DLHS -2 DLHS-2

Himachal Pradesh

Reproductive and Child Health

District Level Household Survey

2002-04

International Institute for Government of India, Society for Applied Research in Population Sciences, Ministry of Health & Humanities Family Welfare, New Delhi – 110 067 (Deemed University) Mumbai – 400 088 New Delhi- 110 011 Reproductive and Child Health

District Level Household Survey (DLHS -2)

Himachal Pradesh

2002-04

International Institute for Ministry of Health & Society for Applied Research Population Sciences, Family Welfare, in Humanities (Deemed University) New Delhi- 110 011 New Delhi – 110 067 Mumbai – 400 088

CONTRIBUTORS

Society for Applied Research in Humanities, New Delhi

O. P. Vig Ummed Singh Ghanshyam Upadhyay B. K. Yadav Ajay Tripathi Ravikesh

International Institute for Population Sciences, Mumbai

F. Ram B. Paswan L. Ladu Singh K. C. Lakhara Akash Wankhede

CONTENTS Page Tables …………………………………………………………………………….……… iv Figures …………………………………………………………………………..…..……vii Maps… …………………………………………………………………..……………….vii Preface and acknowledgement ……………………………………………………………ix Key Indicators …………………………………………………………………….………xi Salient Findings …………………………………………………………………..………xiii CHAPTER I INTRODUCTION 1.1 Background and Objectives of the Survey ………...……….………………………. 1 1.2 Survey Design..………………………….………..…………….…………………. 1 1.3 House Listing and Sample Selection …………….………….……….…………….2 1.4 Questionnaire ….……………………………….….………..…………….………..3 1.5 Fieldwork and Sample Coverage ……………..…………..………………………..4 1.6 Data processing ………………………………………..………………………….. 5 1.7 Sample Weights ………………………………..…………………………………..5 1.8 Sample Implementation ………………………..…………………………………..6 1.9 Basic Demographic Profile of the State…….………..………..……………………7 CHAPTER II BACKGROUND CHARACTERISTICS OF HOUSEHOLD 2.1 Age –Sex Structure.…………………………………………………………………9 2.2 Household Characteristic …………………………………………………………..10 2.3 Educational Level .…………………………………………………………………11 2.4 Marital Status of the Household Population ……………………………………….14 2.5 Marriages ……….………………………………………………………………….15 2.6 Morbidity Rates …..……………………………………………………………….. 16 2.7 Morbidity Rates by District……………………………………………………….. 18 2.8 Housing Characteristics ……………………………………………………………18 2.9 Housing Characteristics by District…………………………………………………21 2.10 Iodization of Salt ……………………………………………………………………22 2.11 Iodization of Salt by District……………… .………………………………………23 2.12 Availability of Facilities and Services in Rural Population…………………………24 2.13 Availability of Education Facility and Health Services by District…………………26 CHAPTER III CHARACTRERISTICS OF WOMEN, HUSBANDS AND FERTILITY

3.1 Background Characteristics of Women ……………………………………………31 3.2 Educational Level of Women ………………………………………………………33 3.3 Background Characteristics of Husbands’ of Eligible Women ……………………34 3.4 Educational Level of Husbands’ of Eligible Women ………………………………36 3.5 Children Ever Born and Surviving …………………………………………………37 3.6 Completed Fertility by District……………. ………………………………………38 3.7 Birth Order …………………………………………………………………………39 3.8 Birth Order by District ……………………………………………………………..40 3.9 Fertility Preference …………………………………………………………………41 3.10 Pregnancy Outcomes ………………………………………………………………42

Page CHAPTER IV MATERNAL HEALTH CARE 4.1 Antenatal Check-Ups…………………………………………………………………45 4.2 Antenatal Check-Ups at Health Facility……………………..………………………48 4.3 Antenatal Check-Ups by District…………………………….………………………50 4.4 Components of Antenatal Check-Ups………………………………………….……51 4.5 Antenatal Care Services………………………………………………………..…… 51 4.6 Antenatal Care Indicator by Districts…………………………………………..……56 4.7 Pregnancy Complication and Treatment………………………………………..……58 4.8 Delivery Care……………………………………………………………………...…61 4.8.1 Place of Delivery………………………………………………………………….…61 4.8.2 Assistance during Home Delivery ………………………………………………..…64 4.8.3 Delivery Assisted by Skilled Person…………………..…………………………..…64 4.9 Reasons for Not Going to Health Institutions for Delivery……………………….…66 4.10 Delivery Characteristics by Districts………………………………………………...67 4.11 Complication during Delivery….……….…………………………………………...68 4.12 Post Delivery Complication and Treatment …………………………………..……. 70 4.13 Obstetric Morbidity by District …….……..…………………………………………73 CHAPTER V CHILD CARE AND IMMUNIZATION

5.1 Breastfeeding……………………………….……………..…………………………77 5.1.1 Breastfeeding by Districts……………………………………………………………79 5.2 Immunization of Children……………………………………………………………81 5.3 Source of Immunization………………………………………………………………85 5.4 Vitamin A and IFA Supplements …….. ……………………….……………………86 5.5 Immunization Coverage by Districts…………………………………………………88 5.6 Child Morbidity and Treatment………………………………………………………89 5.6.1 Awareness of Diarrhoea…………………….………………………………………89 5.6.2 Treatment of Diarrhoea………………………………………………………………89 5.6.3 Awareness of Pneumonia …………………….………………………………………91 5.6.4 Treatment of Pneumonia……………………………………………………………92 5.6.5 Knowledge of Diarrhoea Management and Pneumonia by District. …….…………94 CHAPTER VI FAMILY PLANNING 6.1 Knowledge of Family Planning Methods…….………………………………………97 6.1.1 Knowledge of Family Planning Methods by District……..…………………………98 6.1.2 Knowledge of No-Scalpel Vasectomy ….……………..……………………………100 6.1.3 Knowledge of No-Scalpel Vasectomy by District………..…………………………100 6.2 Current Use of Family Planning Methods….……………..…………………………101 6.2.1 Current Use of Family Planning Methods by District……..…………………………103 6.2.2 Current Use and Ever Use of Family Planning Methods by Women.………………104 6.2.3 Current Use and Ever Use of Family Planning Methods as Reported by Husbands. 104 6.3 Reasons for Not Using Male Methods.…….……………..…………………………106 6.4 Source of Contraceptive Methods………….……………..…………………………106

ii Page 6.5 Problems with Current Use of Contraceptive Method……..……………………… 108 6.6 Treatment for Health Problems with Current Use of Contraception……….....……109 6.7 Advice to Non-Users to Use Contraception…………..………………………….…109 6.7.1 Future Intension to Use Contraceptive ….……………..……………………………110 6.7.2 Future Intention to Use Among Women by Number of Living Children……………112 6.8 Reasons for Discontinuation and Non-Use of Contraception………………………112 6.8.1 Reasons for Not Using Contraceptive Methods…………..…………………………113 6.9 Unmet Need for Family Planning Services..……………..…………………………115 6.9.1 Unmet Need for Family Planning Services by District…..…………………………115 CHAPTER VII ACCESSIBILITY AND PERCEPTION ABOUT GOVERNMENT HEALTH FACILITIES 7.1 Home Visit By Health Worker………………………..…………………………… 119 7.2 Home Visit By Health Worker by District..……………..………………………… 121 7.3 Matter Discussed during Home Visit or Visits to Health Facilities.…………………122 7.4 Visit to Health Facility………………….……………..……………………………124 7.5 Visit to Health Facility by District…………….……..………………………………125 7.6 Client’s Perception of Quality of Government Health Services.……………………125 7.7 Reasons for Not Visiting Government Health Centre….……………………..…… 126 7.8 Family Planning Information and Advice Received ………….……………………126 7.9 Availability of Pills and Condom………..…………..…………………………..… 127 7.10 Quality of Care of Family Planning Services……………..…………………………127 7.11 Quality of Care Indicators for Contraceptive Users by District. ……………………129 7.12 Quality of Care of Maternal Health Care….……………..…………………………130 CHAPTER VIII REPRODUCTIVE HEALTH PROBLEMS AND AWARENESS OF RTIs/STIs and HIV/AIDS 8.1 Awareness of RTI/STI……………………………………………………………….133 8.1.1 Knowledge of Mode of Transmission of RTI/STI……………………………………135 8.2 Prevalence of RTI/STI……………….. ………………………………………………138 8.3 Menstruation Related Problems………………………………………………………142 8.4 Prevalence of RTI/STI by District …….. ……………………………………………143 8.5 HIV/AIDS……………………………………………………………………………144 8.5.1 Knowledge of HIV/AIDS……………………………………………………………145 8.5.2 Knowledge of Mode of Transmission about HIV/AIDS…………………………….148 8.5.3 How to avoid HIV/AIDS…………………………………………………………….150 8.5.4 Misconception about HIV/AIDS…………………………………………………….153 8.5.5 Knowledge of Curability of HIV/AIDS………………………………………………155 8.6 Awareness of RTI/STI and HIV/AIDS by District…………….…………………… 155 APPENDICES Appendix A Estimation of Sampling Errors ……………………….…..………….… 157 Appendix B DLHS Staff …………………………………………………………..…163 Appendix C Questionnaire ……………………………………………………..…… 167

iii TABLES Page Table 1.1 Number of households interviewed..…………………………..……………. 7 Table 1.2 Number of women and husbands interviewed ……………………..…..……7 Table 1.3 Basic demographic indicator ……………………………………………..… 8 Table 2.1 Household population by age and sex …………………………………..……10 Table 2.2 Household characteristics ………………………….……………………..…11 Table 2.3 Educational level of the household population …………………………..…12 Table 2.4 Marital status of the household population ……………………………..……15 Table 2.5 Marriage ……………………………………………………………..………16 Table 2.6 Morbidity rates ……………………….…………………………………..…17 Table 2.7 Morbidity rates by district……… …………………………………..………18 Table 2.8 Housing characteristics …………………………………………………..… 19 Table 2.9 Housing characteristics by district……….. ………………………..……….21 Table 2.10 Iodization of salt…………………………………………………………..…23 Table 2.11 Iodization of salt by district……… ………………………………..………. 24 Table 2.12 Distance from the nearest education facility …………………………..……25 Table 2.13 Distance from the nearest health facility ………………………………..……25 Table 2.14 Availability of services …………………………………………………..… 26 Table 2.15 Availability of facility and services by district…………. …………..………26 Table 3.1 Background characteristics of women …………………………………..……32 Table 3.2 Level of education of eligible women …………………………………..……34 Table 3.3 Background characteristics of men ……………………………………..……35 Table 3.4 Level of education of men ………………………………………………..…36 Table 3.5 Children ever born and living …………………………………………..……38 Table 3.6 Completed fertility by district …………………………………………..……39 Table 3.7 Birth order ……………………………………………………………..……40 Table 3.8 Birth order by district …………………………………………………..……42 Table 3.9 Fertility preference ……………………………………………………..……43 Table 3.10 Outcomes of pregnancy ……….………………………………………..……44 Table 4.1 Antenatal check-up ……………………………………………………..……46 Table 4.2 Place of antenatal check-up ……………………………………………..……49 Table 4.3 Antenatal check-ups by district …………………………………………..…50 Table 4.4 Components of antenatal check-ups ……………………………………..… 51 Table 4.5 Antenatal care ………………………………….…………………..………. 53 Table 4.6 Antenatal care indicators by district ……………………………………..… 57 Table 4.7 Pregnancy complications …….……………………………………..……… 59 Table 4.8 Treatment for pregnancy complications ………………………………..……61 Table 4.9 Place of delivery…………………………………………………………..…62 Table 4.10 Assistance during home delivery and safe delivery ……………………..……65 Table 4.11 Reasons for not going to health institutions for delivery ………………..……67 Table 4.12 Delivery characteristics by district ……………………………………..……68 Table 4.13 Delivery complications …………………………………………………..…69 Table 4.14 Post delivery complications ……………………………………………..……71 Table 4.15 Treatment for post delivery complication….…………………...…………...73 Table 4.16 Pregnancy, delivery and post delivery complications…………………..….. 74

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Table 5.1 Initiation of breastfeeding ………………………………………………..… 78 Table 5.2 Exclusive breastfeeding by child’s age ………………………………………80 Table 5.3 Breastfeeding by district ………………………………………………..……80 Table 5.4 Vaccination of children …………………………………………………..… 82 Table 5.5 Childhood vaccination received by 12 months of age ……………………… 85 Table 5.6 Source of childhood vaccination ………….…………………………..…… 86 Table 5.7 Vitamin a and IFA supplementation for children ………………………..… 87 Table 5.8 Childhood vaccination by district ………………………………………..… 88 Table 5.9 Awareness of diarrhoea …………………………………………………..… 90 Table 5.10 Treatment of diarrhoea …………………………………………………..… 91 Table 5.11 Awareness of pneumonia ………………………………………………..……93 Table 5.12 Treatment of pneumonia ………………………………………………..……94 Table 5.13 Knowledge of diarrhoea management and pneumonia by district ……..……95 Table 6.1 Knowledge of contraceptive methods …………………………...…………. 98 Table 6.2 Knowledge of contraceptive methods by districts ……………………..…… 99 Table 6.3 No-scalpel vasectomy (NSV)……………………………………………..… 100 Table 6.4 No-scalpel vasectomy by district ………………………………………..……101 Table 6.5 Contraceptive prevalence rate …………………………………………..……102 Table 6.6 Contraceptive prevalence rates by districts ……………………………..……103 Table 6.7 Use of contraception by women ………………………………………..……105 Table 6.8 Use of contraception by men ……………………………………………..… 106 Table 6.9 Reasons for not using male methods ……………………………………..… 107 Table 6.10 Source of modern contraceptive methods ………………………………..… 107 Table 6.11 Health problems with current use of contraception……………………..……109 Table 6.12 Sought treatment for health problems with current use of contraception ……110 Table 6.13 Advice on contraceptive use ……………………..………………..………. 111 Table 6.14 Future intention to use …………………………………………………..……111 Table 6.15 Future use of contraception by number of living children ……………..……113 Table 6.16 Reasons for discontinuation of contraception …………………………..……114 Table 6.17 Reason for not using contraceptive method ………….………………..…… 114 Table 6.18 Unmet need for family planning services ………………………………..… 116 Table 6.19 Unmet need by district …………………………………………………..……117 Table 7.1 Home visit by health worker ……………………………………………..… 120 Table 7.2 Home visit by health worker by district ………………………………..……122 Table 7.3 Matter discussed during contact with a health worker ….………………..… 123 Table 7.4 Visit to health facility …………………………………………………..……124 Table 7.5 Visit to health facility by district ………………………………………..……125 Table 7.6 Quality of government health facility …………………………………..……126 Table 7.7 Reason for not preferring government health facility …………………..……127 Table 7.8 Advise to adopt family planning method ………………………………..……127 Table 7.9 Availability of regular supply of condoms/pills ………………………..……128 Table 7.10 Information of other modern method before sterilization ………………..… 128

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Table 7.11 Information on side effect and follow-up for current method …………..……129 Table 7.12 Quality of care indicators for contraceptive users by district ……………… 130 Table 7.13 Advised to have delivery at health facility and follow-up services for post partum check-up ………………….………..…………………………..…… 131 Table 7.14 Quality of care indicators for maternal care …………….………………..… 131 Table 8.1 Source of knowledge about RTI/STI among women ……………………… 134 Table 8.2 Source of knowledge about RTI/STI among men ………………………..… 136 Table 8.3 Source of knowledge about mode of transmission of RTI/STI among women ……………………………………………………………..………. 137 Table 8.4 Source of knowledge about mode of transmission of RTI/STI among men …138 Table 8.5 Symptoms of RTI/STI among women …………………………………..……140 Table 8.6 Symptoms of RTI/STI among men ……………………………………..……141 Table 8.7 Abnormal vaginal discharge …………………………………………..…… 142 Table 8.8 Menstruation related problems …………………………………………..… 143 Table 8.9 Reproductive health care indicators by district …………………………..… 144 Table 8.10 Source of knowledge about HIV/AIDS among women ………………..……146 Table 8.11 Source of knowledge about HIV/AIDS among men ……………………..… 147 Table 8.12 Source of knowledge about mode of transmission of HIV/AIDS among women ……………………………………………………………..………. 149 Table 8.13 Source of knowledge about mode of transmission of HIV/AIDS among men ……………………………………………………………..………….. 150 Table 8.14 Knowledge about avoidance of HIV/AIDS among women ……………..… 151 Table 8.15 Knowledge about avoidance of HIV/AIDS among men ………………..……152 Table 8.16 Misconception about transmission of HIV/AIDS among women ……………153 Table 8.17 Misconception about transmission of HIV/AIDS among men …………..… 154 Table 8.18 Knowledge of curability about HIV/AIDS ……………………………..……155 Table 8.19 Awareness of RTI/STI and HIV/AIDS by district ……………………..……156

vi FIGURES Page Figure 2.1 Age-sex-pyramid ………………………………………………………..……9 Figure 2.2 Percentage literate by age and sex ………….…………………………..……13 Figure 3.1 Birth order 3 & above by selected background characteristic …………..……41 Figure 3.2 Birth order 3 & above by district …………………………………..……….42 Figure 3.3 Fertility preference……………………………………………………..……43 Figure 4.1 Source of antenatal care ………………………………………………..……47 Figure 4.2 Full antenatal care by background characteristic ………………………..……57 Figure 4.3 Percentage of women with pregnancy complication and by symptoms ……60 Figure 4.4 Place of delivery and assistance during delivery ………………………..……63 Figure 4.5 Delivery assisted by skilled person by background characteristic ………… 66 Figure 4.6 Percentage of women with delivery complication and by symptoms ………70 Figure 4.7 Percentage of women with post delivery complication and by symptoms.…72 Figure 5.1 Initiation of breastfeeding ………………………………………………..…79 Figure 5.2 Percentage of children age 12-23 months who have received specific vaccination ……………………………………………………………..……83 Figure 5.3 Percentage of children age 12-23 months who have received all vaccination ……………………………………………………………..……84 Figure 5.4 Child vaccination by age ………………………………………………..……86 Figure 6.1 Knowledge of family planning method …………………………………..…99 Figure 6.2 Practise of family planning method ……………………………………..……101 Figure 6.3 Source of family planning among current users of modern contraceptive methods ……………………………………………………………..………108 Figure 7.1 Distribution of districts by home visit by health worker ………………..……121. Figure 8.1 Symptoms of RTI/STI among women …………………………………..……135 Figure 8.2 Symptoms of RTI/STI among men ……………………………………..……139 Figure 8.3 Awareness of RTI/STI by sex according to residence …………………..……140 Figure 8.4 Awareness of HIV/AIDS by sex according to residence ………………..……148

MAPS Page Map 1 Percent Girl Marrying Below Legal Age at Marriage……………………….. 28 Map 2 Percentage of Households Using Salt that Contains 15 ppm Level of Iodine 29 Map 3 Percentage of Women Received Three or More Antenatal Check Ups……… 75 Map 4 Percentage of Delivery Attended by Skilled Person.……….…………………76 Map 5 Percentage of Children (Age 12-23 Months) Who Have Received Full Vaccination………………………. ………………………………………… 96 Map 6 Current Use Of Any Family Planning Method……………………………..…118

vii PREFACE AND ACKNOWLEDGEMENT

Government of India had launched the Reproductive and Child Health (RCH) program to ensure that couples have access to adequate information and services for reproductive health care. As a first step, family planning target has been withdrawn and an effort is being made to provide a package of reproductive services at different levels of health care centres.

