with a special focus on the Dalit women. Watch it here  

c.    This video focuses on the story of Kiran Yadav, an Indian woman who died needlessly in childbirth. It has been nominated for a Webby award. Watch it here

 

News/Magazine Articles:

 

a.    “For an emerging global economic power famous for its medical prowess, India continues to have unacceptably high maternal mortality levels. In 2005, the last year for which international data is available, India's maternal mortality ratio was 16 times that of Russia, 10 times that of China, and 4 times higher than in Brazil. Of every 70 Indian girls who reach reproductive age, one will eventually die because of pregnancy, childbirth, or unsafe abortion, compared to one in 7,300 in the developed world. More will suffer preventable injuries, infections, and disabilities, often serious and lasting a lifetime, due to failures in maternal care.” This report talks about Maternal Mortality and Morbidity in India, Improving Accountability, Health system gaps, and preventing maternal deaths. Read it here

  

        Study:

  1.  ‘A Study of Knowledge, Attitudes and Understanding of Legal Professionals about Safe Abortion as a Women’s Right’ was conducted by ASAP in 2008-2009. The study was conducted with local partner India (Foundation for Researchin Health Systems - FRHS). The court is a powerful arena to effect changes in society. Through the avenue of the courts, restrictive laws may be stricken down as invalid; failure to implement the law by state agents, may hold these state agents liable, in their official as well as personal capacity; refusal to heed the requirements of the law, may also compel the courts to enforce compliance by these state agents. Legal profession, when used in this study, however, does not simply refer to those who have had formal schooling in law and are bestowed the titles as such. This study adopts an expanded definition of the legal profession and includes also legislators, high ranking police personnel, jailers, medical practitioners, head of hospitals, and other persons who are tasked with the implementation of the law, as well as those whose opinion and experience may be given weight in legal and policy advocacy. While the members of the legal profession are important agents of change in society, they cannot effect lasting change on their own. We recognize that these changes in the field of law and policy need to be propelled and informed by the experiences and wisdom of those at the ground level in the implementation of the law. The study findings are expected to help in a greater understanding of the perspectives of this group and will inform future capacity building, attitude reconstruction efforts and the development of advocacy tools for action. This study is unique in its attempt to move beyond the women/community-provider interface and look at gatekeepers outside the service provision field.  To read the study, please click here 

   


 

5.2 PROPORTION OF BIRTHS ATTENDED BY SKILLED HEALTH PERSONNEL:  

a.    2000: 42.5[11]

b.    2006: 46.6[12]

c.    2007:

A skilled attendant, according to WHO, refers to “an accredited health professional-such as a midwife, doctor or nurse- who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.” Traditional Birth attendants (TBA) either trained or untrained are excluded from the category of skilled health workers.

Skilled attendants at birth in 2005-06 in India were reported to be 46.6.[13] 

 

Critical indicators to comprehensively monitor skilled health attendance would include not just skilled birth attendants but also access to basic and comprehensive emergency obstetric care services and post-partum care 

  

The quality of care provided by skilled attendants at birth is crucial. Particularly when complications occur, skilled personnel need access to essential drugs, supplies, equipment and emergency obstetric care. They should receive training on required competencies. And they need supervision that helps ensure high standards of care, which is vitally important[14].

Global and country studies on skilled attendants showed that the overall effectiveness of skilled attendants depends on their access to a functioning health system with a basic and comprehensive level of obstetric care, including surgery and blood transfusions in case of complications. The key to maternal death reduction is universal access to emergency obstetric care which is a major challenge in most of the Asian countries.

It is therefore critical to not just look at skilled attendants at birth, but also look at a) access to emergency obstetric care services and b) postpartum care so as to reduce maternal deaths meaningfully.

