NGJI, An International Peer-Reviewed Journal NGSI-BHU, ISSN: 0027-9374/2019/1720 Vol. 65, No. 4, December 2019

Implications of Human Development on Contraception and Maternal Health: A Study of Regional Patterns in Divyanshi Singh1 and Vijay Kumar Baraik2 1Ph.D. Scholar, Discipline of Geography, School of Sciences, IGNOU, New , 2Associate Professor, Discipline of Geography, School of Sciences, IGNOU, (Corresponding Email- [email protected])

Abstract Women's right to have choices, sense of self- worth and their right to have access to opportunities have been a subject of serious concern. The level of human development in the society is reection of better status of a woman, which has a clear impact on the usage of contraceptive methods and maternal health. The study is an attempt to assess the performance of Uttar Pradesh on the parameters of levels of human development and to see how the developmental trajectory is inuencing the choice for contraception and maternal health. Multiple Regression has been done to analyse the relationship between development aspect, contraception and maternal health. Better education and health facilities along with good income show strong impact on choice of contraception which ultimately leads to better maternal health. Keywords: contraceptives, maternal health, multiple regression, human development, women's right Introduction Empowerment refers to principles, such as choices, with choices incorporating the ability of individuals and groups to act in dimensions like resources, agency and order to ensure their own well-being or their achievements (Kabeer, 1999, 2005). Women right to participate in decision making. empowerment is a process that occurs over N u m e r o u s t e r m s h a v e b e e n u s e d time and involves women as agents who have interchangeably to dene or capture the ability to formulate choices, control empowerment including autonomy, power, resources and take decisions affecting status, agency and so on (Dyson and Moore, important life outcomes (Pande, Malhotra & 1983; Jejeebhoy, 1995; Kishor, 1995; Mason, Namy, 2012). 1987; Presser and Sen, 2000). Women Women's empowerment is measured in empowerment has been dened as women's terms of resources, agency and achievements ability and freedom to make strategic life along with highlighting the interdependence of Implications of Human Development on Contraception and Maternal Health... 377 individual and structural change in the process There are serious health outcomes for a of empowerment. These structures shape women and her child when she is powerless, individual resources, agency and achievements denied to access opportunities and of low social (Kabeer, 1999). Autonomy to both sexes mean status. Women's desires and ability to control equal decision making ability in personal her fertility and her choice to use affairs. Moreover local level kinship structure contraceptives and choice of contraceptive have demographic implications and also decide methods are affected by her status in household the extent to which women can pursue their self and her own self of empowerment. But choice interest (Dyson and Moore,1983). The issue of of contraception and maternal health is also important role of women in economic reection of developmental status of a society. development addresses issues like need to Access to education, availability of free and invest and provide support to women, compulsory education, better health care constraints on realizing full potential of women facilities and per capita income play a major and future interventions needed to overcome role in uses of family planning methods and the constraints (Castellino and Diop, 2013). maternal health. The progress of a society in Women's status has been very detrimental human development leads to strengthening of in maternal health. The health of women and women's status which has clear implications on their children in Indian society is adversely choice for contraception and maternal health. affected by the women's inferior status within In the present study is an attempt to explore households. The subjugated position of women women's choice to use contraception is mainly result of socio-culturally determined depending upon their levels of human roles for her which dominates every aspect of development and to analyse the extent to which her life (Hameed, Azmat, and Ali, 2014). Lack the development trajectory is inuencing the of knowledge of health care, lack of regular maternal health outcomes. Many of the studies medical assistance, nutritional deciency, high focus on maternal heath and contraception but fertility resulting into greater frequency of the implications of human development on birth, repeated abortions leading to maternal contraception and maternal health is serious death and high Infant Mortality Rate- all these issue which needs greater attention. The study are evidences of or result of poverty, argues that differences in levels of human powerlessness and low social status of women. development have different implications for Maternal mortality is symptomatic of gender- maternal health and contraception. based social, cultural, economic, educational inequalities and multiple deprivations that The objective of the study is to investigate undermine women's access to health services. the impact of levels of human development on Early marriage, early pregnancy, unprotected usage of contraceptives and maternal health in sex, unwanted pregnancies and abortions bring the districts of Uttar Pradesh and to examine the down her resistance to morbidity nally relationship among the three. The study will leading to high mortality. Gender biasness in provide evidence on implications of human health care seeking behavior has been a global development on contraception and maternal picture. Women's status is a powerful source of health which would help in policymaking to longevity, mental and physical health. Lesser improve in human development parameters to the empowered women is, higher the risk of better the usage of contraception and maternal reproductive health complications will be. health in the lagging behind districts. 378 Divyanshi Singh and Vijay Kumar Baraik Study Area satisfactory level. Drop-out rate at primary Uttar Pradesh (U.P.) has been taken as the level is eight percent. 32 percent of the married study area in order to see the implications of women in Uttar Pradesh are deprived of human development on contraceptive usage institutional delivery (NFHS-4th Round 2015- and maternal health. Uttar Pradesh, the most 16). On the basis of economic development, the populous state in , has an estimated position of the state in per capita Gross population of 197 million people in 2011 Domestic Product is second last. Human (Census, 2011), approximately 17 per cent of development in the study area needs urgent India's total population. U.P. falls behind most attention. of the other Indian states with respect to health Data sources and methodology indicators like Neo-natal Mortality Rate, Data for contraceptives usage has been Maternal Mortality Rate, Total Fertility Rate, taken from National Family Health Survey proportion of Low-Birth Weight among new (NFHS) round 4 (2015-16). NFHS is a large born, Institutional Deliveries, immunization scale, multi round survey that is conducted in and utilization of Anti-Natal and Post-Natal representative sample of households in India. care. For the proposed study, data related to the The rationale behind choosing Uttar currently married women aged 15-49 has been Pradesh for the study is that the state is the poor taken who were exposed to pregnancy during performer in Contraceptive Prevalence Rate the survey. Data on indicators of maternal (CPR, 45.5%) which is below national average health (Maternal Mortality Rate, women (53.5%) as per National Family Health Survey suffered abortions and women got infection (NFHS) Report 4th round 2015-16. Moreover, during intercourse) have been taken from the state has also been one of the poor NFHS round 4 (2015-16) and Annual Health performers in maternal health care. Neonatal Survey Report of Uttar Pradesh (2013-14). mortality and under ve mortality rate is 30 and These indicators of maternal health are selected 46 per 1000 live births (Sample Registration as they better represent the choice for System report, 2014-16) respectively in Uttar contraception. Effective Literacy Rate data has Pradesh. In the year 2016, IMR for U.P. was 41 been taken from census 2011. Infant Mortality per 1000 live births whereas for India it was 33 Rate has been taken from Annual Health per 1000 live births (Sample Registration Survey Report of Uttar Pradesh (2012-13) and System Report, 2014-16). Maternal Mortality district domestic product has been taken from Rate for Uttar Pradesh is very high with 216 per data.gov.in (2012-13). 100000 live births, whereas for India it is 122 For the study, both qualitative and per 100000 live births (MMR Special Bulletin, quantitative approach has been adopted to get 2015-17). Human Development Index value the desired goals. Calculation of Contraceptive for the state is 0.59 (2017). However, the Prevalence Rate has been done using the performance of the state in education index, following formula: health index and income index is below Implications of Human Development on Contraception and Maternal Health... 379 Maternal Health Index to investigate the been obtained by using the following formula: impact of contraception on maternal health has