Monitoring of the services is also being improved. New indicators are being added to assess quality of services and provision of an integrated reproductive health care service. The District Level Household Survey (DLHS) was initiated by Government of India and financed by the World Bank covering all the districts in the country. For the second time, district level estimates will be available for most of the critical reproductive health indicators. These important initiatives are certainly quite satisfying for all those who are concerned with taking ICPD reproductive health agenda ahead. The project is being coordinated by International Institute for Population Sciences, Mumbai and implemented by a number of consulting agencies.

For the purpose of data collection, uniform questionnaires, sampling design and field procedures were used throughout the country. The survey thus provided comparable data for all the districts in the state. The present report provides salient findings of Himachal Pradesh and covered all the districts. The findings of selected indicators of reproductive and child health services from the state of Himachal Pradesh are presented in the report.

It is believe that the data generated through the survey will meet the requirements of the Programme Administrators and Policy Makers for making effective interventions for providing quality services and achieving multiple objectives.

The DLHS-RCH could not have been successfully completed without cooperation and support from innumerable sources at various stages of the project. Although, it is not possible to acknowledge everyone involved in the survey, several organizations and individuals deserve special mention.

We would like to take this opportunity to acknowledge Shri P.K. Hota, Secretary, Ministry of Health and Family Welfare (MoHFW), Government of India. Our special thanks are due to Shri Y.N. Chaturvedi, Shri A.R. Nanda and Shri J.V.R. Prasada Rao, former Secretaries, Department of Family Welfare, GoI, who have gave us an opportunity to participate as consulting organisation in the survey of the national importance. Our special thanks are due to Shri S.K. Sinha, Additional Director General, Ministry of Health and Family Welfare, GoI. Thanks are due to Shri K.V. Rao, Shri S.K. Das and Shri D.K. Joshi, former Chief Directors for their help. We are also thankful to Shri Partha Chattopadhyaya, Chief Director and Mr. K.D. Maiti, Director, Mrs Rashmi Verma, and Mr. Rezimohn, Assistant Director, Statistics division of MoHFW for all the support extended by them. Our special thanks are due to Dr. T.K. Roy, former Director and Senior Professor, IIPS, Mumbai, for his timely advice and valuable guidance. Thanks are due to Dr. G. Rama Rao, Officiating Director, IIPS, Mumbai. We also acknowledge the contribution of Dr. f. Ram, Dr. B. Paswan, Dr. L. Ladu Singh coordinators of the project at IIPS, Mumbai. Our thanks are also due to the Directors of Census Operations and the state Department of Health and Family Welfare in all the states and Union Territories. It also gives us immense pleasure to thank to Dr. G. N.V. Ramana, Public Health Specialist, World Bank, New Delhi for the able guidance and technical support to the project. We would also like to thank to NSSO for their help in providing UFS Block for DLHS-2.

Thanks are also due to Ms. Preeti Chauhan, Shri A.K. Jha and Shri Uttam J. Sonkamble Research Officers at IIPS for their assistance at various stages of the project.

We are thankful to Shri Vineet Choudhary, former Secretary, Government of Himachal Pradesh Department of Health & Family Welfare, for his help and encouragement for the survey work. We also acknowledge Dr. P.C. Kapoor, former Secretary, Government of Himachal Pradesh, Department of Health & Family Welfare for his keen interest and encouragement. We further acknowledge Dr. J.P. Nada, former Director of Health Services, and Dr. M.L. Mahajan, Director of Health Services, Government of Himachal Pradesh for their for their kind cooperation and logistic support. Thanks are due to officials of the Census Department at the centre and the state and officials of the NSSO and other district authorities for all the support rendered, which facilitated the smooth and timely completion of the data collection.

Thanks are due to our field and supervisory staff for timely completion of the fieldwork, in-spite of difficult terrain and other field hazards. Their hard work will be truly rewarded only when results of the survey meet requirements of the user agencies, especially the Ministry of Health & Family Welfare, New Delhi. Thanks are also due to Shri Brij Kishore Yadav for his hard work in timely completion of data processing and computational work. We would be failing in our duty if we do not thank our respondents who spent their valuable time with tremendous patience.

O.P.VIG Project Director New Delhi Society for Applied Research In Humanities June, 2006

x KEY INDICATORS, Himachal Pradesh DISTRICT LEVEL HOUSEHOLD SURVEY- REPRODUCTIVE AND CHILD HEALTH, (DLHS-RCH), 2002-04

Sample size 3 Adequate Iron folic acid tablets/syrup ………………… 42.8 Households surveyed………………………………… 13,136 4 Full antenatal check-up ………………………………… 32.5 Currently married women age 15-44………………. 8,618 2 Delivery characteristics Husband’s of eligible women……………………….. 4,550 54.3 Characteristics of households Delivery at home………………………………………… Delivery at government health institutions…………… 36.9 Percent rural…………………………………………… 77.5 Delivery at private health institutions…………………. 8.2 Percent Hindu…………………………………………. 95.7 5 Delivery attendant by skilled persons ……………….. 51.4 Percent Muslim………………………………………... 1.3 Child health Percent other religion (Sikh)………...... ……... 1.7 Percent of children whose mother squeezed out milk Percent scheduled caste…………………………….. 21.0 from her breast6…………………………………………. Percent scheduled tribe………………………………. 4.4 48.1 Percent of children7 with diarrhoea8 who received Percent with electricity……………………………….. 97.9 ORS………………………………………………………. Percent with flush toilet………………………………. 26.2 50.9 Percent of children7 with pneumonia8 who were taken Percent with no toilet facility…………………………. 56.2 to a health facility or provider…………………………… Percent living in Kachcha houses…………………… 26.1 78.3 Percent living in Pucca houses……………………... Percent of children who received 46.3 9 Percent with low standard of living………………….. 25.2 vaccinations Percent with high standard of living…………………. 35.0 BCG………………………………………………………... 96.1 Percent with iodized salt (15+ppm)…………………. 78.0 DPT (3 injections)………………………………………… 90.8 Characteristics of currently married Polio (3 drops)……………………………………………. 88.0 women age 15-44 years Measles……………………………………………………. 88.6 All vaccinations10….……………………………………… Percent below age 30 …………………………….. 44.1 79.3 No vaccination at all. ……………………………………. Percent with age at first cohabitation below age 18. 23.7 2.1 Percent illiterate……………………………………….. Percentage of women who had 21.7 2 Percent having 10 or more years of schooling…….. 39.6 Pregnancy complication ………………………………… 28.2 Delivery complication2…………………………………… 27.8 Percent with illiterate husband………………………. 9.0 2 Percent with husband 10+ years of schooling…… 57.4 Post delivery complication ……………………………… 25.6 Marriage Symptoms of RTI/STI……………………………………. 31.0 Problems of vaginal discharge…………………………. 17.6 Mean age at marriage for boys………………………. 26.0 Menstruation related problem…………………………... 17.6 Mean age marriage for girls………………………….. 21.7

Percent of boys married below age 21……………... 4.3 Awareness of RTI/STI and HIV/AIDS Percent of girls married below age 18………………. 2.9 Percent of women who have heard of RTI/STI……….. 37.2 Fertility Percent of women who have heard of HIV/AIDS……... 79.0 Mean children ever born women age 40-44 years… 3.2 Utilization of government health services Percent of births of order 3 and above1……………... 24.4 Antenatal care……………………………………….. 81.5 Current use of family planning method Treatment for pregnancy complication………………… 83.1 Treatment for post-delivery complication……………… 70.9 Any method…………………………………………….. 70.1 Treatment for vaginal discharge………………………... 71.1 Any modern method…………………………………… 65.4 Treatment for children with diarrhoea………………….. 62.1 Pill………………………………………………………. 3..8 Treatment for children with pneumonia………………... 57.1 IUD…………………………………………………….. 2.0 Quality of family planning services Condom……………………………………………….. 12.9 Percent non-users ever advised to adopt the family Female sterilization………………………………….. 41.1 planning method………………………………………….. 15.6 Male sterilization…………………………………….. 5.3 Percent users told about side effects of method……… 33.3 Any traditional method………………………………... 4.5 Percent users who received follow-up services………. 16.5 Rhythm/safe period………………………………….. 1.2

Withdrawal……………………………………………… 3.3

Unmet need for family planning Characteristics of husband of eligible Percent with unmet need for spacing……………….. 3.4 women Percent with unmet need for limiting………………... 8.4 Percent of husband knowing NSV……………………… 54.4 Percent with total unmet need……………………….. 11.8 Percent of men who have heard of RTI/STI…………... 34.4 2 Maternal care Percent of men who have heard of HIV/AIDS….…….. 90.2 Percent of women received antenatal check-ups 91.0 Percentage who had any symptoms of RTI/STI…….. 3.8 Antenatal check-up at home…………………………. 0.4 Sought treatment for RTI/STI …………………………. 59.6 Antenatal check-up in first trimester………………… 52.8 Three or more visit for ANC………………………….. 67.7 Two or more tetanus toxoid injections………………. 58.1

1 For births in past three years, 2 For live/still births during three years preceding the survey, 3 100 or more IFA tablets/Syrup, 4 A minimum of three visits for ANC, at least one TT injections and 100 or more IFA tablets/syrup, 5 Either institutional delivery or home delivery assisted by Doctor/ANM/nurse, 6 Children age below 3 years, 7 Last but one living children below age 3 years, 8 Last two weeks preceding the survey, 9 Last but one living children (age 12-23 months) born during three years preceding the survey. 10 BCG, three injections of DPT, three drops of polio and measles.

SALIENT FINDINGS

For the assessment of district level Reproductive and Child Health indicators, Government of India proposed to undertake district level household surveys through non-governmental agencies on an annual basis. The District Level Household Survey (DLHS) was the result of government’s initiative. In Himachal Pradesh, Society for Applied Research in Humanities, India was entrusted to carry out the survey work. The survey for Phase-1 of the DLHS covering six districts of the state was conducted during April 2002 to August 2002. The survey for Phase-2 covering the remaining six districts of the state was carried out during January 2004 to June 2004. The focus of the survey was on: i) Coverage of ante natal care (ANC) and immunization services, ii) Extent of safe deliveries, iii) Contraceptive prevalence rate and unmet need for family planning, iv) Awareness about RTI/STI and HIV/AIDS and v) Utilization of government health services and users’ satisfaction. The salient findings of the survey are presented here.

For both the phases together, the data was collected from 13,137 households in Himachal Pradesh. From these households, 8,618 eligible women (usual resident or visitors who stayed in the sample household the night before the interview, currently married aged 15-44 years whose marriage was consummated) and 4,550 husbands of eligible women were interviewed.

Of the total households interviewed in Himachal Pradesh, over 22 percent were from urban areas. There were 96 percent Hindu households, one percent Muslim and three percent from other category in the sample. Twenty-five percent of the households belonged to either scheduled castes or scheduled tribes. Twenty–six percent of the households lived in Kachcha, 27 percent in Semi-pacca and 46 percent in pucca houses. Twenty-five percent of the households were with low SLI, 40 percent with medium SLI and 35 percent with high SLI.

Eight-tenth of the population aged seven and above was literate. Percent literate among females was 72 percent as against 88 percent among males. Proportion of non-literate was much higher among the older cohort compared to the younger ones. Nearly 22 percent of eligible women in the state were non-literate and 40 percent have completed 10 or more years of schooling. In Himachal Pradesh the level of literacy among the eligible women and their husbands was quite high. As regards distribution of non-literate women, lesser proportion of younger women’s below age 30 were illiterate compared to older women age 30 and above, but in case of non-literate husbands across age was more or less uniform, though it was marginally more for women below 30 years.

The reporting of marriages during three yeas prior to survey gives the mean age at marriage among the boys and girls in the state as 26.0 years and 21.7 years respectively. Over one percent of boys and about two percent of girls in the state got married before attaining the minimum legal age at marriage of 21 and 18 years respectively. In all the districts, except Chamba, Kinaur, Kullu, and Lahul & Spiti districts 10 percent or more of boys got married below the legal minimum age at marriage. On the other hand, only in Kinnaur and Kullu districts 10 percent or more of girls got married below the legal minimum age at marriage.

More than three-fourth of the households (78 percent) use cooking salt that was iodized at the recommended level of 15 parts per million or higher level of iodine content whereas six percent of households used salts that were not iodized at all. The lowest proportion of households (less than one percent) in Hamirpur district was using non-iodized salt whereas in Sirmaur district the highest proportion of households (29 percent) used non-iodized salt. While more than 14 percent (state average) of the households in Bilaspur, Chamba, Kinnaur, Kullu, Lahul & Spiti, Shimla and Sirmaur districts were consuming adequately iodized salt.

The mean number of children ever born to a woman was 2.31 children in the state – 2.40 children in rural areas and 2.00 children in urban areas. Further, mean number of children ever born to women aged 40-44 years was 3.24 children, which is close to the completed family size of the women. The completed fertility in the state varies from the lowest of 2.9 children in Solan district to the highest of 4.0 children in Sirmaur district.

The share of births of order 3 and above in the total births that occurred three years prior to survey was 24 percent. In most of the district, proportion of higher order births was quite high, ranging from the lowest of 18 percent in Shimla district to the highest of 42 percent in Chamba district.

The data collected on the utilization of ANC services for the women who had their last live/still birth during three years prior to survey shows that the ANC coverage in the state was quite high as 91 percent of the women received at least one ante-natal care during pregnancy. Less than one percent of the women during their pregnancy were visited by health worker at their residence for providing ANC. Only nine percent of the women visited private health facility, while 81 percent visited government health facility for ANC. The percent of women who got some kind of ANC during pregnancy range between 81 percent in Kullu district to 97 percent in Hamirpur and Kangra districts. In eight out of 12 districts 90 percent or more women got ANC.

Though 91 percent of the women in Himachal Pradesh received ANC, only 74, 73 and 75 percent women had check-up of weight, blood pressure and abdomen respectively. Eighty-seven percent women received Iron and Folic Acid (IFA) tablets and 902 percent got at least one TT injection. A full package of ANC including minimum three ANC visits, at least one TT injection and 100 or more IFA tablets/Syrup was received by over 32 percent of women.

Minimum three ANC and timing of first check up are crucial for maternal and childcare. More than two-third (68 percent) of the women in Himachal Pradesh made three or more ANC visit, while more than one-half (53 percent) of the women visited health facility for the first antenatal check-up in the first trimester of pregnancy. The extent of women who had ANC in first trimester varies from minimum of 29 percent in Chamba district to the maximum of 66 percent in Hamirpur district. Similarly, extent of women who received three or more ANC varies from minimum of 53 percent in Chamba district to the maximum of 80 percent in Hamirpur district.

Less than one-half (45 percent) of the total deliveries in Himachal Pradesh were conducted in health institutions; 13 percentages point up from RCH Round-I. Thirty-seven percent of the institutional deliveries were conducted in government institutions as against eight percent in private institution. About 12 percent of the total deliveries, that took place at home, were assisted by midwifery trained persons i.e. doctor and ANM/Nurse/LHV and 31 percent by TBA. Thus, 43 percent of the deliveries, 18 percent points up from RCH Round- I, were assisted by skilled personnel in the state. The extent of institutional deliveries varies from the highest of 62 percent in Bilaspur and Shimla districts to the lowest of 25 percent in Chamba district. Safe deliveries vary from the highest of 65 percent in Kangra and Shimla districts to the lowest of 28 percent in

xiv Chamba district. The percent of the institutional deliveries was the highest (64 percent) for women who had studied for 10 years and more and the lowest (17 percent) for non-literate women. Similarly, percent of institutional deliveries was the highest (71 percent) for women with high SLI and the lowest (24 percent) for women with low SLI. The variation in the institutional deliveries by women’s economic status is much conspicuous than that by women’s education.

In Himachal Pradesh, 28, 28 and 26 percent of the women experienced pregnancy, delivery and post delivery complications respectively. About 69 percent of the women sought treatment for the pregnancy and 52 percent for the post-delivery complications. The pregnancy complication varies from the lowest of 14 percent in Hamirpur and Solan districts to the highest of 47 percent in Kangra district. The incidence of all the three types of complications seems to be linked with each other. In the districts where the incidence of pregnancy complications is high, the incidence of delivery and post-delivery complications is also high.

In most of the districts and the state as a whole, the practice of breast-feeding is almost universal. However, only 41 percent of the women breastfed the child within two hours of birth, while 64 percent women breastfed the child within one day of birth. More than one-third of the women started breastfeeding the child after one day of birth. There is great deal of variation in the pattern of breastfeeding across the districts. The extent of women initiating breastfeeding within two hours of birth was the highest (67 percent) in Bilaspur district and the lowest (around 33 percent) in Chamba and Una districts.

In Himachal Pradesh, 96, 91, 88 and 89 percent of the children received BCG vaccine, three doses of DPT, Polio and measles vaccine respectively. There is eight percentage points drop from BCG to measles. It means that large numbers of children who have contact with service providers are missed out of subsequent services. The complete schedule of immunization including BCG, three doses of DPT and Polio each and measles was received by 79 percent of the children, whereas two percent of the children did not at all receive any vaccination under the routine programme. Sixty-eight percent of the children received supplementation of at least one dose of vitamin-A and only four percent children received IFA tablets/liquid for iron supplementation.

The extent of complete immunization consisting of BCG, three injections of DPT, three doses of Polio and measles was the lowest (38 percent) in Bilaspur district and the highest (92 percent) in Hamirpur and .Una districts. In six districts (Hamirpur, Kangra, Mandi, Shimla, Solan and Una) more that 80 percent of the children received complete immunization.