 

5.2.1 Access to emergency obstetric care

Of the 82 facilities surveyed in India, in 2000, 36% had five EmOC facilities per 500,000 population [15]. A cohort study in Maharastra, India by McCord,  (2001), concluded that EmOC was “effective in preventing maternal deaths in area[s] with high rates of home deliveries(85%); 79% of women with obstetric complications self-referred to a hospital, even though all deliveries began at home.”[16]

 

5.2.2 Post partum care

 

A large proportion of maternal deaths occur during the 24 hours after delivery and hence postnatal care constitutes a critical safe pregnancy intervention. The first two days following delivery are critical for monitoring complications arising from the delivery.

 

The single most common cause of maternal mortality is obstetric haemorrhage, generally occurring postpartum and accounting for 25—33% of all maternal deaths. The rate of death due to post partum haemorrhage (PPH) varies widely in the developing world. PPH-related mortality rates based on hospital studies are estimated to be 25—30% in India, and 43% in Indonesia. However, women who come to a hospital for care do not represent the general population of women. Because haemorrhage is more apt to occur and more difficult to treat in the community, studies have suggested higher rates of PPH-related mortality in these areas, but there is comparatively little data available outside of a hospital setting.[17] 

In India, according to the 2006 National Family Health Survey, “a majority of women (58 %) did not receive any postpartum check-up after their most recent birth. Only one-quarter of women (27 %) received a health check-up in the first four hours after birth and 37 % received a health check-up within the critical first two days after delivery. The likelihood of a birth being followed by a postpartum check-up at all and within two days increases with the educational level of the mother and the household wealth index.”[18]  

 

 

 

5.3 ADOLESCENT BIRTH RATE    (per 1000 women):

a.    1998: 51.0[19]

b.    2005: 45.9[20]

c.    2007:

The adolescent birth rate measures the annual number of births to women 15 to 19 years of age per 1,000 women in that age group. It represents the risk of childbearing among adolescent women 15 to 19 years of age. It is also referred to as the age-specific fertility rate for women aged 15-19[21].

The adolescent birth rate declined from 51.0 in 1998 to 45.9 in 2005 in India.

 

According to the National Family Health Survey -3 (2005-06), early marriages and teenage pregnancies are not a rarity in India. Among young women age 15-19, 16 percent have already begun childbearing. Young women in rural areas are more than twice as likely to be mothers as young women in urban areas. In Jharkhand, West Bengal, and Bihar, at least one in four teenage women have begun childbearing.

 

Teenage fertility and pregnancies are a major health concern because teenage mothers and their children are at high risk of reproductive morbidity and mortality. Early childbearing  also impedes the overall development of teenage girls and their access to education and labour force participation.

 

Critical indicators to comprehensively monitor adolescent birth rate would look at the median age at marriage, the legal age at marriage and access to sex and sexuality education

5.3.1 Median age at marriage

The median age for marriage for women aged (25-49) in India is 17.2 years.  According to NFHS-3 data, “men get married more than six years later, at a median age of 23.4 years. Almost half (46%) of women age 18-29 years got married before the legal minimum age of 18. Women and men living in urban areas and those with higher levels of education marry later than their rural and less educated counterparts.”

 

5.3.2 Legal age of marriage 

The legal age of marriage in India is 18 for women and 21 for men.

Arranged marriages are very much prevalent in India. Conventionally, in India the normative framework of the right to marry does not reflect women’s autonomy and decision making in the realm of relationships per se and, more specifically in terms of marriage, the different dimensions of the right to choose if, when, and whom to marry. Digression from this leads to sanctions and violations by the family and the community reinforcing the pressures with regards to marriage whether child marriage, early marriage, practices of forced marriage (forcing a person to marry per se or marry a person of the family’s choice, denying a person’s right to marry of her own free will, a person of her own choice), adultery, and bigamy.[22] There is an overall agreement that this practice was essentially a way of uniting and maintaining the differences between the rich and the poor, as well as those between the various different castes. Recently, the Indian government has come up with an innovative approach - offering people cash incentives for marrying into a lower caste.[23]  