Maternal Health Index has been generated Human Development Index for all the by taking Geometric Mean of all the three districts of Uttar Pradesh has been calculated indices (MMR, women suffered abortion and using human development approach using the women got infection during intercourse). following indicators:

Health Index · Infant Mortality Rate Education Index · Effective Literacy Rate Economy Index · Gross District Domestic Product in Rupees at constant prices.

Computation of Human Development Index Individual Dimension Index which is as includes two steps. 1st one is computation of follows-

For negative indicators the numerator where 70 per cent of the married women of 15- becomes maximum value- actual value. The 49 age groups use contraception. Top ve second step involves the geometric mean of all districts where the rate of contraception is the three indices (Health Index, Education exceptionally high are , Mahamaya Index and Economy Index). Thus, Human Nagar, Kanshiram Nagar, and Etah Development Index has been generated (Table 1). following the above steps. The class intervals The districts with high CPR are situated in for human development has been categorized the region which is into 3 categories- high, medium and low. The considered to be economically prosperous class intervals have been made by using (Figure 1). The districts where the percentage mean+1 SD and mean-1 SD. of women using contraception is low are Basti, Result and discussion Shrawasti, Bahraich, Gonda and Balrampur Family planning has widespread positive (Table 1). In Balrampur, the CPR is extremely impacts on human health and well-being. low. Only 7 per cent of married women in Contraceptive decreases unintended Balrampur use any type of contraception. The pregnancies and reduces infant and maternal other districts of eastern U.P. also fall under the mortality and morbidity. It is expected that this low CPR category. These are the districts, would enable women to choose an appropriate which perform poor in health and education method and initiate contraception. It is found sector. The population of eastern Uttar Pradesh that the Contraceptive Prevalence Rate is is mostly dependent upon subsistence maximum in Gautam Buddha Nagar (Noida) agriculture, which is reected in their socio- 380 Divyanshi Singh and Vijay Kumar Baraik