In Himachal Pradesh, 80 percent of the women were aware of diarrhoea management and 64 percent were aware of Oral Rehydration Salt (ORS). During the two-week period prior to survey, children of over 10 percent of the women suffered from diarrhoea. And 51 percent women treated diarrhoea among children by giving ORS. In comparison to awareness about diarrhoea management, the awareness about danger sings of pneumonia is quite low. Only 27 percent of the women reported awareness about danger sings of pneumonia. Fifteen percent of the women reported that their children suffered from cough, cold and difficulty in breathing in two-week period prior to survey and 78 percent sought treatment.

The knowledge of family planning methods is universal in all districts of Himachal Pradesh,

xv with over 99 percent of the women reporting knowledge of one method or the other. However, the knowledge of any spacing method was marginally low, but the proportion per se was quite high (96 percent). The knowledge of any modern methods was also universal in all the districts, though the knowledge of all modern methods was only 80 percent. Knowing of all modern methods (males and females’ sterilization, IUD, oral pills and condom) varies from 35 percent in Bilaspur district to 92 percent in Kangra and Kinnaur districts.

In DLHS, knowledge about No-scalpel vasectomy has been asked to husbands of eligible women. More than one-half (54 percent) of the husbands were aware of no-scalpel vasectomy in the state. The proportion of husbands knowing No-scalpel vasectomy varies from 44 percent in Mandi district to 64 percent in Kangra.

The contraceptive prevalence rate (any methods) in the state is 70 percent, six-percentage point up from RCH Round-I, comprising of prevalence of over 65 percent of modern methods and over four percent of traditional methods. Over 46 percent of the couples adopted sterilization. The percent user of the male methods of sterilization and condom was only 18 percent. There appears to be negative association between contraceptive use and female education. The highest (79 percent) contraceptive prevalence was in Shimla district, followed by 75 percent in Kullu district and the lowest (58 percent) in Una district.

In Himachal Pradesh, a total of 11 percent of women were found to have unmet need for family planning, with over eight percent for limiting and over three percent for spacing. The total unmet need varies from the highest (20 percent) in Una district, followed by 14 percent in Hamirpur district and the lowest (seven percent) in Kullu district.

Only over five percent of the women in the state reported that either ANM/LHV or health worker visited them at their residence at least once in the past three months. Sixty-nine percent of the women who were visited by ANM felt that ANM had given them sufficient time to discuss health-related matters.

Only in four districts five percent or more women reported the visit of ANM/LHV to their residence. In the remaining eight districts of Bilaspur, Chamba, Kinnaur, Kullu, Mandi, Shimla, Solan and Una less than five percent. of the women reported visits of ANM/LHV.

It has been observed that in three months period prior to survey, 75 percent of the eligible women who were required to consult health facility visited any of the government health facilities. Very small proportion of the women who visited the health facility rated it as poor. On the other hand, two-third of the women who did not visit the government health facility reported government health facility “non-conveniently located” or “time is not suited” or “ poor quality of services” or “ heavy rush” as reasons.

The district level variation in the utilization of the government health facilities ranges from 71 percent in Chamba and Kangra districts to 95 percent in Lahul & Spiti district. A large percentage of women visited private health facilities (24 percent), which ranges from four percent in Lahul & Spiti district to 29 percent in Kangra district.

In Himachal Pradesh 37 and 79 percent of women were aware of RTI/STI and HIV/AIDS respectively. The corresponding level of awareness among husbands of eligible women was 34

xvi and 90 percent. The percent of women who are aware of RTI/STI is the highest (90 percent) in Kangra district, followed by 35 percent in Chamba district and the lowest (four percent) in Lahul & Spiti district. Similarly, percent of women who were aware of HIV/AIDS was the highest (94 percent) in Kangra district, followed by 91 percent in Hamirpur district and the lowest (56 percent) in Kullu district.

Awareness level of husbands of eligible women of RTI/STI was the highest (71 percent) in Kangra district, followed by 58 percent in Sirmaur district and the lowest (over three percent) in Lahul & Spiti district. Similarly, awareness level of husbands of eligible women of HIV/AIDS was the highest (98 percent) in Hamirpur district, followed by 97 percent in Kangra district and the lowest (71 percent) in Kullu district. Out of 12, in 9 districts the awareness of HIV/AIDS was higher than that of the state (90 percent) for men and in 1five districts for women.

Thirty-one percent of women and four percent of husbands of eligible women in the state reported having at least one symptoms of RTI/STI. In most of the districts the reported prevalence of RTI/STI among husbands was quite low. The prevalence of RTI/STI among women was the highest (51 percent) in Sirmaur district and the lowest (17 percent) in Kullu district. Similarly, prevalence of RTI/STI among husbands of eligible women was the highest (nine percent) in Solan district, followed by eight percent in Sirmaur district and the lowest (less than one percent) in Lahul & Spiti district.

About 18 percent of the women reported vaginal discharge with lowest (10 percent) in Una district to highest (32 percent) in Kinnaur district. Forty-one percent of women sought treatment for vaginal discharge problem and 60 percent of husbands with at least one symptoms of RTI/STI sought treatment. It may be noted that in all the districts less than 50 percent of the sought treatment of vaginal discharge.

xvii CHAPTER I

INTRODUCTION

1.1 Background and Objectives of the Survey

The Reproductive and Child Health (RCH) programme that has been launched by Government of India (GoI) in 1996-97 is expected to provide quality services and achieve multiple objectives. It ushered a positive paradigm shift from method-oriented, target-based activity to providing client- centred, demand-driven quality services. Also, efforts are being made to reorient provider’s attitude at grassroots level and to strengthen the services at outreach levels.

The new approach requires decentralization of planning, monitoring and evaluation of the services. The district being the basic nucleus of planning and implementation of the RCH programme, Government of India has been interested in generating district level data on utilization of the services provided by government health facilities, other then that based on service statistics. It is also of interest to assess people’s perceptions on quality of services. Therefore, it was decided to undertake District Level Household Survey (DLHS) under the RCH programme in the country.

The Round-I of RCH survey was conducted during the year 1998–99 in two phases (each phase covered half of the districts from all states/union territories) in 504 districts for which International Institute for Population Sciences (IIPS), Mumbai was designated as the nodal agency.

In Round-II, survey was completed during 2002-04 in 593 districts as per the 2001 Census. In DLHS-RCH, information about RCH has been collected using a slightly modified questionnaire. In Round-II, some new dimensions, such as test of cooking salt to assess the consumption of salt fortified with iodine, collection of blood of children, adolescents and pregnant women to assess the level of anaemia, and measurement of weight of children to assess the nutritional status, were incorporated.

The main focus of the DLHS-RCH has been on the following aspects:

¾ Coverage of ANC & immunization services ¾ Proportion of safe deliveries ¾ Contraceptive prevalence rates ¾ Unmet need for family planning ¾ Awareness about RTI/ STI and HIV/AIDS ¾ Utilization of government health services and users’ satisfaction.

For the purpose of conducting DLHS-RCH, all the states and the union territories were grouped into 16 regions. A total of twelve research organizations including Population Research Centres (PRCs) were involved in conducting the survey in 16 regions with IIPS as the nodal agency.

1.2 Survey Design

In Round-II, a systematic, multi-stage stratified sampling design was adopted. In each district, 40 Primary Sampling Units (PSUs – Villages/Urban Frame Size) were selected with probability proportional to size (PPS) using the 1991 Census data. All the villages were stratified according to population size, and female literacy was used for implicit arrangement within each strata. The number of PSUs in rural and urban areas was decided on the basis of percent of urban population in the district. However, a minimum of 12 urban PSUs were selected in each district in case the percent urban was low. The target sample size in each district was set at 1,000 complete residential households from 40 selected PSUs. In the second stage, within each PSU, 28 residential households were selected with Circular Systematic Random Sampling (CSRS) procedure after house listing. In order to take care of non-response due to various reasons, sample was inflated by 10 percent (i.e. 1,100 households).

For selecting the urban sample, the National Sample Survey Organization (NSSO) provided the list of selected urban frame size (UFS) blocks in the district. The UFS blocks were made available separately for each district for urban areas. The maps of selected blocks were obtained from the NSSO field office located in each state/union-territory.

But in each state, in two districts, the PSUs that were surveyed in Round-I of DLHS- RCH (also known as RHS-RCH) were also selected for survey in Round-II. This was done in order to measure the changes more accurately. Two districts, one with the highest proportion of safe delivery and another with the lowest proportion of safe delivery among those surveyed during Round-I of the survey were selected for this purpose. In all other districts, fresh sample of PSUs were selected.

1.3 House Listing and Sample Selection

The household listing operation was carried out in each of the selected PSU segment prior to the data collection that provided the necessary frame for selecting the households. The household listing operation also involved preparation of location map and layout sketch map of the structures and recording the details of the households in these structures in each selected PSU. This exercise was carried out by independent teams each comprising of one lister, one mapper and one supervisor under the overall guidance and monitoring of the survey coordinator of the selected regional agencies.

A complete listing of households was carried out in villages with households up to 300. In case of villages with more than 300 households but less than or equal to 600 households, two segments of more or less same size were formed and one segment was selected at random and household listing was carried out. In case of villages with more than 600 households, segments each of about 150 households were formed and two segments were selected for listing using the systematic random sampling method.

Small villages with less than 50 households were linked with a nearest village. After combining it with the nearest village, the same sampling procedure was adopted as mentioned above. For the urban PSUs, the selected UFS blocks needed no segmentation as they were of almost equal size and contained less than 300 households. No replacement was made if selected household was absent during data collection.

No replacement was made if selected household was absent during data collection. However, if a PSU was inaccessible, a replacement PSU with similar characteristics was selected by the IIPS and provided to the regional agency for survey.

2 1.4 Questionnaire

DLHS-RCH collected information on a various indicators pertaining to RCH that would assist policymakers and programme managers to formulate and implement the goals set for RCH programmes. The International Institute for Population Sciences (IIPS), Mumbai, the Nodal Agency for DLHS–RCH project has made necessary modifications in the two Questionnaires: Households Questionnaire and Women’s Questionnaire and added three more Questionnaires i.e., Husband’s Questionnaire, Village Questionnaire and Health Questionnaire, in consultation with MoHFW and World Bank. These Questionnaires were discussed and finalized in training cum workshop organized at IIPS during the first week of November 2001.

These modified questionnaires had been canvassed during round-II of the DLHS–RCH survey, taking into consideration the views of all the regional agencies involved. The house– listing teams and the interviewers and the supervisors for the main survey were given rigorous training based on the manuals developed for the purpose by the Nodal Agency.

All the questionnaires were bilingual, with questions in both regional and English language.

The Details of questionnaires are as follows:

Household Questionnaire: The household questionnaire lists all usual residents in each sample household including visitors who stayed in the household the night before the interview. For each listed household member, the survey collected basic information on age, sex, and marital status, relationship to the head of the household, education and the prevalence /incidence of tuberculosis, blindness and malaria. Information was also collected on the main source of drinking water, type of toilet facility, source of lighting, type of cooking fuel, religion and caste of household head and ownership of other durable goods in the household. In addition, a test was conducted to assess whether the household used cooking salt that has been fortified with iodine. Besides, details of marriages and deaths, which happen to usual residents within reference period, were collected. Efforts were also made to get information about maternal deaths.

Women Questionnaire: Women questionnaire is designed to collect information from currently married women age 15 – 44 years who are usual residents of the sample household or visitors who stayed in the sample household the night before the interview. The women questionnaire covered the following sections:

Section I: Background Characteristics: In this section the information collected on age, educational status and birth and death history of biological children including still birth, induced and spontaneous abortions.

Section II: Antenatal, Natal and Post natal Care: In this section the questionnaire collect information only from the women who had live birth, still birth, spontaneous or induced abortion during last three years preceding the survey date. The information on whether women received antenatal and postpartum care, who attended the delivery and the nature of complications during pregnancy for recent births were also collected.

3 Section III: Immunisation and childcare: This section gives information about feeding practices, the length of breastfeeding, immunization coverage and recent occurrence of diarrhoea, and pneumonia for young children (below age 3 years).

Section IV: Contraception: This section provides information on knowledge and use of specific family planning methods. Questions were included about reasons for non-use, intentions about future use, desire for additional child, sex preference for next child etc.

Section V: Assessment of quality of Government health services and client satisfaction. In this section the questions are targeted to assess the quality of family planning and health services provided by Government health facilities. The information were also collected about the rating of Government health facilities and staffs and reasons for not visiting to government health facilities by eligible woman.

Section VI: Awareness about RTI/STI and HIV/AIDS: In this section the information were collected about women’s knowledge of RTI/STI about awareness, Source of knowledge, aware of mode of transmission, curability, symptoms and treatment seeking behaviour. About HIV/AIDS; Awareness, Source of knowledge, aware of mode of transmission and prevention etc were canvassed.

Husband Questionnaire: In DLHS-RCH, round II, husband questionnaire was used to collect information from eligible women’s husbands about age, educational status, knowledge and source of knowledge of RTI/STI and HIV/AIDS reported symptoms of RTI/STI and male participation. Apart from these information desires for children, reasons for not using F.P. methods, future intention to use F.P. methods and knowledge about no scalpel vasectomy (NSV) has also been collected.

Health Questionnaire: In DLHS-RCH, round II, a health questionnaire is included. The information collected were on weight of children age 0–71 months old and the blood sample to assess the haemoglobin levels of children age 0–71 months old, adolescents 10–19 years old and pregnant eligible women. This information is useful for assessing the levels of nutrition prevailing in the population and prevalence of anaemia among women, adolescent girls and children.

Village Questionnaire: A village questionnaire is also added in this round of DLHS. The information collected on the availability and accessibility of various facilities in the village especially on accessibility of educational and health facilities.

1.5 Fieldwork and Sample Coverage

The fieldwork for RCH Round II was done in two phases. During Phase I, 6 districts were covered from April 2002 to August 2002 and remaining 6 districts were covered during Phase II from January 2004 to July 2004.

During Round II, a total of 13,136 households were covered. From these surveyed house- holds, 8,618 currently married women (aged 15-44 years) and 4,550 husbands of eligible women were interviewed.

4 1.6 Data processing

All the five types of completed questionnaires were brought to the headquarter of regional agencies and data were processed using microcomputers. The process consisted of office editing of questionnaires, data entry, data cleaning and tabulation. Data cleaning included validation, range and consistency checks. For both data entry and tabulation of the data, IIPS developed the software package. The district and state level reports were prepared by regional agency whereas national report is prepared by the nodal agency.

1.7 Sample Weights

In generating district level demographic indicator sample weight for household, women and husband, weight have been used and these for a particular district are based on three selection i i i th probabilities f1 , f2 and f3 pertaining to i PSU of the district. These probabilities are defined as

i th f 1 = Probability of selection of i PSU in a district ( * ) = nr H i H Where, is the number of rural PSU to be selected in a district, refers to the number of nr H i th household in the i PSU and H = ∑ Hi , total number of household in a district.

i

f 2 = Probability of selecting segment (s) from segmented PSU (in case the ith selected PSU is segmented)

= (Number of segments selected after segmentation of PSU) / (number of segment created a PSU) i

The value of f 2 is to be equal to one for un-segmented PSU.

i

f 3 = probability of selecting a household from the total listed households of a PSU or in segment(s) of a PSU

= 28*HRi HLi

th Where HRi is the household response rate of the i sampled PSU and HLi is the number of households listed in i th PSU in a district.

i For urban PSU, f1 is computed either as the ratio of number of urban PSUs to be included from the district to the total number of UFS blocks of the district or as the ratio of urban population of the selected PSU to the total urban population of the district.

The probability of selecting a household from the district works out as;

5 i i i i f = (f 1 * f 2 * f 3) 1 The non-normalized household weight for the ith PSU of the district is, wi = , while the f i normalized weight used in the generation of district indicators as d ∑ n i = i * w i ni i , i= 1,2,3……………40. ∑ n i * w i

th Where ni is the number of households interviewed in the i PSU. The weight for women and husband are computed in the similar manner after multiplication of expression for fi by the corresponding response rate. State weights for households, women and husbands are further derived d th th from the district weights ni for the i psu in d district using external control so that for sample results do not deviate from the corresponding information about the population.

d d Let, ns = ∑ ni and N I = ∑ N i , denote the number of households in the sample and census of i i a particular state, then state level households weights are work out as; ⎛ d ⎞ ⎜ni ⎟ ⎜ ns ⎟ s d ⎝ ⎠ d th n = n * , where n household sample in i district, ns is the total sample in the i i ⎛ d ⎞ i ⎜ N i ⎟ ⎜ ⎟ ⎝ N sc⎠ d th state, N i is the census population in the i district and N sc is the census population in the state. These households’ weights are controlled for rural-urban separately. Considering sample and census currently married women in 15-44 years and married males above 15 years for specified state by districts and rural-urban residence, state level women and husbands’ weights are obtained for estimation of state level indicators.

1.8 Sample Implementation

Table 1.1 shows the period of fieldwork, number of households interviewed and household’s response rates. A total of 13,136 households are interviewed, over three-fourth were rural. The overall household response rate – the number of households interviewed per 100 occupied households – was cent percent. The household response rate was also cent percent in every district.

In the interviewed households, interviews were completed with 8,618 currently married women who are the usual member of the household or stayed night before the household interview and 4,550 husbands of eligible women were also interviewed (Table 1.2). The number of completed interviews per 100 identified eligible women and husbands in the households with completed interviews were 82 and 46 percent respectively. The variation in the women’s response rate by district was highest in Kinnaur (87 percent) and lowest in Kullu (75 percent), similarly husband’s response rate was found to be highest in Shimla (58 percent) and lowest in Bilaspur (34 percent).

6 Table 1.1 NUMBER OF HOUSEHOLDS INTERVIEWED Month and year of fieldwork and number of households interviewed by district, Himachal Pradesh, 2002-04

Month and year of field work Number of households interviewed State/District From To Total Rural Urban Response rate

State - - 13,136 10,179 2,957 100.0 State-phase I 05/2002 08/2002 - - - - State-phase II 01/2004 09/2004 - - - -

Bilaspur 01/2004 02/2004 1,094 771 323 100.0 Chamba 06/2004 06/2004 1,075 756 319 100.0 Hamirpur 07/2002 07/2002 1,116 783 333 100.0 Kangra 04/2004 05/2004 1,078 755 323 100.0 Kinnaur 05/2004 05/2004 1,085 1,085 0 100.0 Kullu 06/2002 06/2002 1,099 771 328 100.0

Lahul & Spiti 06/2004 07/2004 1,085 1,085 0 100.0 Mandi 06/2002 07/2002 1,088 757 331 100.0 Shimla 05/2002 05/2002 1,110 885 225 100.0 Sirmaur 03/2004 04/2004 1,077 968 109 100.0 Solan 08/2002 08/2002 1,113 783 330 100.0 Una 07/2002 08/2002 1,116 780 336 100.0 Note: Table based on unweighted cases.