India, according to the CEDAW shadow report, still operates against a “backdrop of feudalistic and patriarchal cultural norms and institutions, regardless of law, child marriages are still being practiced.”[24]  

 

5.3.3 Sex and sexuality education

Sex education is defined as the basic education about reproductive processes, puberty and sexual behaviour. Sex education may include other information, for example about contraception, protection from sexually transmitted infections and parenthood.[25] Sexuality education is defined as education about all matters relating to sexuality and its expression. Sexuality education covers the same topics as sex education but also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually active, and it provides information about SRH services. It may also include training in communication and decision-making skills.[26] 

Sex education is called the Adolescence Education Programme (AEP) in India. The curriculum was developed by the National AIDS Control Programme, and was rejected by several state governments including those of Madhya Pradesh, Chhattisgarh, Rajasthan, Uttar Pradesh, Kerala and Karnataka, with the chief ministers writing to the Ministry of Human Resources Development accusing it of corrupting the morals of the young. The module was revised but, in turn, was rejected by 33 NGOs from across the country, including youth groups, sexual rights groups, women's groups and groups working with child sexual abuse. In a joint statement, they declared: "The thrust of the… curriculum is abstinence. It is silent even about the biological aspects of reproduction. The lesson on conception, whilst addressing internal biological mechanisms, omits any description of intercourse. Sexual intercourse is shrouded in the euphemism 'intimate physical relationships.' Without the knowledge of what does cause conception, the curriculum will fail in one of its own objectives -- that of addressing teenage pregnancy.”[27]  

5.3.4 Access to reproductive health services for adolescents within the public health system

In India, there is limited access for youth to SRH services and socio-cultural norms constrain unmarried adolescents from seeking these services. Thus contraceptives remain out of their reach. Social stigma prevents unmarried girls and their family members from seeking services related to abortion. Providers are often judgemental and lack counselling skills.[28] However, the National Youth Policy talks about the inclusion of information on reproductive health as part of the curriculum and of setting up clinics in rural areas to address the health needs of adolescents, and of access to antenatal, postnatal and natal health services.[29] 

 

 

Voices from the ground:

 

    Videos:

a.    This video highlights the plight of many young women in India: how they are pressured to marry and have children at very young ages. This video focuses on teaching these young women about reproductive health.  Watch it here 

b.    This video shows how forced weddings are frequent in the western Indian state of Rajasthan, with the brides sometimes as young as five. It's been an illegal practice since 2006, but families struggling to feed their children see little alternative. Watch the video

 

 News/MagazineArticles:

a.    “According to official figures, over 68% girls in the state (Rajasthan) are married by the age of 18.” This article explores the topic of teen pregnancies, and why they occur. Read it here 

b.    “Though child marriages have been strongly prevalent in India the results of which are girls becoming mothers in their teens. In addition to that, the spate of incidents of rape on minors and the rising levels of promiscuity among teenagers are also a cause of great concern as they lead to teenage or say adolescent pregnancies.” Read more 

c.    This story is written by a young woman who was pregnant as a teen, pointing out that teen pregnancy can happen to anyone, even the ‘good’ girls. Read it here

d.    This is a cross-sectional study on the effect of maternal child marriage on Morbidity and Mortality of Children under 5 in India. Read it here

e.    Upheld and sanctioned by traditional customs, child marriage is still significantly practiced across India. The 205th Law Commission Report cites significant statistics on the scale of child marriages in India. This report maps the trajectory of legal reforms when it comes to child marriages in India.  Read it here 

f.     This article focuses on how forced marriages are forcing unwilling women to take

drastic measures, a woman in India had a sex change operation so she would not be forced to marry someone she didn’t want. Read it here 

 

 

5.4 CONTRACEPTIVE PREVALENCE RATE(Current contraceptive use among married women 15-49 yrs old any method%):

a.    2001: 46.9[30]

b.    2006: 56.3[31]

c.    2007:

CPR in India went from 46.9 in 2001 to 56.3 in 2006.