Table 1: Contraceptive Prevalence Rate (CPR) of best and poor performer districts District CPR (in percentage) Top Five Districts Gautam Buddha Nagar 70.32 Mahamaya Nagar 63.25 Kanshiram Nagar 63.00 Meerut 59.65 Etah 59.32 Bottom Five Districts Basti 26.22 Gonda 20.64 Bahraich 19.00 Shrawasti 18.00 Balrampur 7.22 Source: National Family Health Survey (NFHS) 4th Round (2015-16)

economic condition. All of these factors have led to the low contraceptive prevalence rate in eastern Uttar Pradesh. Difference in the type of contraceptives usage is also found in the districts of Uttar Pradesh. Most of the married women (69.25 percent) use modern contraceptive methods, whereas 31 per cent of them use traditional contraceptive methods. Lalitpur, Jhansi, and are the districts where the usage of modern contraceptives is high (more than 45 Per cent) which clearly shows the impact of development in these districts of western Uttar Pradesh. However the percentage of married women using modern contraception is not very high in the district of U.P. because of preference towards traditional methods and female sterilization. In districts like Siddharthnagar, Badaun, Fatehpur and Balrampur it is below 20 percent. Maternal Health of Married Women Uttar Pradesh has been one the poor Figure 1: District-wise Patterns of performer in controlling maternal mortality. Contraceptive Prevalence Maternal mortality of Uttar Pradesh is around Source: National Family Health Survey 216 per 100000 live births which is very high (NFHS) 4th Round (2015-16) than the national average. Implications of Human Development on Contraception and Maternal Health... 381 districts of western U.P. (Figure 2). Abortions and Still Births Districts like Sonbhadra, Hamirpur, Jalaun, Lalitpur and Mirzapur are the least sufferers of this particular problem (Table 2). Married women of districts like Mau, Siddharthnagar, Bahraich, Kaushambi and fall the under the moderate category. The districts of western Uttar Pradesh show high abortion and still birth rates and the prime reason behind such pattern may be large reporting and institutional abortions due to higher level of development (Goli & Jaleel, 2014). The married women of , Ghaziabad, Saharanpur, and suffer most of the abortions, miscarriages and still births out of pregnancy (Table 2).