Table 1.2 NUMBER OF WOMEN AND HUSBANDS INTERVIEWED Number of women and husbands interviewed by district, Himachal Pradesh, 2002-04 Number of women interviewed Number of husbands interviewed Response Response State/District Total Rural Urban rate Total Rural Urban rate

State 8,618 6,748 1,870 82.2 4,550 3,489 1,061 46.0

Bilaspur 834 613 221 85.1 325 223 102 34.3 Chamba 726 521 205 84.9 439 314 125 53.7 Hamirpur 764 544 220 85.2 301 181 120 38.3 Kangra 749 535 214 84.2 363 251 112 49.2 Kinnaur 674 674 0 87.3 390 390 0 51.5 Kullu 690 485 205 74.7 412 299 113 45.6

Lahul & Spiti 606 606 0 86.1 355 355 0 52.5 Mandi 716 537 179 75.7 434 331 103 48.7 Sirmaur 830 756 74 82.3 437 402 35 45.6 Shimla 700 558 142 81.0 490 353 137 57.6 Solan 683 468 215 79.5 335 223 112 39.9 Una 646 451 195 82.2 269 167 102 37.1 Note: Table based on unweighted cases.

1.9 Basic Demographic Profile of the State

Before presenting the survey result, the basic demographic features of Himachal Pradeshl and its districts (as per census, 2001) are presented below.

The geographical location of Himachal Pradesh is quite unique. The state is bordered by Jammu & Kashmir on the north, Punjab on the west and south-west, Haryana on the south and south-east and China on the east. It lies between 300 22’ 40’’ to 330 12’ 40’’ north latitude and 750 45’ 55’’ to 790 04’ 2’’ east longitude. In 2001, its population was only six million and is the 20th largest state in India in terms of population. The state consists of 12 districts, 52 sub-divisions, 75 tahsils, 34 sub-tahsils and 20,118 villages. The urban areas of the state comprise 56 statutory towns with one census town during 2001. Shimla is the capital of the state.

7 According to 2001 census the population of Himachal Pradesh is 6.1 million out of which 3.1 millions are males and 3.0 millions are females. The rural and urban breakup of the population shows that 90 percent of the population was enumerated in rural areas and 10 percent in urban areas. Keeping pace with the national average, Himachal Pradesh has recorded a sharp decline in the decadal growth rate from 20.8 per cent in 1981-91 to 17.5 percent during 1991-2001. Among the districts, Solan with 30.6 percent has the highest decadal growth rate whereas Lahul & Spiti with 6.2 percent has the lowest decadal growth rate of total population during 1991-2001.

The Scheduled Caste and Schedule Tribe population have both experienced a marginal decline in percentage term during 1991-2001. The proportion of schedule caste and scheduled tribe population to total population of 2001 are 24.7 percent and 4.0 percent respectively. The highest proportion of Schedule Caste population has been recorded in Sirmaur district (29.6 per cent) and that of Schedule Tribe in Lahul & Spiti district (73.0 per cent), while Kinnaur district has the lowest (9.7 percent) proportion of Schedule Caste population and Hamirpur and Una districts have negligible Schedule Tribe population. With a population density of 99 per sq. km., Himachal Pradesh ranks 31st among the states and union territories in India and this figure is almost one-third of the all India density of 325 persons per square km. Among the districts, Hamirpur has the highest density (369 person/sq. km.) and Lahul & Spiti has the lowest (2 person/sq. km).

The sex ratio of the total population in the state has marginally declined since 1991 Census from 975 to 970 per 1000 males. Kangra district has recorded the highest sex ratio (1027) and Lahaul & Spiti district has the lowest (804) within the state.

The literacy rate (7+) in the state has improved from 63.9 percent in 1991 to 77.1 percent in 2001 and it is higher even the national average of 64.8 percent. The literacy rate in urban areas (88.9 percent) is considerably higher in the rural areas (75.1 percent) in the state. Among the districts, Hamirpur district has the highest literacy rate of 82.5 percent. Chamba district has the lowest literacy rate of 62.9 percent. The male literacy for the state is 85.3 percent and the female literacy rate is 67.4 percent. Both the rates have increased from 1991 census to 2001 census.

Table 1.3 BASIC DEMOGRAPHIC INDICATOR Basic demographic indicator of India, state and districts, Census 2001 Percentage literate 7+ Population Percentage Percentage decadal 1 2 India/state/district (in thousand) urban growth rate Sex ratio Male Female Persons

India 1,028,737 27.8 21.5 933 75.3 53.7 64.8

State 6,078 9.8 17.5 968 85.3 67.4 76.5

Bilaspur 341 6.4 15.4 990 86.0 69.5 77.8 Chamba 461 7.5 17.1 959 76.4 48.8 62.9 Hamirpur 413 7.3 11.6 1,099 90.2 75.7 82.5 Kangra 1,339 5.4 14.0 1,025 87.5 73.0 80.1 Kinnaur 78 0.0 17.8 857 84.3 64.4 75.2 Kullu 382 7.9 25.6 927 84.0 60.9 72.9

Lahul & Spiti 33 0.0 6.2 802 82.8 60.7 73.1 Mandi 901 6.8 16.1 1,013 85.9 64.8 75.2 Shimla 723 23.1 16.9 896 87.2 70.1 79.1 Sirmaur 459 10.4 20.7 901 79.4 60.4 70.4 Solan 501 18.2 30.6 852 84.8 66.9 76.6 Una 448 8.8 18.4 997 87.7 73.2 80.4

Source: Primary Census Abstract, Series 20, Census of India, 2001. 1 1991-2001, 2 Females per 1,000 male

8 CHAPTER II

BACKGROUND CHARACTERISTICS OF HOUSEHOLD

This chapter provides a socio-economic and demographic profile of households interviewed in the District Level Household Survey-Reproductive and Child Health. Facilities and services such as Health, Education and Communication available in the representative sampled village are also presented here. The de facto procedure of enumeration is adopted in order to include every individual staying in the selected household of the sample Primary Sampling Units (PSU), either a village or an urban area, the night before the survey. The objective of adopting the de facto method is to avoid duplication of persons who are in transit.

2.1 Age –Sex Structure

The age-sex distribution of sampled household population classified by residence is presented in Table 2.1. The percent distribution is based on sampled de facto population of 63,092 persons of whom 80 percent lived in the rural areas of Himachal Pradesh. The state of Himachal Pradesh depicts a young and growing population with 29 percent below the age of 15 years (Figure 2.1). There are more children below 15 years recorded in rural areas (30 percent) compared to those in urban areas (25 percent).

Figure 2.1 Age-sex pyramid 80+ 75-79 Female 70-74 65-69 Male 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4

6420246 Percent

Himachal Pradesh, DLHS-RCH, 2002-04

The overall sex ratio of 102 males per 100 females is recorded for the de facto population. The sex ratio is more skewed, 106 in favour of males in urban areas compared to 101 in rural areas. Table 2.1 HOUSEHOLD POPULATION BY AGE AND SEX Percent distribution of the household population by age and by residence and sex, Himachal Pradesh, 2002-04 Total Rural Urban Age Total Male Female Total Male Female Total Male Female

< 1 1.8 2.1 1.5 1.8 2.1 1.5 1.8 2.1 1.5 1-4 7.0 7.4 6.6 7.4 7.9 6.8 5.5 5.3 5.8 5-9 9.2 9.8 8.6 9.3 9.7 8.9 8.7 10.1 7.3 10-14 10.7 11.0 10.4 11.1 11.2 10.9 9.3 9.9 8.7 15-19 10.4 10.5 10.2 10.4 10.5 10.4 10.2 10.7 9.6 20-24 10.0 9.4 10.7 10.1 9.6 10.5 9.9 8.6 11.2 25-29 8.7 8.4 9.1 8.6 8.5 8.8 9.1 7.9 10.4 30-34 7.0 6.7 7.2 6.8 6.5 7.0 7.8 7.5 8.1 35-39 6.3 5.9 6.7 5.9 5.6 6.3 7.7 7.1 8.2 40-44 5.4 5.6 5.1 5.1 5.3 4.9 6.4 6.9 5.9 45-49 6.0 5.2 6.8 5.7 4.9 6.6 7.1 6.4 7.7 50-54 4.6 4.5 4.7 4.5 4.3 4.7 5.0 5.4 4.5 55-59 3.2 3.5 2.9 3.3 3.6 3.0 2.8 3.1 2.5 60-64 3.2 3.3 3.2 3.3 3.3 3.3 2.9 3.1 2.7 65-69 2.3 2.2 2.5 2.3 2.2 2.4 2.3 2.1 2.6 70-74 1.9 2.1 1.7 2.0 2.1 1.8 1.6 1.9 1.3 75-79 0.9 1.0 0.8 0.9 1.0 0.8 0.9 0.7 1.0 80+ 1.3 1.5 1.2 1.4 1.6 1.3 1.1 1.0 1.1

Total percent 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0

Number of persons 63,092 31,854 31,238 50,506 25,385 25,121 12,585 6,468 6,117

Sex ratio1 102 NA NA 101 NA NA 106 NA NA Note: Table is based on the de facto population, i.e. persons who stayed in the household the night before the interview (including both usual resident and visitors) NA: Not applicable 1- Male per 100 females

2.2 Household Characteristics

The percent distribution of 13,137 households surveyed in the state of Himachal Pradesh by selected characteristics of the household head and the number of usual household members are shown in Table 2.2. This is based on de jure, the usual resident population. About 90 percent of household heads are male irrespective of place of resident while only 10 percent are female- headed households. More than two-third of household heads are in the age group 30-59 years. The median age of household heads is more than 48 years for the state as a whole, while it is 49 years in rural areas and 48 years in urban areas. Six percent of household heads are younger than 30 years and more than one-fourth are at least 60 years old. Majority of the household heads are Hindu (96 percent), more than one percent are Muslim, two percent Sikh and one percent belong to other religions. Hindus constitute a higher proportion of population in rural areas (97 percent) than in urban areas (91 percent). Muslim households constitute one percent in rural areas and two percent in urban areas.

More than one-fifth of the households in Himachal Pradesh belong to schedule caste, over four percent schedule tribe and 10 percent other backward classes. Thus, more than 35 percent of the households belong to schedule caste, schedule tribes and other backward classes and 64 percent of the households are headed by other castes, while caste of less than one percent household heads

10 Table 2.2 HOUSEHOLD CHARACTERISTICS Percent distribution of the household head by selected characteristics of the household head and household size, according to residence, Himachal Pradesh , 2002-04 Residence Total Characteristic Rural Urban

Sex of the household head Male 89.6 89.5 90.0 Female 10.4 10.5 10.0

Age of the household head < 30 6.0 6.3 4.9 30-44 33.2 32.6 35.6 45-59 34.8 34.5 36.1 60+ 26.0 26.7 23.5

Median age of the household head 48.5 48.7 47.9

Religion of the household head Hindu 95.7 97.0 91.2 Muslim 1.3 1.2 1.7 Christian 0.1 0.0 0.5 Sikh 1.7 1.0 4.2 Buddhist 0.9 0.8 1.4 Jain 0.1 0.0 0.6 Other 0.0 0.0 0.2 Missing 0.1 0.1 0.1

Caste/tribe of the household head Scheduled caste 21.0 23.3 13.2 Scheduled tribe 4.4 4.9 2.3 Other backward class 10.1 11.0 7.0 Other # 64.2 60.5 77.1 Don’t know 0.2 0.2 0.3 Missing 0.1 0.1 0.1

Number of usual members 1 2.4 2.3 2.7 2 6.8 6.8 6.7 3 10.7 9.8 14.0 4 24.1 21.9 31.7 5 22.4 22.6 21.8 6 14.6 15.9 10.2 7 8.0 9.0 4.6 8 4.8 5.2 3.4 9+ 6.2 6.5 4.9

Mean household size 4.9 5.1 4.6

Total percent 100.0 100.0 100.0

Number of households 13,137 10,179 2,958 Note: Table is based on the de jure population # Higher caste (Not belonging to a scheduled caste, a scheduled tribe and an other backward class) was not known/missing. Twenty eight percent of the household head belong to schedule caste or tribe in rural areas and it is only 15 percent in urban areas. The overall average household size is 4.9 persons in the state - 5.1 persons in rural areas and 4.6 persons in urban areas.

2.3 Educational Level

The educational background of Himachal Pradesh presented in this section is based on de jure household population. Level of literacy and years of schooling, according to age, sex and residence are shown in Table 2.3. The data shows that one-fifth of the population aged seven and above are

11 Table 2.3 EDUCATIONAL LEVEL OF THE HOUSEHOLD POPULATION Percent distribution of household population age 7 and above by literacy level and years of schooling, according to age , residence and sex, Himachal Pradesh, 2002-04 Years of schooling Literate Non- but no 11 or Total Number of Age literate schooling 1-5 6-8 9-10 more Missing Percent persons Total Male 7-9 3.8 1.0 93.4 1.2 0.0 0.0 0.6 100.0 1,888 10-14 1.7 0.0 41.0 50.2 6.7 0.0 0.4 100.0 3,496 15-19 1.4 0.2 5.5 25.6 39.5 27.9 0.0 100.0 3,353 20-29 3.1 0.1 6.5 16.0 26.5 47.8 0.0 100.0 5,668 30-39 9.6 0.2 11.5 19.1 30.8 28.8 0.0 100.0 4,023 40-49 13.7 0.1 15.9 19.1 29.3 22.0 0.0 100.0 3,428 50+ 36.6 0.6 15.0 13.7 19.3 14.8 0.0 100.0 5,743

Total 12.0 0.3 20.4 20.9 23.2 23.2 0.1 100.0 27,600 Female 7-9 4.0 1.2 93.9 0.7 0.0 0.0 0.2 100.0 1,630 10-14 2.2 0.0 39.7 49.6 8.0 0.0 0.5 100.0 3,259 15-19 2.7 0.1 8.0 21.5 40.2 27.4 0.0 100.0 3,186 20-29 10.9 0.2 10.6 15.7 25.6 37.0 0.0 100.0 6,171 30-39 29.2 0.2 22.0 15.0 18.6 14.9 0.0 100.0 4,344 40-49 44.0 0.4 22.9 10.4 11.8 10.6 0.0 100.0 3,734 50+ 72.7 0.4 13.3 5.1 4.5 3.9 0.0 100.0 5,320

Total 27.8 0.3 22.6 16.6 16.7 15.9 0.1 100.0 27,643 Total 7-9 3.9 1.1 93.6 1.0 0.0 0.0 0.4 100.0 3,518 10-14 1.9 0.0 40.4 49.9 7.3 0.0 0.4 100.0 6,755 15-19 2.1 0.2 6.7 23.6 39.8 27.6 0.0 100.0 6,539 20-29 7.2 0.2 8.6 15.9 26.0 42.1 0.0 100.0 11,839 30-39 19.8 0.2 16.9 17.0 24.5 21.6 0.0 100.0 8,367 40-49 29.5 0.3 19.5 14.5 20.2 16.1 0.0 100.0 7,162 50+ 54.0 0.5 14.2 9.6 12.2 9.6 0.0 100.0 11,063

Total 19.9 0.3 21.5 18.7 19.9 19.6 0.1 100.0 55,243 Note: Table is based on de facto population. Contd.

non-literate in the state. The proportion of non-literates is 2 percent for females compared to 12 percent for males. The proportion of non-literate is much higher among the older cohorts (30+ years) compared to the younger ones (below 30 years) irrespective of sex. For both males and females, going by expected trend, the level of literacy is higher in the younger population than in the older age groups with the exception of the youngest age group of 7-9 years (Figure 2.2).

Around 94 percent of males as well females in the age group 7-9 years had 1-5 years of schooling. One-fifth of males as against 22 percent of females had education for 1-5 years of schooling. In other words, females are better of compared to their male counterparts who had 1-5 years of schooling. Further, males are having edge over females in higher education of 6-8 years, 9-10 years and 11 or more years. However, only less than one percent of the total population are found to be literate without any formal schooling irrespective of sex in the state.

An examination of the educational attainment by place of residence shows that the rural- urban differential was quite pronounced. Only 8 percent of the total population is non-literate in urban areas in comparison to 23 percent in rural population. Further, percentage of non-literate males is14 percent in rural areas in comparison to 5 percent in urban areas. Similarly, percentage of

12 Figure 2.2 Percentage Literate by Age and Sex

100

80

60

40 Percent

20

0 7-9 10-14 15-19 20-29 30-39 40-49 50+ Age

Male Female Himachal Pradesh, DLHS-RCH, 2002-04

Table 2.3 EDUCATIONAL LEVEL OF THE HOUSEHOLD POPULATION Percent distribution of household population age 7 and above by literacy level and years of schooling, according to age, residence and sex, Himachal Pradesh, 2002-04 Years of schooling Literate but Non- no 11 or Total Number of Age literate schooling 1-5 6-8 9-10 more Missing Percent persons RURAL Male 7-9 3.8 0.7 93.6 1.1 0.0 0.0 0.8 100.0 1,482 10-14 1.7 0.0 42.0 49.5 6.4 0.0 0.4 100.0 2,856 15-19 1.6 0.2 5.7 28.1 39.4 24.9 0.0 100.0 2,659 20-29 3.4 0.1 7.0 17.5 29.4 42.6 0.0 100.0 4,595 30-39 11.5 0.2 13.5 22.0 32.9 19.9 0.0 100.0 3,077 40-49 16.6 0.1 19.1 22.3 30.2 11.7 0.0 100.0 2,567 50+ 42.2 0.5 16.6 14.9 17.7 8.1 0.0 100.0 4,618

Total 13.9 0.3 21.7 22.5 23.7 17.9 0.1 100.0 21,855 Female 7-9 4.6 1.2 93.2 0.8 0.0 0.0 0.3 100.0 1,342 10-14 2.5 0.0 41.8 48.2 7.2 0.0 0.3 100.0 2,729 15-19 3.2 0.2 9.3 23.7 42.0 21.7 0.0 100.0 2,601 20-29 12.8 0.3 12.3 17.6 28.4 28.7 0.0 100.0 4,849 30-39 34.8 0.2 25.2 16.8 16.7 6.3 0.0 100.0 3,348 40-49 52.5 0.4 25.5 10.2 8.2 3.2 0.0 100.0 2,899 50+ 80.6 0.3 12.4 3.4 2.2 1.1 0.0 100.0 4,361

Total 31.8 0.3 24.2 17.2 16.1 10.4 0.1 100.0 22,128 Total 7-9 4.2 0.9 93.4 0.9 0.0 0.0 0.5 100.0 2,824 10-14 2.1 0.0 41.9 48.9 6.8 0.0 0.4 100.0 5,585 15-19 2.4 0.2 7.5 25.9 40.7 23.3 0.0 100.0 5,261 20-29 8.2 0.2 9.7 17.5 28.9 35.4 0.0 100.0 9,444 30-39 23.6 0.2 19.6 19.3 24.4 12.8 0.0 100.0 6,425 40-49 35.6 0.3 22.5 15.9 18.5 7.2 0.0 100.0 5,466 50+ 60.8 0.4 14.5 9.3 10.1 4.7 0.0 100.0 8,979

Total 22.9 0.3 22.9 19.8 19.9 14.1 0.1 100.0 43,984 Contd.