 

 

Critical indicators to comprehensively monitor contraceptive prevalence rate would include looking at range of methods available including access to modern methods and provision of informed choice.

 

5.4.1 Range of contraceptive methods available.

Beyond the numbers for CPR it is essential to look at access to a range of contraceptive services.

Permanent methods of contraception are highly used: female sterilization accounts for a whopping two-thirds - 66.25% of all methods!! A preponderence of one method often demonstrates provider bias/ service provision bias. In comparison, male sterilization forms a mere 1.77% of all methods.

In countries that strongly implement population control policies, such as India, permanent methods are favoured. Targets for permanent methods are women.

 

5.4.2 Provision of informed choice service provision. 

Informed choice of family planning methods is an important rights indicator. However it has not been commonly regarded as an important aspect of the service provided with the contraception method. Informed choice includes: information on the full range of methods including traditional and male methods; information on side-effects of all methods and the appropriate course of action; and information on the efficacy of each of the methods.[32]

In India, information on the full range of methods was not commonly disseminated - “less than 30 % were ever informed about other types of family planning methods,” [33]

In India, information on side-effects and appropriate courses or action was given to few users - “only about one-third of modern contraceptive users were informed about the side effects or problems of their method, and only one-quarter were told what to do about side effects.” [34] 

However, it was noted that “IUD users were most likely to be provided with each of the three types of information and users of female sterilization were least likely to be provided with this information.” [35]  

Informed choice, in India is noted as being consistently higher in urban areas, and is somewhat more common in private than in public medical facilities.[36]  

 

 

 

5.5 UNMET NEED FOR CONTRACEPTION:

 

a.    2003: 21.1[37]

b.    2006: 6.6[38]

c.    2007:

Unmet need reduced from 21.1% in 2003 to 6.6% in 2006.

Younger women (age 15-24) have a greater unmet need for spacing than for limiting. Rural women have higher unmet need than urban women for both spacing and limiting. Unmet need for both spacing and limiting decreases with an increase in wealth quintiles.[39] 

Women with lower education or are uneducated, who are poor, who live in remote areas and rural areas face the greatest challenge in controlling their own fertility. Socio-economic inequities are closely inter-linked with higher rates of unintended births and it is important to ensure access to contraception to all groups of women.[40]

The accepted definition of “[u]nmet need for contraception is the percentage of fertile, married women of reproductive age who do not want to become pregnant and are not using contraception.”[41] The concept of unmet need is an important one because it assesses the ‘need’ for contraception based on whether and when a woman wants a child or another one rather than focusing on government limits on family size. The limitation, currently, is that the DHS calculates unmet need based on a sample of married, heterosexual women and not single, unmarried women and this does not accurately capture the extent of unmet need in a country. Another limitation is that it assumes all users as having their need ‘met’ including women with infertility and secondary infertility. But many women may be using a contraceptive method not of their choice due to provider bias or government policy as earlier discussed and this constitutes an ‘unmet need’ too. It is also important to keep in mind that contraception is primarily focused on pregnancy prevention. There is also an urgent unmet need for disease/infection prevention which is not being considered.[42] 

 

Critical indicators to comprehensively monitor unmet need would take into account differences between total and wanted fertility rates and reasons for non-use of contraception.