Table 2: Best and poor performer districts in women suffering abortions and still births Figure 2: District-wise Patterns of Maternal Mortality Rate District Abortions and Still Births (%) Source: National Family Health Survey Best Five Districts (NFHS) 4th Round (2015-16) Sonbhadra 7.53 Hamirpur 7.05 The poor condition of maternal health in Jalaun 6.83 Uttar Pradesh is due to the subordinated status Lalitpur 4.71 attributed to females within the family and Mirzapur 3.93 society, poor health care infrastructure, lack of Bottom Five Districts institutional deliveries, low nutritional level, Aligarh 47.64 anaemia problem and lack of anti-natal and Ghaziabad 44.82 post-natal care (Dasgupta, Jashodhara, 2011). Saharanpur 41.23 The districts of eastern Uttar Pradesh have high Moradabad 38.82 Maternal Mortality Rate whereas districts of Bareilly 38.78 western Uttar Pradesh have very low Maternal Mortality Rate. Districts like Baghpat, Gautam Source: National Family Health Survey Buddha Nagar, Ghaziabad and Meerut have (NFHS) 4th Round (2015-16) very low Maternal Mortality Rate whereas Shrawasti, Gonda, Siddharthnagar and More than 35 percent of the married Sultanpur have high Maternal Mortality Rate. women in these districts suffer this problem. This pattern can be generally associated with The problem is more evident in these districts the development and multi-dimensional due to more reporting and availability of impacts of National Capital Region in the advanced technology. 382 Divyanshi Singh and Vijay Kumar Baraik Infant Mortality Rate Infant Mortality Rate of Uttar Pradesh is comparatively high. It is 68 per thousand live births. Spatial variation in Infant Mortality Rate is also very evident across different districts of Uttar Pradesh. The Infant Mortality Rate is extremely high in Shrawasti district. It is 96 per thousand live births. There are 36 such districts whose Infant Mortality Rate is more than state's average Infant Mortality Rate. Districts like Faizabad, Balrampur, Siddharthnagar and Pratapgarh have very high Infant Mortality Rates. On the other hand, districts like , , Noida, Jhansi and Nagar have very low Infant Mortality Rates. In Kanpur Nagar, IMR is 31 per thousand live births, which is close to the national average. It is very clear that eastern Uttar Pradesh has high Infant Mortality Rate, whereas western Uttar Pradesh has low Infant Mortality Rate (Figure 3). One of the reasons behind this is the availability of good health and educational infrastructure in western Uttar Figure 3: District-wise Patterns of Infant Pradesh. Moreover, districts of western Uttar Mortality Rate Pradesh are economically more prosperous. Source: National Family Health Survey IMR and MMR are closely associated since the th (NFHS) 4 Round (2015-16) factors explaining these two indicators are the same and decline in one will denitely lead to a corresponding decline in the other (Goli & the regional level differences and it can be Jaleel, 2014). deduced that regional inuences are quite Levels of Human Development instrumental in determining the performance of Uttar Pradesh comes under Empowered the districts therein. Action Group. The developmental level is low The Human Development Index (HDI) for in the state be it economic, human or social. all districts of Uttar Pradesh show that eastern The literacy rate of the state is 67.68 per cent, region still continues to remain the most which is less than the national average. backward region of the state with an HDI of Male literacy rate is 77 per cent and female 0.574 i.e., quite below the state's score (Figure literacy rate is 57.18 per cent. Given the social 4). and spatial disparities prevailing in the state, it Although this region records comparat- becomes essential to analyse the Human ively high score in education and health Development status of the districts, which lie in dimensions but lag behind in terms of standard different geographical regions. The of living, which indicates the lack of avenues aforementioned results give a clear picture of and forward bearing of health and education. Implications of Human Development on Contraception and Maternal Health... 383 Table 3: District-wise Human Development

Source: Calculated by authors from National Family Health Survey (NFHS) 4th Round (2015-16) 384 Divyanshi Singh and Vijay Kumar Baraik from the place of highest number of districts of this region in the 'High' category of HDI. The western region which is known to be the richest and most developed region of the state has stood rst if we rank the regions on the basis of their HDI performance. Most of the state's industrial hubs are located in this region. With an HDI score of 0.630 (three indicators), logically, this region has maximum number of districts to its credit falling in the 'High' human development group. In addition, the region has done quite well in education and health dimensions and in terms of standard of living it has accomplished the highest HDI score. Relationship of Contraceptive Prevalence Rate, Maternal Health and Levels of Human Development In order to see the relationship between contraceptive prevalence rate and maternal health, the correlation between the indicators of Figure 4: District-wise Patterns of Human Maternal Health Index and Contraceptive Development Index Prevalence Rate was calculated. Correlation Source: National Family Health Survey between CPR and MMR is found to be -0.749, (NFHS) 4th Round (2015-16) between CPR and IMR, it was -0.49. Correlation between maternal health indicators But in comparison to the other regions, it faces has also been calculated which is 0.44 for IMR a challenging situation in all three dimensions and MMR whereas between MMR and of human development. abortions, still birth experiencing women it was According to the Uttar Pradesh Human 0.509. When correlation between Maternal Development Report 2003, among the four Health Index and CPR was calculated, it came regions, incidence of poverty was the lowest in to be 0.618. It is very clear that higher the the western region, while it was the highest in contraceptive prevalence rate, good the the central region (UPHDR, 2008). The eastern maternal health will be. Both the contraceptive region exhibits a comparatively better prevalence rate and maternal health condition performance with the HDI score of 0.625 (three follow the same pattern in western and eastern indicators) but the pattern is similar to eastern Uttar Pradesh. The districts of western Uttar region i.e., high human development in terms Pradesh show that higher the Contraceptive of educational and health attainments but a Prevalence Rate, better the maternal health will discouraging living standard. The benets be. Moreover, the districts of northern Uttar accrued from the green revolution boom have Pradesh show that they are backward in placed the Western region of Uttar Pradesh in contraceptive prevalence rate as well as quite a developed territory in the fashion same maternal health conditions. as of and Punjab. This is apparent There is a strong positive relationship Implications of Human Development on Contraception and Maternal Health... 385 between Contraceptive Prevalence Rate and negative correlation (-0.589) and between Human Development Index (0.589). Gross District Domestic Product and Effective Moreover, the correlation between the Literacy Rate, strong positive relationship is indicators of human development has also been found (0.526). calculated. Between Gross District Domestic As indicated by Table 4, it is very evident Product and IMR, there is strong negative from the gures that the districts of western correlation (-0.41). Between IMR and Uttar Pradesh which perform better in human Effective Literacy Rate, there is strong development, they also perform better in