13 Table 2.3 EDUCATIONAL LEVEL OF THE HOUSEHOLD POPULATION Percent distribution of household population age 7 and above by literacy level and years of schooling, according to age, residence and sex, Himachal Pradesh, 2002-04 Years of schooling Literate Non- but no 11 or Total Number of Age literate schooling 1-5 6-8 9-10 more Missing Percent persons URBAN Male 7-9 3.8 1.9 92.8 1.4 0.0 0.0 0.1 100.0 406 10-14 1.7 0.0 36.9 53.2 7.9 0.0 0.3 100.0 641 15-19 0.6 0.0 4.5 16.1 39.6 39.2 0.0 100.0 694 20-29 2.1 0.2 4.2 9.5 14.2 69.9 0.0 100.0 1,073 30-39 3.6 0.1 5.0 9.7 24.0 57.6 0.0 100.0 946 40-49 5.0 0.0 6.2 9.5 26.4 53.0 0.0 100.0 861 50+ 13.6 0.7 8.6 8.7 26.1 42.3 0.0 100.0 1,125

Total 4.9 0.3 15.4 14.5 21.3 43.5 0.0 100.0 5,745 Female 7-9 1.3 1.3 96.9 0.5 0.0 0.0 0.1 100.0 288 10-14 0.5 0.1 29.3 56.7 12.0 0.0 1.5 100.0 530 15-19 0.8 0.0 1.8 12.0 32.5 52.9 0.0 100.0 585 20-29 4.2 0.0 4.3 9.0 15.1 67.4 0.0 100.0 1,322 30-39 10.4 0.3 11.2 9.1 25.2 43.8 0.0 100.0 997 40-49 14.4 0.4 13.9 10.8 24.3 36.3 0.0 100.0 835 50+ 37.1 0.7 17.4 13.1 15.1 16.6 0.0 100.0 959

Total 11.7 0.3 16.2 14.5 19.1 38.0 0.2 100.0 5,515 Total 7-9 2.7 1.7 94.5 1.0 0.0 0.0 0.1 100.0 694 10-14 1.1 0.0 33.5 54.8 9.7 0.0 0.9 100.0 1,170 15-19 0.7 0.0 3.2 14.2 36.4 45.5 0.0 100.0 1,278 20-29 3.2 0.1 4.2 9.2 14.7 68.5 0.0 100.0 2,395 30-39 7.1 0.2 8.2 9.4 24.6 50.5 0.0 100.0 1,942 40-49 9.6 0.2 10.0 10.1 25.4 44.7 0.0 100.0 1,696 50+ 24.5 0.7 12.7 10.8 21.0 30.4 0.0 100.0 2,084

Total 8.2 0.3 15.8 14.5 20.2 40.8 0.1 100.0 11,260

non-literate females is 32 percent in rural areas in comparison to only 12 percent in urban areas. This shows that prevalence of illiteracy is much less in urban areas than in rural areas of Himachal Pradesh. The rural-urban differences in educational level of 11 or more years are more pronounced for both the sexes. The percentage of females with 11 or more years of schooling is only 10 percent in rural areas as against 38 percent in urban areas. Similarly, percentage of males with 11 or more years of schooling is 18 percent in rural areas as against 43 percent in urban areas. The difference is 25 percentage points for both the sexes.

2.4 Marital Status of the Household Population

The DLHS, collected information on the marital status of all household members aged 10 years and above. Table 2.4 gives percent distribution of household population aged 10 years and above by marital status, according to age and sex. The percentage of currently married females was only four percent in the age group 15-19 years, followed by 52 percent in the age group 20-24 years, 89 percent in the age group 25-29 years and 93 percent in the age group 30-44 years. That is, before reaching 45 years almost every female is married in the state. The proportion of never married is 42 percent for males as against 32 percent for female. It is higher for males than for females and the difference is 10 percentage points. The proportion of never married among males’

14 Table 2.4 MARITAL STATUS OF THE HOUSEHOLD POPULATION Percent distribution of the household population aged 10 years and above by marital status, according to age and sex, Himachal Pradesh, 2002-04 Marital status Married, Widowed/ Never Currently gaunna not divorced/ Total Age married married performed Separated Percent Number of persons Male 10-14 98.6 1.1 0.0 0.2 100.0 3,496 15-19 98.3 1.5 0.1 0.0 100.0 3,353 20-24 87.5 11.9 0.5 0.1 100.0 2,994 25-29 40.2 59.3 0.2 0.2 100.0 2,674 30-44 4.0 94.5 0.1 1.4 100.0 5,801 45-59 0.8 94.8 0.0 4.4 100.0 4,208 60+ 1.1 81.3 0.1 17.6 100.0 3,186

Total 41.8 54.8 0.1 3.3 100.0 25,712 Female 10-14 98.4 0.8 0.2 0.5 100.0 3,259 15-19 96.1 3.7 0.1 0.1 100.0 3,186 20-24 47.2 52.4 0.0 0.4 100.0 3,328 25-29 8.8 89.4 0.1 1.7 100.0 2,843 30-44 1.6 93.3 0.0 5.1 100.0 5,942 45-59 0.4 85.3 0.0 14.2 100.0 4,512 60+ 1.0 45.1 0.3 53.6 100.0 2,943

Total 31.6 58.2 0.1 10.0 100.0 26,013 Total 10-14 98.6 1.0 0.1 0.3 100.0 6,755 15-19 97.3 2.6 0.1 0.1 100.0 6,539 20-24 66.3 33.2 0.3 0.3 100.0 6,322 25-29 24.0 74.8 0.2 1.0 100.0 5,516 30-44 2.8 93.9 0.0 3.3 100.0 11,744 45-59 0.6 89.9 0.0 9.5 100.0 8,719 60+ 1.0 63.9 0.2 34.9 100.0 6,129

Total 36.7 56.5 0.1 6.7 100.0 51,725 Note: Table is based on de facto population

declines with increasing age and reaches the lowest by the time they are in the age group 45-59 years. A similar pattern has been observed in the case of females, with the lowest proportion never married for the age group 30-44 years. The proportions of divorced, separated or widowed are negligible and limited to the older ages. Fifty four percent of women aged 60 years or above are widowed/divorced/separated. Among the de facto population aged 10 years and above, 55 percent of males and 58 percent of females are currently married in the state.

2.5 Marriage

Marriage in the household is an important event that reflects the socio-cultural practices of the communities surveyed in DLHS. This section covers marriages sermonised during three years preceding the survey. Mean age at marriage by sex and percentage of total marriages which are below legal age at marriage of 21 years for boys and 18 years for girls by resident at the state and at district levels are shown in Table 2.5.

Mean age at marriage for boys and girls in urban areas of Himachal Pradesh are 26 years and 21.7 years respectively. The corresponding figures for rural areas are 25.7 years and 21.4 years. However, only four percent of boys and three percent of girls got married below the specified

15 Table 2.5 MARRIAGE Mean age at marriage and percentage of marriages below legal at marriage by sex and by districts, Himachal Pradesh, 2002-04 Percentage of marriage below Mean age at marriage legal age at marriage Place of residence/ District Boy Girl Boy (<21) Girl (<18) State – Total 26.0 21.7 4.3 2.9 State – Rural 25.7 21.4 4.9 3.2 State – Urban 27.3 22.9 1.3 1.7

District Bilaspur 26.3 21.7 3.0 1.1 Chamba 24.8 22.2 9.6 3.6 Hamirpur 26.3 21.4 0.6 2.5 Kangra 27.2 22.6 1.3 1.7 Kinnaur 25.9 21.6 16.0 16.4 Kullu 24.5 21.5 12.9 9.8

Lahul & Spiti 25.5 22.8 15.4 1.5 Mandi 25.6 20.7 6.2 2.7 Shimla 26.0 22.3 4.2 3.8 Sirmaur 24.7 20.8 6.7 3.9 Solan 26.4 22.1 0.0 1.6 Una 26.5 22.1 1.5 0.0 Note: Table based on de jure population. Reference period: - January 1st, 1999 to survey date for phase-1, and January 1st, 2001 to survey date for phase-2.

legal age marriage in the state. The proportion of such marriages is higher in the rural areas compared to the urban areas of the state. On the whole, as far as Himachal Pradesh is concerned, people have accepted the Child Marriage Restraint Act of 1978 both for boys and girls.

The district level variation in mean age at marriage of boys shows that it was the highest (27.2 years) in Kangra district, followed by 26.5 years in Una district and lowest (24.5 years) in Kullu district. Similarly, mean age at marriage for girls was the highest (22.8 years) in Lahul & Spiti district, followed by 22.6 years in Kangra district and lowest (20.7 years) in Mandi district. The variations in the mean age at marriage between the districts are not serious as the difference between the lowest and highest values is 2.1 years for girls and 2.7 years for boys.

It is also found that, the percentage of girls who were married below the legal age at marriage was the highest (16.4 percent) in Kinnaur district, followed by 9.8 percent in Kullu district and the lowest (zero percent) in Una district. Similarly, percentage of boys who were married below the legal age at marriage was the highest (16.0 percent) in Kinnaur district, followed by 15.4 percent in Lahu & Spiti district and the lowest (zero percent) in Solan district. Less than five percent of girls were married before 18 years in 10 districts and boys before 21 years in six districts. However, Kullu district has the distinction of having married the highest percentage of boys and girls before the stipulated minimum legal age at marriage (see Map-1).

2.6 Morbidity Rates

The DLHS-RCH has collected information on the morbidity status relating to blindness, tuberculosis and malaria of the de jure members of the household. Tables 2.6 and 2.7 provide prevalence rates.

Partial, Complete and Night Blindness

The prevalence rate of partial blindness was 4,992 in rural areas and 3,136 in urban areas, while it was 4,605 in the state. Further, the prevalence rate of partial blindness was 5,268 for females and

16 Table 2.6 MORBIDITY RATES Prevalence of blindness, tuberculosis, and malaria, according to place of residence, Himachal Pradesh, 2002-04 Residence Morbidity Total Rural Urban Prevalence rate of blindness

Male

Partial 3,973 4,248 2,952 Complete 431 440 398 Night blindness 188 234 16

Female

Partial 5,268 5,764 3,336 Complete 270 225 443 Night blindness 251 307 37

Persons

Partial 4,605 4,992 3,136 Complete 352 334 420 Night blindness 219 269 26

Prevalence rate of tuberculosis

Male 455 475 332 Female 263 291 152 Person 361 385 272

1 Prevalence rate of malaria Male 138 172 12 Female 116 118 106 Person 127 146 57 Note: All the rates refer to de jure population. Prevalence rate per 100, 000 population Reference period: - January 1st, 1999 to survey date for phase-1, and January 1st, 2001 to survey date for phase-2. 1 Last two weeks prior to the survey

3,973 for males, while it was 4,605 for the population. Again, the prevalence rate of complete blindness was 334 in rural areas and 420 in urban areas, while it was 352 in the state. The prevalence rate of complete blindness was 270 for females as against 431 for males, while it was 352 for the population. These data have shown that prevalence rate of partial blindness is higher among females than among males, while in the case of complete blindness scenario is just the reverse. Similarly, prevalence rate of partial blindness is higher in rural areas than in urban areas and it was just the reverse in the case of complete blindness. The prevalence rate of night blindness due to vitamin A deficiency was 251 for females as against 188 for males, while it was 219 for the population. Further, the prevalence rate of night blindness due to vitamin-A deficiency was 269 in rural areas as against 26 in urban areas, while it was 219 for the state. These data have shown that prevalence rate of night blindness due to vitamin-A deficiency was higher in rural areas than in urban areas, while it was higher among females than males.

Tuberculosis

The prevalence rate of tuberculosis was 385 in rural areas and 272 in urban areas, while it was 361 in the state. Further, prevalence rate of tuberculosis was 455 for males as against 263 for females, while it was 361 for the population. These data have shown that prevalence of TB was higher among males than among females, and it was higher in rural areas than urban areas.

Malaria

In the DLHS-RCH, household respondents were asked to state whether any member of their house-

17 hold suffered from malaria (characterized by recurrent fever with shivering) any time during the two weeks prior the survey. In the state of Himachal Pradesh, 127 persons per 100,000 population were reported to have suffered from malaria. The prevalence rate of Malaria was 146 in rural areas as against 57 in urban areas, while it was 127 in the state. This means that the rural residents are almost three times more likely to suffer from malaria than urban residents. The prevalence rate of malaria was 138 for males as against 116 for females. These data have shown that prevalence of malaria was higher among males than females, while it was higher in rural areas than urban areas.

2.7 Morbidity Rates by District

Table 2.7 gives prevalence of blindness, tuberculosis and malaria by district. The prevalence of partial blindness was the highest (7,245) in Bilaspur district, followed by 6,757 in Kangra district and the lowest (797) in Kullu district. The prevalence of partial blindness was higher than that of the state (4,605) in Bilaspur, Hamirpur, Kangra, Sirmaur, Solan and Una districts, while it was lower than that of the state in the remaining six districts. The prevalence of complete blindness was the highest (857) in Shimla district, followed by 539 in Una district and the lowest (73) in Bilaspur district. The prevalence of complete blindness was the higher than that of the state (352) in Hamirpur, Mandi, Shimla, Solan and Una districts, while it was lower than that of the state in the remaining seven districts.

Table 2.7 MORBIDITY RATES BY DISTRICTS Prevalence of blindness, tuberculosis, and malaria, by district, Himachal Pradesh, 2002-04 Prevalence1 of morbidity 2 District Partial blindness Complete blindness Tuberculosis Malaria Bilaspur 7,245 73 236 86 Chamba 3,532 116 246 13 Hamirpur 5,011 433 206 109 Kangra 6,757 155 308 27 Kinnaur 3,231 82 181 95 Kullu 797 222 25 73

Lahul & Spiti 1,277 81 99 0 Mandi 2,522 453 245 113 Shimla 2,798 857 581 444 Sirmaur 5,697 97 1072 263 Solan 4,687 462 411 80 Una 5,380 539 378 101

Himachal Pradesh 4,605 352 361 127

Note: All the rates refer to de jure population. 1 Prevalence rate per 100, 000 population. Reference period: - January 1st, 1999 to survey date for phase-1, and January 1st, 2001 to survey date for phase-2. 2 Last two weeks prior to the survey

Further, prevalence of tuberculosis was the highest (1072) in Sirmaur district, followed by 581 in Shimla district and the lowest (25) in Kullu district. The prevalence of tuberculosis was higher than that of the state (361) in Shimla, Sirmaur, Solan and Una districts, while it was lower than that of the state in the remaining eight districts. Again, prevalence of malaria was the highest (444) in Shimla district, followed by 263 in Sirmaur district and the lowest (zero) in Lahul & Spiti district. The prevalence of malaria was higher than that of the state (127) in Shimla and Sirmaur districts, while in the remaining 10 districts it was lower than that of the state.

2.8 Housing Characteristics

This section describes the availability of basic amenities in the state. Tables 2.8 and 2.9 present the percent distribution of households by selected housing characteristics. Ninety-eight percent of

18

Table 2.8 HOUSING CHARACTERISTICS Percent distribution of the household by housing characteristics and percentage of households owing selected durable goods, according to residence, Himachal Pradesh, 2002-04 Residence Total Housing characteristic Rural Urban Electricity Yes 97.9 97.4 99.5 No 2.0 2.5 0.3

Source of drinking water 34.2 22.7 73.8 Tap inside 44.9 52.3 Tap shared public 19.7 6.2 7.3 2.3 Hand pump/ bore well 1.2 1.5 Well covered 0.1 2.4 3.0 0.4 Well uncovered 0.2 0.2 River 0.0 0.3 0.4 0.1 Pond 4.6 5.3 Spring 2.2 5.8 7.1 1.3 Other

Sanitation facility Own flush toilet 26.2 13.9 68.6 Own pit toilet / latrine 15.3 16.1 12.7 Shared toilet of any type 1.8 1.0 4.4 Public / community toilet 0.4 0.2 1.1 No toilet facility 56.2 68.7 13.1

Main type of fuel used for cooking

Liquid petroleum gas/ electricity 34.7 19.6 86.9 Kerosene 2.2 1.6 4.2 Wood 62.9 78.6 8.8 Other 0.1 0.1 0.0

Type of house 31.8 Kachcha 26.1 6.6 Semi - pucca 27.5 31.1 15.1 46.3 37.0 78.1 Pucca

Household assets 57.5 54.1 69.4 Fan 57.5 52.4 75.0 Radio/transistor 64.6 60.3 79.1 Sewing machine 70.4 64.0 92.5 Television 36.6 29.4 61.5 Telephone 11.1 9.6 15.9 Bicycle 13.1 8.9 27.8 Motor cycle/ scooter 6.4 2.8 18.7 Car / Jeep 1.0 1.0 0.7 Tractor

Standard of living index Low 25.2 31.4 3.6 Medium 39.8 45.5 20.4 High 35.0 23.1 76.0

Number of households 13,137 10,179 2,958

the households have been electrified in Himachal Pradesh. The percentage of households electrified is more than 99 percent in urban areas and over 97 percent in rural areas. The percentage of households without electricity were more than two percent in rural areas and less than one percent in urban areas, while it was two percent in the state.

The distribution of household by source of drinking water shows that 34 percent house- holds were having tap inside the house as source of drinking water in the state - 23 percent in rural

19 areas and 74 percent in urban areas. Similarly, percentage of household with tap (shared/public) as source of drinking water was 45 percent in the state - 52 percent in rural areas and 20 percent in urban areas. Thus, source of drinking water was tap water in more than three-fourth (79 percent) of the households in the state – 75 percent in rural areas and more than 93 percent in urban areas. Further, hand pump/bore well was the source of drinking water in six percent of the households in the state – seven percent in rural areas and two percent in urban areas. Over one percent households were getting water from covered well. In other words, more than 86 percent of the households were receiving safe drinking water through tap/hand pump/bore well/well covered in the state - 84 percent in rural areas and 96 percent in urban areas. The remaining over 13 percent of the households were not having access to potable water for drinking purposes in the state -16 percent in rural areas and four percent in urban areas. The sources of unsafe drinking water were (i) Well-uncovered (2.4 percent), (ii) River (less than one percent), (iii) Pond (less than one percent), (iv) Spring (4.6 percent) and (v) Other (5.8 percent).