 

5.5.1 Total and Wanted Fertility Rates

     Wanted fertility rates compared to Total Fertility Rates

 

a.    Total Fertility Rate (2005): 2.68[43]

b.    Wanted Fertility Rate (2005): 1.9[44]

c.    % difference: 41%[45]

 

It is important to look at Wanted Fertility Rates and Total Fertility Rates to also establish unmet need. In the NFHS 2005-6, the TFR was 2.68 and the WFR was actually 1.9; this means women were having 41% more children than they actually wanted and this constitutes an unmet need.[46]

 

5.5.2 Reasons for non-use of contraception

One of the most common reasons given by married women with an unmet need for not using contraception is associated with the supply of methods and services and within this category, concerns about the side effects, health consequences and inconvenience of methods were the most prominent reasons. The prevalence of these concerns is particularly high in South Asia.[47]

Apart from the fertility-related reasons, method-related reasons and health concerns, a major reason for non-use of contraception in India is ‘fatalism’ (5.9%) i.e. fertility is still seen as something ‘fate’ deals out rather than a matter of exercising choice. In addition, opposition to use (both own and spousal) constitute 5.5% and religious prohibition constitutes 5.0% all of which are not being considered in discussing unmet need.[48]

 

 

5.6 ANTENATAL CARE COVERAGE 

a.    At least one visit (%):

Ø  2000: 61.8[49]

Ø  2006: 74.2[50]

Ø  After 2005: 90.9[51]

b.    At least four visits(%):

Ø  1999: 29.5[52]

Ø  2006: 37.0[53]

Ø  2007:

 

Voices from the ground:

Fact Sheet:

The District Level Household and Facility survey is one of the largest ever demographic and health surveys carried out in India, with 

sample size of about seven lakhs households covering all the districts of the country. This fact sheet  presents information on the key

indicators and trends for the state of Assam. Read it here

 



[1] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[2] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[3] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[4] The International Classification of Diseases, Injuries and Causes of Death – 9th revision (ICD9) defines a maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” These are subdivided into Direct, Indirect, and Fortuitous, but only Direct and Indirect deaths are counted for statistical purposes. The latest revision, ICD10, recognises that some women die as a consequence of Direct or Indirect obstetric causes after this period, and has introduced a category for Late maternal deaths defined as “those deaths occurring between 42 days and one year after abortion, miscarriage or delivery that are due to Direct or Indirect maternal causes.” The ICD 10 further defines direct maternal deaths as those resulting from obstetric complications of the pregnant state (pregnancy, labour, and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. Indirect deaths are those resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.  Late deaths are those occurring between 42 days and one year after abortion, miscarriage, or delivery that are due to Direct or Indirect maternal causes. Please refer to ICD-10, WHO. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Geneva, World Health Organization (WHO).

[5] World Health Organization (WHO); United Nations Chidlren’s Fund (UNICEF); United Nations Population Fund (UNFPA); The World Bank. (2007). Maternal Mortality in 2005. Estimates developed by WHO,UNICEF and UNFPA. Geneva, Switzerland: WHO.

[6] World Health Organization (WHO); United Nations Chidlren’s Fund (UNICEF); United Nations Population Fund (UNFPA); The World Bank. (2007). Maternal Mortality in 2005. Estimates developed by WHO,UNICEF and UNFPA. Geneva, Switzerland: WHO.

[7] World Health Organization (WHO); United Nations Chidlren’s Fund (UNICEF); United Nations Population Fund (UNFPA); The World Bank. (2007). Maternal Mortality in 2005. Estimates developed by WHO,UNICEF and UNFPA. Geneva, Switzerland: WHO.

[8]. John Wilmoth . (2009). The lifetime risk of maternal mortality: concept and measurement. . Published online: 13 February 2009 World Health Organization  (WHO)

[9] World Health Organization (WHO), Department of Reproductive Health and Research. (2007). Unsafe abortion: global and regional estimates of incidence of unsafe abortion and associated mortality in 2003. Geneva. Switzerland: WHO

[10] Khan, A.G; Ramachandran; Sureender, S. (2004). Abortion Pills in Family Welfare Programe? Pitfalls (Unpublished).