Table 4: Categorization of Districts on the Basis of their Performance in Contraceptive Prevalence Rate, Maternal Health Index and Human Development Index High HDI, High HDI, Low HDI, Low HDI, High CPR and High Maternal High CPR and Low CPR and High Maternal Health Index Low Maternal Low Maternal Health Index low CPR Health Index Health Index Ÿ Gautam Buddha Ÿ Auraiyya¹ Ÿ Etah¹ Ÿ Balrampur² Nagar¹ Ÿ Firozabad¹ Ÿ Etawah¹ Ÿ Bahraich² Ÿ Ghaziabad¹ Ÿ Mirzapur² Ÿ Meerut¹ Ÿ Basti² Ÿ Hathras¹ Ÿ Mainpuri¹ Ÿ Pilibhit¹ Ÿ Shrawasti² Ÿ ¹ Ÿ Kanpur Dehat² Ÿ Faizabad² Ÿ Gonda² Ÿ Lucknow² Ÿ Siddharthnagar² Ÿ Kanpur Nagar² Ÿ Baghpat¹

¹Districts of Western Uttar Pradesh ² Districts of Eastern Uttar Pradesh Source: National Family Health Survey (NFHS) 4th Round (2015-16) contraceptive prevalence rate and maternal and Maternal Mortality Rate and this high health, whereas districts of eastern Uttar usage of contraceptives is due to higher level of Pradesh where percentage of married women literacy and better economic conditions. using contraceptives is low, maternal health is Auraiya, Firozabad, Mirzapur and Kanpur very poor and they are the poor performer on perform better in human development but Human Development Index. contraceptive prevalence rate is low in these Districts like Gautam Buddha Nagar, districts. Strong relationship between levels of Ghaziabad, Lucknow, Hathras and Kanpur human development and maternal health can Nagar are the best performer districts on be easily asserted from Table 4. Moreover, the Human Development parameter. More than 55 Table shows a clear regional pattern of per cent of the married women of these districts contraceptive usage and maternal health. The use contraceptives and this high usage of districts belonging to Harit Pradesh (western contraceptives have resulted into better Part of U.P.) which are more urbanized and maternal health, reduced Infant Mortality Rate industrialized and where the development has 386 Divyanshi Singh and Vijay Kumar Baraik spread to the adjacent districts are better lead to less infant mortality and less maternal performer in contraceptive usage and maternal mortality. There is a moderate positive relation health. The contraceptive usage pattern and between levels of human development and maternal health condition follow the contraceptive prevalence rate (0.589). Districts development trajectory where the eastern part showing high human development have high is a clear looser and the western one is be percentage of contraceptives' usage by married winner. High human developments have women which is evident in districts of western shown positive impact on maternal health Uttar Pradesh. There is positive relation condition in Auraiyya, Firozabad and Mainpuri between levels of human development and but still the family planning methods have not maternal health where districts of eastern Uttar got enough popularity in these areas. The Pradesh with inadequate education and health strong roots of classical patriarchy and taboo facilities show clear inuence on maternal attached to family planning methods have health. Better human development has resulted discouraged the women from using into better maternal health care in western Uttar contraceptives in these areas. In districts like Pradesh. Etah, Etawah, Meerut and Siddharthnagar the The regional analysis of this pattern reveals CPR is high but maternal health and levels of that the eastern region adjoining is still human development is low where high IMR very traditional having lack of many facilities and high MMR exist. The argument behind and services coupled with lower level of such situation has been given as one of the development. The western region has highest proportions of women reporting any locational or geographical advantage in many maternal and reproductive health problems respects starting from green revolution and belong to these districts of western Uttar agriculture, industries, urbanization, tourism, Pradesh (Prasad and Satyamala, 2006). proximity of many propulsive urban centres, Balrampur, Bahraich, Basti, Shrawasti and and multi-dimensional impacts of National Gonda have very low level of human Capital Region, where one of the very development which is evident in low usage of important factors is the breaking of taboos and contraceptives and poor maternal health. In adaptation of modern health care services these districts, literacy rate is very low, along with living conditions, food and economically also, they are very backward. nutrition, health care facilities, employment Infant Mortality Rate and Maternal Mortality and income. 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