The distribution of households by sanitation facilities shows that only 26 percent of the households have own flush toilet, 15 percent have own pit toilet/latrine, two percent depend on shared toilet of any type and less than one percent use public/community toilet, while 56 percent of the households have no toilet facility at all. The percentage of households having no toilet facility at all was 69 percent in rural areas and 13 percent in urban areas. On the other hand, 69 percent of the households were having own flush toilet in urban areas as against 14 percent in rural areas.

The distribution of households by type of fuel used in the households for cooking shows that 35 percent of the households were using liquid petroleum gas or electricity for cooking in the state - 20 percent in rural areas and 87 percent in urban areas. Only two percent of the households were using kerosene for cooking in the state. On the other hand, 63 percent of the households were using wood for cooking in the state - 79 percent in rural areas and nine percent n urban areas. The data shows that wood is the main source of cooking in rural areas and liquid petroleum gas or electricity in urban areas.

There is considerable variation in the quality of housing. On the basis of building material, type of floor, walls and roof, households are categorised into kachcha, semi-pucca and pucca. More than one-fourth (26 percent) of the households were living in kachcha houses and 27 percent in semi pucca houses, while 46 percent of the households were living in pucca houses. Seventy- eight percent of the households live in pucca houses in urban areas compared to 37 percent in rural areas.

The possession of consumer durable goods is an indication of a household’s socio-economic status. The data shows that majority of the households in the state own fan (57 percent), radio/ transistor (57 percent), sewing machine (65 percent) and television (70 percent), while only 37 percent households have telephone. The other consumer durable goods owned by the households were bicycles (11 percent), motor cycle/scooter (13 percent), car/jeep (6 percent) and tractor (one percent). The rural-urban differentials are quite appreciable in the possession of consumer durable goods in the state. The urban households owning these durable goods have an edge over the rural households for all these items except tractor.

Considering household amenities, such as, source of drinking water, type of house, source of lighting, fuel for cooking, toilet facility and ownership of durable goods a composite measure,

20 standard of living index (SLI) is made for classification of households. The standard of living index is calculated by adding the following scores; Source of drinking water: 3 for Tap (own), 2 for Tap (shared), 1 for hand pump and well, and 0 for other; Type of house: 4 for pucca, 2 for semi-pucca, and 0 for kachcha; Source of lighting: 2 for electricity, 1 for kerosene, and 0 for other; Fuel for cooking: 2 for LPG gas/electricity, 1 for kerosene and 0 for other; Toilet facility: 4 for own flush toilet, 2 for own pit toilet, 2 for shared toilet and 0 for no toilet; Ownership for items: 4 each for car and tractor, 3 each for television, telephone and motorcycle/scooter, and 2 each for fan, radio/transistor, sewing machine and bicycle. The total of the scores may vary from the lowest of a 0 to maximum of 40. On the basis of total score, households are divided into three categories as; a) Low – if total score is less than or equal to 9, b) Medium – if total score is greater than 9 but less than or equal to 19 and c) High – if total score is greater than 19.

The distribution of the households by the standard of living index shows that one-fourth of the households come under the low standard of living index, 40 percent of households have medium standard of living index and 35 percent of the households have high standard of living index. The proportion of sample households with high standard of living index was comparatively higher in urban areas than in rural areas, while the proportion of households with low and medium standard of living index was much higher in rural area than in urban areas in the state.

2.9 Housing Characteristics by District

Table 2.9 gives selected housing characteristics by district. The percentage of households with electricity was equal to or higher than that of the state (98 percent) in Bilaspur, Hamirpur, Kangra, Lahul & Spiti, Mandi, Shimla, Solan and Una districts, while in the remaining four districts it was lower than that of the state. However, more than 90 percent of the households were electrified in all the districts.

Further, percentage of households with drinking water was the highest (96 percent) in Lahul & Spiti

Table 2.9 HOUSING CHARACTERISTICS BY DISTRICT Selected housing characteristics by district, Himachal Pradesh, 2002-04 Percentage of households: With drinking With toilet Using Liquid petroleum Living in pucca 1 Districts With electricity water facility gas/ electricity house Bilaspur 97.9 88.2 57.8 36.9 59.4 Chamba 93.1 84.3 41.3 33.7 37.8 Hamirpur 99.6 87.9 52.0 32.1 44.5 Kangra 99.5 87.3 42.0 39.5 51.2 Kinnaur 95.0 90.5 34.7 40.8 21.9 Kullu 96.6 94.2 42.5 40.4 24.6

Lahul & Spiti 98.7 95.7 56.7 61.5 29.2 Mandi 98.7 95.2 52.2 33.0 43.4 Shimla 99.1 75.9 44.2 46.7 29.8 Sirmaur 91.4 67.7 28.4 15.3 51.5 Solan 99.5 87.5 53.6 46.0 72.0 Una 99.7 93.3 42.7 33.2 66.3

Himachal Pradesh 97.9 86.5 43.7 34.7 46.3 1 That is piped or from a hand pump/bore well/ covered well

21 district, followed by 95 percent in Mandi district and the lowest (68 percent) in Sirmaur district. The percentage of households with drinking water was higher than that of the state (86 percent) in Bilaspur, Hamirpur, Kangra, Kinnaur, Kullu, Lahul & Spiti, Kullu, Solan and Una districts, while in the remaining three districts it was lower than that of the state.

The percentage of households with toilet facility was the highest (58 percent) in Bilaspur district, followed by 57 percent in Lahu & Spiti district and the lowest (28 percent) in Sirmaur district. The percentage of households with toilet facility was higher than that of the state (44 percent) in Bilaspur, Hamirpur, Lahul & Spiti, Mandi, Shimla and Solan districts, while it was lower than that of the state in six districts.

The percentage of households using liquid petroleum gas/electricity was the highest (61 percent) in Lahul & Spiti district, followed by 47 percent in Shimla district and the lowest (15 percent) in Sirmaur district. The percentage of households using liquid petroleum gas/electricity was higher than that of the state (35 percent) in Bilaspur, Kangra, Kinnaur, Kullu, Lahul & Spiti, Shimla and Solan districts, while it was lower than that of the state in five districts.

The percentage of households living in pucca house was the highest (72 percent) in Solan district, followed by 66 percent in Una district and the lowest (22 percent) in Kinnaur district. The percentage of households living in pucca house was higher than that of the state (46 percent) in Bilaspur, Kangra, Sirmaur, Solan and Una districts while in the remaining seven districts it was lower than that of the state.

2.10 Iodization of Salt

Consumption of salt fortified with iodine is recommended to avoid miscarriages, brain disorders, cretinism and retarded psychomotor development. As per the Prevention of Food Adulteration Act, 1988, the minimum iodine content of edible salt is 30 parts per million (PPM) at the manufacturing level.

In the DLHS-RCH survey, each interviewer was provided with a test kit to measure the level of iodine content of salt consumed by the surveyed households. The test results (Table 2.10) are classified by degree of ionization of salt and categorised by background characteristics. It is seen that 78 percent of the households used salt that contained a minimum recommended 15 ppm or higher level of iodine content whereas six percent of the households used salt that was not iodized at all, while 14 percent households used salt, which was inadequately iodised with 7 ppm.

Eight percent of the households in rural areas as against only one percent in urban areas used non-iodized salts. Percentage of households using inadequately iodized salt in rural areas was more than three times higher compared to that in urban areas. The percentage of households using cooking salt with iodine content of 7 ppm was the highest (20 percent) for non-literate households headed and the lowest (nine percent) for household heads who had studied for 10 and above years, while it was 15 percent for household heads who had studied for 0-9 years. Consumption of cooking salt with iodine content of 7 ppm was the highest (24 percent) for ST household heads, followed by 17 percent for SC household heads and the lowest (seven percent) for OBC household heads.

Differential in the consumption of properly iodized salt was more pronounced when it was analysed by religion of the household head and standard of living index. The percentage of

22 Table 2.10 IODIZATION OF SALT Percent distribution of household heads by degree of Iodization of salt, according to selected background characteristics, Himachal Pradesh, 2002-04 1 Background characteristic Not Iodised 7ppm 15+ppm Other Total percent Number of households

Place of Residence Rural 7.9 16.7 73.6 1.8 100.0 10,179 Urban 0.8 4.7 93.3 1.2 100.0 2,958

Education of the household heads Non-literate 0-9@ years 10.0 20.5 67.4 2.1 100.0 3,467 10 and above 7.8 15.0 75.6 1.6 100.0 4,519 2.4 8.8 87.3 1.4 100.0 5,150 Religion of household head

Hindu 6.4 14.1 77.9 1.7 100.0 12,569 Muslim 3.6 19.0 76.6 0.8 100.0 168 Sikh 4.4 7.2 84.0 4.4 100.0 225 Buddhist 1.3 16.5 82.0 0.1 100.0 122 Other (2.1) (16.7) (81.3) (0.0) 100.0 40

Caste/tribe of the household head# Scheduled caste 7.3 17.3 73.6 1.8 100.0 2,764 Scheduled tribe 4.7 24.3 69.9 1.2 100.0 572 Other backward class 6.1 7.1 85.1 1.7 100.0 1,320 Other 6.1 13.4 78.9 1.6 100.0 8,439

Standard of living index . . Low 14.1 25.1 58.4 2.4 100.0 3,304 Medium 5.4 13.9 79.3 1.5 100.0 5,235 High 1.7 6.3 90.6 1.4 100.0 4,599

Total 6.3 14.0 78.0 1.7 100.0 13,137 Ppm: Parts per million Note: Table includes 1 household head with missing information on education and 40 on religion who are not shown separately. @ Literate persons with no years of schooling are also included. # Total number of cases may not add upto N due to do not know and missing cases. 1 Includes salt not at home, salt not tested, refused and missing cases. ( ) Based on less than 50 unweighted cases

households using cooking salt with 15 ppm or higher level of iodine was 74 percent in rural areas and 93 percent in urban areas, while it was 78 percent in the district. The percentage of households using cooking salt with 15 ppm or higher level of iodine was the highest (87 percent) for household heads who had studied for 10 and above years and the lowest (67 percent) for non- literate household heads, while it was 76 percent for household heads who had studied for 0-9 years. The percentage of households using cooking salt with 15 ppm or higher level of iodine was 78 percent among Hindu households, 77 percent among Muslims whereas the corresponding figures for Sikh, Buddhist and other religion households are 84 percent, 82 percent and 81 percent respectively. Further, percentage of households using cooking salt with 15 ppm or higher level of iodine was the highest (91 percent) for household heads with high SLI and the lowest (58 percent) for households with low SLI, while it was 79 percent for households with medium SLI. The difference in households with high and low SLI using cooking salt with 15 ppm or higher iodine contents was 32 percentage points, which is quite serious. These data have shown that use of cooking salt with 15 ppm or higher level of iodine is positively associated with education and SLI of the household head.

2.11 Iodization of Salt by District

Table 2.11 shows that the percentage of households using non-iodised salt was the highest (29 percent)

23 Table 2.11 IDOIZATION OF SALT BY DISTRICT Percent distribution of household heads by degree of idoization of salt by district, Himachal Pradesh, 2002-04 District Not idoized 7ppm 15+ppm Other1

Bilaspur 7.4 25.6 65.4 1.7 Chamba 6.6 28.3 63.1 1.9 Hamirpur 0.5 1.5 98.0 0.0 Kangra 4.1 13.3 80.6 2.0 Kinnaur 1.4 27.0 70.8 0.8 Kullu 8.6 19.4 71.6 0.3

Lahul & Spiti 1.3 19.1 79.3 0.2 Mandi 4.0 11.0 83.7 1.3 Shimla 8.4 18.1 73.3 0.2 Sirmaur 28.8 14.6 46.8 9.9 Solan 0.6 1.6 97.8 0.0 Una 1.6 1.7 96.3 0.4

Himachal Pradesh 6.3 14.0 78.0 1.7

Note: Ppm: Parts per million. 1 Includes salt not at home, salt not tested, refused and missing cases

in Sirmaur district, followed by nine percent in Kullu district and the lowest (less than one percent) in Hamirpur district. Further, the proportion of households using cooking salt with iodine content of 7 ppm was the highest (28 percent) in Chamba district, followed by 27 percent in Kinnaur district and the lowest (one percent) in Hamirpur district. The proportion of households using cooking salt with 15 ppm or higher level of iodine was the highest (98 percent) in Hamirpur and Solan districts, followed by 96 percent in Una district and the lowest (47 percent) in Sirmaur district. Again, percentage of households using cooking salt with 15 ppm or higher level of iodine was higher than that of the state (78 percent) in Hamirpur, Kangra, Lahul & Spiti, Mandi, Solan and Una districts and in the remaining six districts it was lower than that of the state. The difference in the highest and the lowest proportion of households using cooking salt with 15 ppm or higher level of iodine is 51 percentage points, which is quite serious (see Map-2).

2.12 Availability of Facility and Services to the Rural Population

The DLHS-RCH collected information about surveyed village from knowledgeable persons such as, the ‘Sarpanch’, ‘Pradhan’ (village head), other village officials or other knowledgeable persons including ‘school teacher’ in the villages on health and educational facilities and other services available in the village. One important aspect was to know the distance of the village, if facility is not available within the village, covering various types of education facilities, including primary school, middle school, secondary school, higher secondary school, college, Gurujee scheme and ‘Madarsa’. Further information on the distance of the village, if health facility not available within the village, covering various type of health facility, including sub-centres, primary health centres (PHCs), community health centres/ Rural Hospitals (CHCs/RHs), Government dispensary, hospital, private clinic or hospitals and health facilities of Indian system of Medicine (ISM).

Table 2.12 gives distance of the surveyed villages from an education facility. The unit of analysis is the village. More than three-fourth of the population (de jure population) of Himachal Pradesh lives in villages in rural areas. The data shows that 88 percent of the primary schools were located within the village and 12 percent outside the village. Similarly, 53 percent of the middle schools were located within the village, 35 percent outside the village but within five kms. of the village and 12 percent five or more kms. away from the village. Twenty-nine percent of the secondary schools were located within the village, 38 percent outside the village but within five

24 Table 2.12 DISTANCE FROM THE NEARST EDUCATION FACILITY Percent distribution of rural household population by distance from the nearest education facility, Himachal Pradesh, 2002-04 Distance from the village: Within Don’t know/ Total Education facility village < 5 km 5-9 km 10+ km missing percent

Primary School 88.2 8.7 1.1 1.0 1.1 100.0 Middle School 53.2 35.4 6.9 3.3 1.2 100.0 Secondary School 29.3 37.9 18.1 13.7 1.0 100.0 Higher Secondary School 15.9 31.4 23.0 28.6 1.1 100.0 College 1.4 7.9 16.0 72.7 2.1 100.0 Gurujee Scheme 4.4 15.1 6.3 25.8 48.3 100.0 Madarsa 3.8 12.9 6.4 27.5 49.4 100.0

Note: Table based on rural de jure population kms. of the village and the remaining one-third of the secondary schools were five or more kms. away from the village. Further, 16 percent of the higher secondary schools were located within the village, 31 percent outside the village but within five kms. of the village, while the remaining 53 percent higher secondary schools were located five or more kms. away from the village. Only over one percent of the colleges were located within the village and 99 percent outside the village. Gurujee Scheme was available within over four percent of the villages, while around four percent of the Madarasa were located with the village.

Table 2.13 gives distribution of rural households by distance from the nearest health facility. The data shows that 45 percent sub-centres were located within the village, 33 percent outside the village but within five kms. of the village, while 21 percent sub-centres were located five or more kms. away from the village. Similarly, 14 percent primary health centres were located within the village, 30 percent outside the village but within five kms. of the village, while more than one-half of the primary health centres were located five or more kms. away from the village. Only six percent of the community health centres/referral hospitals were located within the village, 21 percent outside the village but within five kms. of the village, while more than seven- tenth of the community health centres/referral hospitals were located five or more kms. away from the village. Further, 36 percent government dispensaries were located within the village, 27 percent outside the village but within five kms. of the village, while 37 percent government dispensaries were located five or more kms. away from the village. Again, only four percent Government hospitals, 21 percent private clinics, over one percent private hospitals and 13 percent ISM health facility were located within the village.

Table 2.13 DISTANCE FROM THE NEARST HEALTH FACILITY Percent distribution of rural household population by distance from the nearest health facility, Himachal Pradesh, 2002-04 Distance from the village: Don’t know/ Total Health facility Within village < 5 km 5-9 km 10+ km missing percent Rural household population Sub-centre 44.6 33.4 14.0 6.9 1.1 100.0 Primary health centre 14.3 30.4 19.2 34.7 1.4 100.0 Either sub-centre or PHC 48.3 32.5 11.6 6.4 1.1 100.0 Community health centre/ Referral hospital 5.7 20.6 16.9 53.8 3.1 100.0 Government dispensary 35.9 26.8 12.2 24.7 0.4 100.0 Government hospital 4.3 13.3 17.7 61.6 3.1 100.0 Private clinic 21.4 18.3 18.6 39.0 2.7 100.0 Private hospital 1.3 13.7 19.5 61.3 4.2 100.0 ISM health facility 12.7 16.8 15.8 36.4 18.2 100.0

Note: Table based on rural de jure population

25

Table 2.14 gives percentage of rural residents living in villages that have selected services in Himachal Pradesh. The data shows that more that three-fourth of the rural residents have access to anganwadi centre as against about three-fourth having access to anganwadi workers. Similarly, 29 percent of the rural residents have access to the private doctor, 25 percent to visiting doctors and three percent to homeopathic doctors. The percentage of rural residents having access to village health guide (VHG) was six percent as against 26 percent trained birth attendant (TBA). Over three percent of the rural residents have access to traditional healer and 59 percent to dai. These data have shown that 26 percent of the rural residents have access to TBA as against 59 percent to dai within the village.

Table 2.14 AVAILABILITY OF SERVICES Percentage of rural residents living in villages that have selected services, Himachal Pradesh, 2002-04 Services Percentage of Rural Residents

Anganwadi centre 76.5 Anganwadi worker 74.5 Private doctor 28.6 Visiting doctor 24.8 Homeopathic doctor 2.8 Village health guide 5.6 Trained birth attendant 25.7 Traditional healer 3.5 Dai 58.8 Note: Table based on rural de jure population

2.13 Availability of Education Facility and Health Services by Districts

Table 2.15 shows the availability of selected facility and services to the rural population within the villages by districts in Himachal Pradesh. The percentage of rural population with primary or middle schools was the highest (100 percent) in Bilaspur, Chamba, Lahul & Spiti and Una districts, followed by 98 percent in Kinnaur district and the lowest (61 percent) in Solan district, while it was 88 percent for the state.