[11] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[12] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[13] Department of Reproductive Health and Research, World Health Organization (WHO). (2008). Proportion of Births Attended by a Skilled Health Worker 2008 Updates Factsheet. Geneva, Switzerland: WHO

[14] Monitoring the Situation of Children and Women. (2009). Retrieved August 12, 2010, from Childinfo.org: Statistics by Area Web site: http://www.childinfo.org/delivery_care.html

[15] Paxton A; Bailey, P; Lubis, S.M; Fry, D. (2006).  Global patterns in availability of emergency obstetric care. In International Journal of Gynecology and Obstetrics, Vol. 93, Issue 3 (pp. 300-7). Maryland, USA: Elsevier Inc.

[16] Paxton,A; Maine, D; Freedman, L; Fry, D; Lobis, S. (2005).  The Evidence for Emergency Obstetric Care. Averting Maternal Deaths and Disability (AMDD)  Programme, Mailman School of Public Health , Columbia University.In International Journal of Gynecology & Obstetrics, Vol 88, Issue 2, (pp. 181-193). Maryland, USA: Elsevier Inc.

[17] Geller E; Adams,  M.G; Kelly,  P.J; Kodkany, B.S;, Derman R.J. (2006). Postpartum hemorrhage in resource-poor settings. In International Journal of Gynecology and Obstetrics Vol. 92 Issue 3 (pp. 202-211). Maryland, USA:  Elsevier Inc. 

[18] International Institute for Population Sciences (IIPS) and Macro International. (2007).  National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Deonar, Mumbai, India: IIPS

[19] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[20] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[21] http://unstats.un.org/unsd/mdg/Metadata.aspx?IndicatorId=0&SeriesId=761

[22] National Alliance of Women (NAWO). (2006).Article 16: Marriage and Family Life. In India: Second NGO Shadow Report on CEDAW (p.127). India : NAWO

[23] Cakerfare. (2006). A Penny for you Inter-caste Marriage, Please. Retrieved August, 10, 2009, from The Great Indian Mutiny Web site: http://mutiny.wordpress.com/2006/09/15/a-penny-for-your-inter-caste-marriages-please/

[24]  National Alliance of Women (NAWO). (2006).Article 16: Marriage and Family Life. In India: Second NGO Shadow Report on CEDAW (p.129). India : NAWO

[25] Glossary. (2009). Retrieved September 29, 2009, from International Planned Parenthood (IPPF)/ Western Hemisphere Region Web site: http://www.ippfwhr.org/en/resources/glossary#S#ixzz0RtBLHMT9

[26] Glossary Browser. (2009). Retrieved September 29, 2009, from International Planned Parenthood (IPPF) Web site:  http://glossary.ippf.org/GlossaryBrowser.aspx

[27] Sehgal, R. (2008). Sexuality Education, Minus the Sex. Retrieved Aug 18, 2009,  from InfoChange News & Features Web site: http://infochangeindia.org/200809107334/Health/Features/Sexuality-education-minus-the-sex.html

[28] Asian-Pacific Resource and Research Centre for Women (ARROW). Women’s Health and Rights Advocacy Partnership (WHRAP). India. In Advocating Accountability: Status report on maternal and young people’s SRHR in South Asia. Kuala Lumpur, Malaysia: ARROW.

[29] Asian-Pacific Resource and Research Centre for Women (ARROW). Women’s Health and Rights Advocacy Partnership (WHRAP). India. In Advocating Accountability: Status report on maternal and young people’s SRHR in South Asia. Kuala Lumpur, Malaysia: ARROW.

[30] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[31] Department of Economic and Social Affairs, United Nations Statistics Division, United Nations. Retrieved July 30, 2010, from Millennium Development Goals Indicators official site for United Nations’ MDG Indicators Web site: http://mdgs.un.org/unsd/mdg/Data.aspx

[32] Thanenthiran, S; Racherla S.J. (2009).  Reclaiming & Redefining Rights – ICPD+15: Status of Sexual and Reproductive Health and Rights in Asia. Kuala Lumpur, Malaysia: The Asian-Pacific Resource & Research Centre for Women (ARROW).

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