Table 2.15 AVAILABILITY OF FACILITY AND SERVICES BY DISTRICT Selected facility and services of rural household population within village by district, Himachal Pradesh, 2002-04 Percentage of rural household population with: Primary or Any govern-ment Anganwadi 1 2 3 Districts middle school Sub-centre PHCs health facility Doctor TBA worker Bilaspur 100.0 57.9 14.4 63.7 40.3 14.6 86.5 Chamba 100.0 43.6 11.6 50.6 24.6 13.5 84.1 Hamirpur 66.7 22.9 8.1 37.2 36.0 37.2 36.2 Kangra 93.0 50.3 14.7 73.4 82.8 14.3 85.3 Kinnaur 98.2 51.5 25.3 72.1 23.7 46.7 87.9 Kullu 97.4 25.3 14.2 66.0 22.1 8.4 65.8

Lahul & Spiti 100.0 63.3 32.2 89.0 17.3 26.7 82.5 Mandi 78.4 36.9 12.0 55.4 32.6 35.6 73.9 Shimla 84.7 33.7 18.8 53.1 26.3 39.9 74.0 Sirmaur 97.2 65.7 8.7 69.6 43.9 16.9 80.9 Solan 61.0 36.9 13.0 36.9 45.0 31.4 54.5 Una 100.0 63.7 26.0 66.3 60.8 50.4 72.7

Himachal Pradesh 88.4 44.6 14.3 60.0 46.1 25.7 74.5 1 Includes sub-center, primary health center, community health center or referral hospital, government hospital, and government dispensary within the village 2 Either private or visiting doctor 3Trained birth attendant

26 The percentage of rural population visited either by private or by visiting doctors within the village was the highest (83 percent) in Kangra district, followed by 61 percent in Una district and the lowest (17 percent) in Lahul & Spiti district, while it was 46 percent for the state. Similarly, percentage of rural population with trained birth attendant (TBA) within the village was the highest (50 percent) in Una district, followed by 47 percent in Kinnaur district and the lowest (eight percent) in Kullu district, while it was 26 percent for the state. The percentage of rural population having access to visit anganwadi worker within the village was the highest (88 percent) in Kinnaur district, followed by 86 percent in Bilaspur district and the lowest (36 percent) in Hamirpur district, while it was 74 percent for the state.

27 Map – 1

Percent Girl Marrying Below Legal Age at Marriage

28 Map-2

Percentage of Households Using Salt that Contains 15 ppm Level of Iodine

29 CHAPTER III

CHARACTERISTICS OF WOMEN, HUSBANDS AND FERTILITY

The Reproductive and Child Health (RCH) programme is targeted towards the underprivileged section of the population, particularly, women and children. The utilization of RCH services provided across the country depends to a large extent on the characteristics of women, their husbands and episodes of pregnancies, miscarriages, abortions, number of children born to them and survival status of children. Age of women, marital duration, educational attainment, social background and living standard are important factors, which influence reproductive and child health. With this in view, the DLHS-RCH data were collected on demographic characteristics, such as current age, age at consummation of marriage and number of pregnancies, live births and surviving children from eligible women respondents of selected representative households. Information regarding household background characteristics was collected using a separate household questionnaire that covered religion and caste of head of household, type of house, source of drinking water and possession of consumer durables. Fertility preference of women in terms of timing and desire for additional children in comparison to the number of living children provides information on the need for reproductive and child health services.

This chapter provides a comprehensive outline of distribution of currently married women by present age, age at consummation of marriage, duration of marriage, complete years of schooling, pregnancy episodes, children ever born and children surviving, along with social and economic characteristics of households the women represent.

3.1 Background Characteristics of Women

The percent distribution of currently married women in the reproductive age group 15-44 years by residence, religion and caste of head of household, economic standard of household and other demographic characteristics are shown in Table 3.1. A sample of 8,618 eligible women represents the state of Himachal Pradesh in DLHS-RCH and nearly eight-tenth of these women are drawn from rural areas. The age composition of the currently married women shows that 65 percent are in the age range of 20-34 years, 66 percent in rural areas and 60 percent in urban areas. Around one-third of them are in the age group 35-44 years, 32 percent in rural areas and 39 percent in urban areas. In other words, cohort of rural women is comparatively younger than that of urban women. Age at consummation of marriage in rural areas is found to be low with as many as 26 percent of the women having cohabited before 18 years of age, while it was 14 percent in urban areas. Looking at the distribution of marital duration it is noted that more than one third of the women across the state were married for more than 15 years.

Among the 8,618 sample women in Himachal Pradesh, Hindus, Sikh and Muslims constitute 96 percent, two percent and over one percent respectively. The presence of women belonging to other religious groups was insignificant, as it constitutes only less than one percent of the state population. Twenty-two percent of the women belong to scheduled castes, 4 percent to scheduled tribes and 10 percent to other backward classes. Majority of the sample women (64 percent) belong to castes other than scheduled caste/tribe and other backward class. In rural areas, there were more women belonging to scheduled caste, scheduled tribe and other backward classes than in urban areas, while more women from other castes were found in urban areas. The distribution of women Table 3.1 BACKGROUND CHARACTERISTICS OF ELIGIBLE WOMEN Percent distribution of currently married women aged 15-44 by selected background characteristics, according to residence, Himachal Pradesh, 2002-04 Residence Background characteristic Total Rural Urban

Age group 15-19 1.2 1.4 0.5 20-24 17.5 19.5 10.0 25-29 25.4 25.1 26.3 30-34 22.2 21.6 24.2 35-39 19.7 18.6 23.5 40-44 14.1 13.7 15.4 Age at consummation of marriage Below 18 years 23.7 26.3 14.3 18 years & above 76.3 73.7 85.7 Marital duration 0-4 21.4 22.1 18.7 5-9 21.3 20.9 22.8 10-14 20.4 19.8 22.7 15+ 36.9 37.3 35.8 Religion Hindu 95.9 97.1 91.9 Muslim 1.4 1.2 2.2 Christian 0.1 0.0 0.6 Sikh 1.8 1.1 4.4 Buddhist 0.6 0.6 0.7 Jain 0.1 0.0 0.3 Other 0.0 0.0 0.0 Caste/tribe Scheduled caste 21.8 23.8 14.3 Scheduled tribe 4.0 4.4 2.6 Other backward class 9.9 10.9 6.3 Other # 64.1 60.6 76.6 Don’t know 0.2 0.1 0.2 Education (Years of schooling) Non-literate 21.7 25.8 7.3 0-9@ years 38.6 42.7 23.7 10 years & above 39.6 31.5 69.0 Husband’s education (Years of schooling) Non-literate 9.0 10.5 3.5 0-9@ years 33.3 37.8 17.2 10 years & above 57.4 51.3 79.1 Don’t know 0.3 0.3 0.1 Missing 0.1 0.1 0.1 Standard of living index Low 21.9 27.1 3.1 Medium 41.6 48.0 18.3 High 36.5 24.9 78.6

Number of women 8,618 6,748 1,870

# Higher caste (Not belonging to a scheduled caste, scheduled tribe and other backward class). @ Literate persons with no year of schooling are included. by educational attainment shows that 22 percent were non-literate in the state – 26 percent in rural areas and seven percent in urban areas. Thirty nine percent of the women had studied for 0-9 years in the state - 43 percent in rural areas and 24 percent in urban areas. Again, 40 percent of the women had studied for 10 years and above in the state – 31 percent in rural areas and 69 percent in urban areas. These data have shown that there exists rural-urban differential in female literacy and that rural women are lagging behind urban women in their educational attainment.

The percentage of non-literate women was 22 percent as against only 9 percent of husband.

32 Thirty nine percent of the women as against 33 percent of the husband have studied for 0-9 years. Further, 40 percent of women as against 57 percent of husband have completed 10 years or more of schooling. Thus, males are educationally better placed than females in the state. The distribution of household by standard of living index (SLI) shows that more than one-fifth of the households have low SLI; more than four-tenth of the households have medium SLI, while SLI of less than four-tenth households was high. The percentage of households with low SLI was the highest in rural areas and percentage of households with high SLI was the highest in urban areas.

3.2 Educational Level of Women

Table 3.2 provides details of educational level of eligible women in terms of classification by years of schooling, and selected background characteristics, such as, place of residence, religion, and caste and husbands’ education. The distribution of non-literate women shows that around one-fifth of the women aged below 30 years as against around three-tenth of the women aged 30 years and above were non-literate in the state. Further, 23 percent of the women had 9-10 years of schooling, followed by 19 percent with 1-5 years of schooling, while it was around 18 percent for women with 6-8 years of schooling. Only around 19 percent women had 11 or more years of schooling in the state. The percentage of women who had studied for 11 or more years was the lowest (6 percent) in the age group 15-19 years that steadily increases to 25 percent in the age group 25-29 years and thereafter steadily declines to 13 percent in the age group 40-44 years.

One-fourth of women in rural areas as against one-fourteenth of women in urban areas were non-literate in the state. Similarly, 22 percent of women in rural areas as against 9 percent of women in urban areas have 1-5 years of schooling in the state. Nineteen percent of women in rural areas as against 13 percent of women in urban areas have 6-8 years of schooling in the state. Further, 22 percent of women in rural areas as against 25 percent of women in urban areas have 9-10 years of schooling in the state. Only 11 percent of women in rural areas as against 45 percent of women in urban areas have 11 or more years of schooling in the state. These data have shown that percentage of women with 8 or less years of schooling was higher in rural areas than in urban areas, while situation just reverses in favour of urban women with 9 or more years of schooling. Thus, there exists serious rural-urban differential in the level of education in favour of urban women in Himachal Pradesh.

More Muslim women (45 percent) were non-literate compared to Hindu women (22 percent), Sikh women (12 percent) and Buddhist women (25 percent). These data further show that literacy status of Sikh women was better than that of women from all other religious communities, while literacy status of Muslim women was the lowest and lower than that of women from all other religious communities. However, literacy status of Hindu women was higher than that of Buddhist women but lower than that of Sikh women.

The level of educational attainment of women by caste shows that more schedule tribe women (39 percent) were non-literate compared to scheduled caste women (29 percent) and other backward class women (24 percent), while it was 18 percent for women from other castes. The percentage of women with 1-5 years of schooling was the highest (27 percent) for scheduled caste women, followed by other backward class women (22 percent) and the lowest (16 percent) for women from other castes. Similarly, percentage of women with 6-8 years of schooling was the highest (23 percent) for other backward class women, followed by scheduled caste women (19

33 Table 3.2 LEVEL OF EDUCATION OF ELIGIBLE WOMEN Percent distribution of currently married women aged 15-44 by years of schooling, according to selected background characteristics, Himachal Pradesh, 2002-04 Years of schooling Literate 11 or Non- but no 1-5 6-8 9-10 more Total Number of Background characteristic literate schooling years years years years Missing percent women Age group 15-19 9.4 0.0 33.0 31.9 20.0 5.7 0.0 100.0 104 20-24 12.4 0.0 12.7 21.7 30.2 22.8 0.1 100.0 1,506 25-29 14.1 0.1 13.8 18.9 27.8 25.3 0.0 100.0 2,185 30-34 23.7 0.1 19.2 18.4 21.9 16.7 0.0 100.0 1,912 35-39 30.3 0.1 24.7 14.3 17.1 13.4 0.0 100.0 1,698 40-44 33.1 0.2 26.2 12.2 15.6 12.7 0.0 100.0 1,213

Place of residence Rural 25.8 0.1 21.6 18.9 22.4 11.2 0.0 100.0 6,748 Urban 7.3 0.0 9.3 12.7 25.2 45.5 0.0 100.0 1,870

Religion Hindu 21.6 0.1 19.3 17.5 23.1 18.4 0.0 100.0 8,267 Muslim 45.3 0.4 11.2 16.2 17.1 9.8 0.0 100.0 124 Sikh 11.9 0.2 7.3 20.8 25.3 34.5 0.0 100.0 156 Buddhist 24.7 0.2 22.5 20.3 18.5 13.9 0.0 100.0 54

Caste/tribe # Scheduled caste 29.3 0.1 27.2 18.9 17.3 7.2 0.0 100.0 1,876 Scheduled tribe 38.9 0.0 18.4 12.2 21.4 9.2 0.0 100.0 348 Other backward class 23.8 0.1 21.6 23.0 20.5 11.0 0.0 100.0 856 Other 17.7 0.1 15.8 16.6 25.5 24.3 0.1 100.0 5,524

Husband’s education Non-literate 74.4 0.1 15.7 5.9 2.8 1.1 0.0 100.0 774 1-5 years 50.2 0.3 33.4 12.4 3.0 0.7 0.0 100.0 983 6-8 years 28.0 0.1 34.3 25.8 9.7 2.0 0.0 100.0 1,603 9-10 years 10.3 0.1 18.1 24.2 38.1 9.2 0.0 100.0 2,839 11 or more years 2.2 0.0 4.6 10.2 28.7 54.3 0.0 100.0 2,384

Total 21.7 0.1 18.9 17.6 23.0 18.6 0.0 100.0 8,618 # Total number may not add upto N due to don’t know and missing cases. Table includes 18 cases for other religion, 4 cases of literate but not schooling on husband’s education and 31 missing / do not know cases on husband’s education were not shown separately. ( ) Based on less than 50 unweighted cases.

percent) and the lowest (12 percent) scheduled tribe women. Further, percentage of women with 9-10 years and 11 or more years of schooling was lowest for scheduled caste women and the highest for women from other castes.

The husband’s education is an important characteristic, which has strong association with wife’s education. Seventy-four percent women whose husbands are non-literate are also non-literate, while 16 percent of non-literate husband had wives with 1-5 years of schooling and one percent husband had wives with 11 or more years of schooling. Similarly, more than 2 percent of husbands with 11 or more years of schooling have non-literate wives. Fifty four percent of women with 11 or more years of schooling have husbands who have the same level of education.

3.3 Background Characteristics of Husbands of Eligible Women

In DLHS-RCH husbands of eligible women were also interviewed. The response rate for husbands is relatively low compared to that of eligible women. Table 3.3 gives percentage distribution of husband of eligible women by selected background characteristics by residence in the state. Less than four-tenth of the husbands were in the age group 25-34 years, 17 percent husbands were aged

34 Table 3.3 BACKGROUND CHARACTERISTICS OF MEN Percent distribution of husband of eligible women by selected background characteristics, according to residence, Himachal Pradesh, 2002-04 Residence Background characteristic Total Rural Urban

Age group Below 25 3.3 3.9 1.0 25-34 37.3 38.8 32.5 35-44 42.7 41.5 46.7 45 + 16.7 15.8 19.8

Religion Hindu 96.3 96.8 94.4 Muslim 1.1 1.0 1.2 Christian 0.2 0.0 0.6 Sikh 1.6 1.3 2.8 Buddhist 0.9 0.9 0.9 Jain 0.0 0.0 0.1

Caste/tribe Scheduled caste 22.1 24.2 15.3 Scheduled tribe 4.8 5.4 3.0 Other backward class 9.1 10.4 4.9 Other # 63.6 59.7 76.6 Don’t know 0.3 0.3 0.2

Education (Years of schooling) Non-literate 8.9 10.5 4.0 0-9@ years 36.7 42.2 18.5 10 years & above 54.3 47.2 77.5 Missing 0.0 0.1 0.0

Standard of living index Low 22.3 28.3 2.7 Medium 39.6 46.3 17.7 High 38.0 25.3 79.7

Number of living children 0 9.1 9.6 7.4 1 16.6 15.1 21.3 2 37.8 35.0 46.8 3 22.7 24.2 17.9 4+ 13.9 16.1 6.6

Number of Men 4,550 3,489 1,061 # Higher caste (Not belonging to a scheduled caste, scheduled tribe and an other backward class). @ Literate persons with no year of schooling are included.

45 years or older. In Himachal Pradesh, 96 percent of the husbands were Hindus, one percent Muslims, two percent Sikh and one percent Buddhist. Twenty-two percent of the husbands were scheduled caste, five percent scheduled tribe and nine percent other backward classes, while 64 percent husbands were from other castes in the state. Thus, 36 percent of the husbands belong to scheduled caste; scheduled tribe and other backward classes and 64 percent husbands belong to other castes. In urban areas husbands from other castes constitute 77 percent as against 60 percent in rural areas. The educational characteristics of the husbands’ show that only nine percent were non- literate, 37 percent of them have completed 0-9 years of schooling and 54 percent husband had studied for 10 years and above. More than three-fourth of the husbands in urban areas as against less than one-half in rural areas had studied for 10 years or above.

The distribution of husbands by their standard of living index shows that 22 percent have

35 low SLI, 40 percent have medium SLI and 38 percent have high SLI in the state. Further, more than one-fourth of the husbands in rural areas as compared to only three percent in urban areas have low standard of living index. On the other hand, one-fourth of the husbands in rural areas as against 80 percent in urban areas were having high standard of living index. However, husbands with medium standard of living index (46 percent) in rural areas and husbands with high standard of living index (80 percent) in urban areas dominate the state. Around 38 percent of the husbands across the state reported to have two living children. More husbands in urban areas (21 percent) reported to have one living child, while more husbands in rural areas (24 percent) have three living children. The percentage of husbands having four or more children was 16 percent in rural areas and seven percent in urban areas, while it was 14 percent in the state.

3.4 Educational Level of Husbands of Eligible Women

Table 3.4 gives distribution of husbands of eligible women by years of schooling by age, religion and caste/tribe and place of residence. The percentage of non-literate husbands was 13 percent in the age group below 25 years, which declines to over five percent in the age group 25-34 years and thereafter steadily increases to 10 percent in the age group 35-44 years and to 13 percent in the age group 45 years or more, while it was nine percent for all ages. Among the literate husbands, one-third of them have 1-8 years of schooling irrespective of their age. Further, three-tenth of the husbands have 6-8 years of schooling while more than one-fourth of them have 11 or more years of schooling. The percentage of husbands who had studied for 11 or more years was the highest (33 percent) in the age group 25-34 years, followed by 27 percent in the age group 45 or more years and the lowest (19 percent) in the age group below 25 years.

Table 3.4 LEVEL OF EDUCATION OF MEN Percent distribution of husbands of eligible women by years of schooling, according to selected background characteristics, Himachal Pradesh, 2002-04 Literate Years of schooling Non- but no 1-5 6-8 9-10 11 or more Total Number Background characteristic literate schooling years years years years Missing percent of men

Age group Below 25 12.7 0.3 13.3 28.0 26.8 18.9 0.0 100.0 148 25-34 5.5 0.0 10.1 19.4 31.4 33.4 0.1 100.0 1,697 35-44 10.2 0.1 15.0 20.0 31.1 23.5 0.0 100.0 1,944 45 & above 12.7 0.3 16.9 15.6 28.0 26.6 0.0 100.0 760

Place of residence Rural 10.5 0.1 15.8 22.2 32.4 19.0 0.1 100.0 3,489 Urban 4.0 0.1 5.9 9.8 24.5 55.8 0.0 100.0 1,061

Religion Hindu 8.9 0.1 13.5 19.2 30.8 27.5 0.0 100.0 4,379 Muslim (30.4) (1.4) (17.4) (18.8) (14.5) (17.4) (0.0) 100.0 48 Sikh 4.1 0.0 7.0 21.8 26.8 40.2 0.0 100.0 74 Buddhist (11.8) (0.3) (18.6) (22.5) (22.2) (24.5) (0.0) 100.0 41

Caste/tribe # Scheduled caste 16.4 0.1 19.9 23.5 26.8 13.3 0.0 100.0 1,006 Scheduled tribe 18.9 0.0 17.7 18.0 23.8 21.5 0.0 100.0 219 Other backward class 10.1 0.0 19.6 28.0 24.2 18.2 0.0 100.0 416 Other 5.4 0.1 10.0 16.8 33.4 34.2 0.1 100.0 2,895

Total 8.9 0.1 13.5 19.3 30.6 27.6 0.0 100.0 4,550

# Total number may not add upto N due to don’t know and missing cases. ( ) Based on less than 50 unweighted cases. Note: Total includes 8 cases for other religions were not shown separately.

36 The percentage of non-literate husbands was nine percent for Hindus, 30 percent for Muslims, four percent for Sikh and 12 percent for Buddhist. The percentage of husbands who have 1-8 years of schooling was 33 percent for Hindus, 36 percent for Muslim, 29 percent for Sikh and 41 percent for Buddhist. The proportions of husbands who have 11 or more years of schooling was 27 percent for Hindu, 17 percent for Muslim, 40 percent for Sikh and 24 percent for Buddhist. Educational attainment of husbands of eligible women varies according to the caste/tribe they belong. There are more non-literate husbands belonging to scheduled tribes (19 percent), followed by scheduled caste (16 percent), other backward caste (10 percent) and five percent for husbands from other caste. The percentage of husbands who have 1-8 years of schooling was 43 percent for scheduled caste, 36 percent for scheduled tribe, 48 percent for other backward caste and 27 percent for husbands from other caste. The percentage of husbands who have 11 or more years of schooling was the highest (34 percent) for other caste, followed by scheduled tribe (21 percent) and the lowest (13 percent) for scheduled caste, while it was 18 percent for other backward class husbands. These data have shown that 33 percent of the husbands have 1-8 years of schooling, 31 percent husbands have 9-10 years of schooling and 28 percent of then have 11 or more years of schooling in the state.

3.5 Children Ever Born and Surviving

In DLHS-RCH, currently married women in the age group of 15-44 years were asked about the children ever born alive and the number of children surviving. Table 3.5 shows mean children ever born and mean surviving children by selected background characteristics and sex of children. The mean children ever born were 2.31 children as against 2.17 mean children surviving. In other words, mean child loss was 0.14 children in the state. On the average, women in the reproductive age group have given birth to 1.24 male children and 1.08 female children and similar sex differential was noted in mean surviving children. Completed fertility, that is, mean children ever born to currently married women in the age group 40-44 years was 3.24 children in the state and it comprises of 1.75 male children and 1.49 female children. However, only 2.98 mean children ever born survived. Thus, the average loss of child experienced by a woman during the reproductive period of 30 years was 0.26 children.

Data shows that mean children ever born increases with increase in the duration of marriage. The mean children ever born was 0.82 children for women with 0-4 years of marriage duration, which increases to 1.97 children for 5-9 years of marriage duration and to 3.21 children for women who were married for 15 or more years. There is a clear rural-urban divide in terms of mean children ever born with 2.4 children in rural areas and 2.0 children in urban areas. The mean children ever born were the highest (2.61 children) for Buddhist women, followed by Hindu women (2.32 children) and the lowest (2.02 children) for Sikh women. The average numbers of children ever born also vary by caste/tribe of the eligible women. The mean children ever born were the highest (2.54 children) for scheduled caste women, followed by other backward classes (2.52 children) and the lowest (2.20 children) for other castes women. For all religious groups, the mean number of surviving children was 2.35 children for scheduled caste and other backward castes, 2.28 children for scheduled tribe and 2.08 children for other castes

The mean children ever born was the highest (3.16 children) for non-literate women and the lowest (1.67 children) for women who had studied for 10 years and above, while it was 2.49 children for women who had studied for 0-9 years. Further, mean number of surviving children for

37 Table 3.5 CHILDREN EVER BORN AND LIVING Mean children ever born (CEB) and children surviving (CS) by selected background characteristics of currently married women aged 15-44 years, Himachal Pradesh, 2002-04 Mean children ever born Mean children surviving Number of

Background characteristic Total Male Female Total Male Female women Age group (years) 15-19 0.3 0.2 0.1 0.3 0.1 0.1 104 20-24 1.1 0.6 0.5 1.0 0.5 0.5 1,506 25-29 1.9 1.0 0.8 1.8 1.0 0.80 2,185 30-34 2.7 1.4 1.2 2.5 1.3 1.2 1,912 35-39 3.0 1.6 1.4 2.8 1.5 1.4 1,698 40-44 3.2 1.7 1.5 3.0 1.6 1.4 1,213

Marital duration 0-4 0.8 0.4 0.4 0.8 0.4 0.4 1,840 5-9 2.0 1.1 0.9 1.9 1.0 0.9 1,836 10-14 2.6 1.4 1.2 2.5 1.4 1.1 1,759 15+ 3.2 1.7 1.5 3.0 1.6 1.4 3,183

Residence Rural 2.4 1.3 1.1 2.2 1.2 1.1 6,748 Urban 2.0 1.1 0.9 1.9 1.0 0.9 1,870

Religion Hindu 2.3 1.2 1.1 2.2 1.2 1.0 8,267 Muslim 2.3 1.3 1.0 2.2 1.2 0.9 124 Sikh 2.0 1.1 0.9 1.9 1.1 0.9 156 Buddhist 2.6 1.2 1.4 2.4 1.1 1.3 54

Caste/tribe # Scheduled caste 2.5 1.3 1.2 2.3 1.2 1.1 1,876 Scheduled tribe 2.5 1.3 1.2 2.3 1.2 1.1 348 Other backward class 2.5 1.4 1.1 2.3 1.3 1.0 856 Other 2.2 1.2 1.0 2.1 1.1 1.0 5,524

Education Non-literate 3.2 1.7 1.5 2.9 1.5 1.4 1,874 0-9@ years 2.5 1.3 1.2 2.3 1.2 1.1 3,326 10 years & above 1.7 0.9 0.8 1.6 0.9 0.7 3,415

Standard of living index Low 2.8 1.4 1.4 2.6 1.3 1.3 1,888 Medium 2.3 1.3 1.0 2.2 1.1 1.0 3,583 High 2.0 1.1 0.9 1.9 1.0 0.9 3,147

All women 2.3 1.2 1.1 2.2 1.2 1.0 8,618

# Total number may not add upto N due to don’t know and missing cases. Table includes 18 cases for other religion and 3 women with missing information on education. @ Literate women with no year of schooling are included. women corresponding to these educational levels was 2.9, 2.35 and 1.61 respectively. Further, mean children ever born were the highest (2.82 children) for women with low SLI and the lowest (1.97 children) for women with high SLI, while it was 2.34 children for women with medium SLI. The mean number of surviving children corresponding to low, median and high standard of living index was 2.60, 2.20 and 1.89 respectively. These data have shown that mean number of children ever born to women decreases with increase in the level of her education and standard of living index. In other words, there exists inverse association between mean number of children ever born and educational attainment of women and also the standard of living index.

3.6 Completed Fertility by District

Table 3.6 gives mean children ever born (CEB) and children surviving (CS) to currently married women

38 Table 3.6 COMPLETED FERTILITY BY DISTRICT Mean children ever born (CEB) and children surviving (CS) to currently married women aged 40-44 years by district, Himachal Pradesh, 2002-04 Mean children ever born Mean children surviving

District Total Male Female Total Male Female

Bilaspur 3.2 1.6 1.6 2.9 1.5 1.4 Chamba 3.8 2.0 1.8 3.3 1.7 1.6 Hamirpur 3.1 1.6 1.5 2.9 1.5 1.4 Kangra 3.1 1.7 1.4 2.9 1.6 1.3 Kinnaur 3.5 1.9 1.6 3.0 1.6 1.4 Kullu 3.1 1.9 1.3 2.9 1.7 1.2

Lahul & Spiti 3.3 1.8 1.4 2.9 1.6 1.2 Mandi 3.1 1.6 1.4 2.9 1.6 1.3 Shimla 3.0 1.7 1.4 2.7 1.5 1.3 Sirmaur 4.0 2.3 1.7 3.6 2.1 1.5 Solan 2.9 1.5 1.4 2.8 1.5 1.3 Una 3.6 1.9 1.7 3.4 1.8 1.6

Himachal Pradesh 3.2 1.8 1.5 3.0 1.6 1.4

aged 40-44 years by districts in Himachal Pradesh. On the average, women on the verge of completing reproductive period have given birth to 3.2 children in their reproductive life of 30 years, while children surviving was 3.0 children in the state. Mean children ever born were the highest (4.0 children) in Sirmaur district, followed by Chamba district (3.8 children) and the lowest (2.9 children) in Solan district. Further, mean children ever born was equal to or higher than that of the state (3.2 children) in Bilaspur, Chamba, Kinnaur, Lahul & Spiti, Sirmaur and Una districts and in the six districts it was below the state level. Similarly, mean number of children surviving was equal to or higher than that of the state (3.0 children) in Chamba, Kinnaur, Sirmaur and Una districts and in the remaining eight districts it was below the state level. Looking at the absolute difference between mean number of children ever born and mean number of surviving children, it seems that infant and child mortality was quite high and varies among districts in Himachal Pradesh.

3.7 Birth Order

Table 3.7 gives distribution of births during three years preceding the survey by birth order by selected background characteristics of women in Himachal Pradesh. This distribution can be used as a measure of fertility in the absence of formal measures of fertility, such as, crude birth rate and total fertility rate. The data shows that 41 percent of the births during the three years period preceding the survey were first order birth, 34 percent second order births, over 14 percent third order births and the remaining 10 percent were fourth and higher order births in the state.

The percentage of third and higher order births was nine percent of births to women in the age group 20-24 years as against 25 percent to women in the age group 29-34 years. Similarly, percentage of third and higher order births was 56 percent of births to women in the age group 30-34 years as against 79 percent to women in the age group 35-39 years. In other words, percentage of higher births increases with age of the women.

The percentage of third and higher order births constitute 26 percent in rural women and 17 percent in the urban areas of the state. Further, percentage of third and higher order births were

39 Table 3.7 BIRTH ORDER Percent distribution of births during three years preceding the survey by birth order by selected background characteristics, Himachal Pradesh, 2002-04 Birth order Total Number of Background characteristic 1 2 3 4+ percent births Age of women 15-19 (85.1) (14.9) (0.0) (0.0) 100.0 31 20-24 59.1 32.0 7.9 1.1 100.0 1,147 25-29 34.7 40.4 16.0 8.9 100.0 1,186 30-34 15.6 28.4 30.0 26.1 100.0 409 35-39 5.7 15.8 14.5 64.1 100.0 93

Place of residence Rural 41.5 32.5 14.7 11.3 100.0 2,359 Urban 42.1 40.7 13.3 3.9 100.0 522

Education (Years of schooling) Non-literate 23.0 24.5 19.7 32.8 100.0 442 0-9@ years 34.2 35.0 20.2 10.7 100.0 1,033 10 years & above 52.9 36.3 8.6 2.2 100.0 1,405

Religion Hindu 41.4 34.0 14.6 10.0 100.0 2,730 Muslim 44.1 25.3 12.6 18.1 100.0 60 Sikh 47.0 40.4 10.6 2.0 100.0 68

Caste/tribe # Scheduled caste 33.4 33.6 18.0 15.0 100.0 716 Scheduled tribe 40.8 27.7 13.8 17.7 100.0 113 Other backward class 46.5 30.5 17.2 5.9 100.0 321 Other 44.0 35.3 12.6 8.1 100.0 1,727

Standard of living index Low 31.6 30.0 16.5 21.8 100.0 717 Medium 41.5 34.1 16.8 7.6 100.0 1,174 High 48.9 36.8 10.3 4.1 100.0 990

Total 41.6 34.0 14.5 9.9 100.0 2,881 # Total number of births may not add upto N due to don’t know and missing cases. ( ) Based on less than 50 unweighed cases. Note: Total includes 16 cases of women age 40-44 years and 23 cases for other religion were not shown separately.

the highest (over 52 percent) for non-literate women and the lowest (11 percent) for women who have studied for 10 years and above, while it was 31 percent for women who have studied for 0-9 years. Again, percentage of third and higher order births were 25 percent for Hindu women, 31 percent for Muslim women and 13 percent for Sikh women. Further, distribution of women by caste shows that the percentage of third and higher order births was the highest (33 percent) for scheduled caste women, followed by over 31 percent for scheduled tribe women and the lowest (21) percent for women from other castes. The distribution of women by their standard of living index shows that proportion of higher order (3+) births were the highest (38 percent) for women with low SLI and the lowest (14 percent) for women with high SLI, while it was 24 percent for women with medium SLI. Figure 3.1 shows higher order births by selected background characteristics.

3.8 Birth Order by District

Table 3.8 gives percent distribution of births during three years preceding the survey by birth order by districts in Himachal Pradesh. The percentage of births of third and higher order birth ranges from the lowest of 18 percent in Shimla district to the highest of 42 percent in Chamba district. Further, percentage of births of third and higher order birth were higher than that of the

40 Figure 3.1 Birth Order 3 & above by Selected Background Characteristic

TOTAL 24 Rural 26 Urban 17 EDUCATION Non-litertate 53 0-9years@ 31 10 & above 11 CASTE Schedulde caste 33 Schedulde tribe 32 Other backward class 23 Other 21 STANDARD OF LIVING Low 38 Medium 24 High 14

0 102030405060Percent

@ Literate women with no years of schooling are also included Himachal Pradesh, DLHS-RCH, 2002-04

state (24 percent) in Bilaspur, Chamba, Hamirpur, Kinnaur, Lahul & Spiti, Sirmaur and Una districts, while in the remaining five districts it was lower than that of the state. Again, proportion of births of fourth and higher order births was the highest (26 percent) in Sirmaur district, followed by Chamba district (22 percent) and the lowest (four percent) in Kangra district. Figure 3.2 shows births of birth order 3 and above by district.

3.9 Fertility Preference

Table 3.9 gives distribution of currently married women desiring additional children and preferred sex of additional children by number of living children of the women. Out of the 806 women with no living child, 30 percent were currently pregnant and seven percent were currently using spacing methods, while 54 percent want next birth within two years, less than one percent want to delay next birth for two or more years, about one percent were undecided about the timing of birth and 2 percent want have no more children. Among the currently married women, the desire for additional children decreases with increasing number of living children. As many as 41 percent women having one living child were using spacing methods, 16 percent of them want next birth within two years, 4 percent wants to delay next birth for two or more years, 3 percent were undecided about the timing of the next child, six percent of them want no more additional children and five percent were sterilized. Use of permanent as well as temporary means of contraception tends to be accelerated with number of living children. In the state of Himachal Pradesh, out of the 8,618 surveyed women, nine percent desired to have next birth within two years, one percent wants to delay next birth for two or more years, eight percent want no more children, seven percent were currently pregnant and 70 percent were using either terminal or temporary contraceptive methods.

41 Table 3.8 BIRTH ORDER BY DISTRICT Percent distribution of births during three years preceding the survey by birth order, according to district, Himachal Pradesh, 2002-04 Birth order

District 1 2 3 4+

Bilaspur 37.5 37.1 17.4 7.9 Chamba 30.6 27.3 20.3 21.8 Hamirpur 46.3 28.8 16.6 8.4 Kangra 48.1 32.8 15.3 3.8 Kinnaur 35.9 33.3 14.9 15.9 Kullu 40.0 37.4 9.4 13.1

Lahul & Spiti 37.1 31.0 16.7 15.2 Mandi 44.0 35.7 13.8 6.5 Shimla 45.5 36.7 11.4 6.4 Sirmaur 31.3 27.7 14.7 26.3 Solan 41.8 39.7 11.0 7.5 Una 39.6 34.0 16.3 10.2

Himachal Pradesh 41.6 34.0 14.5 9.9

Figure 3.2 Birth Order 3 & above by District

40+ 17% 2 Districts <25 41% 5 Districts

25-40 42% Himachal Pradesh, DLHS-RCH, 2002-04 5 Districts

A total of more than 11 percent women want additional children irrespective of the number of living children. Out of 473 women who have no living children and desire additional children, 14 percent want a boy as the first child, four percent desired a girl, for 69 percent, the sex of the child was immaterial and over 12 percent leave it to God. With increasing number of living children, male child dominates the preferred sex of the next child though a sizeable proportion of women desiring additional children expressed that the sex of the child was immaterial. Figure 3.3 shows fertility preference.

3.10 Pregnancy Outcomes

Table 3.10 shows distribution of pregnancy outcomes including live birth, stillbirth, induced abortion and spontaneous abortion by districts in Himachal Pradesh. For the state as a whole, 92 percent pregnancy ended in live births, three percent in induced abortions, three percent in spontaneous abortion and over one percent in stillbirth. More pregnancies in rural areas ended in live births (93 percent) than in urban areas (89 percent), while the incidence of induced abortion was more in urban areas (four percent) than in rural areas (three percent). The proportion of pregnancies ending in

42 Figure 3.3 Wants no more Fertility Preference 8% Other 3%

Curren Pergnant 7%

Sterilized Currently users 46% 24%

Wants another, after 2 years Wants 1% another,undecided when Wants another,within 2 2% years 9% Himachal Pradesh, DLHS-RCH, 2002-04

Table 3.9 FERTILITY PREFERENCE Percent distribution of currently married women by desire for children, according to number of living children, Himachal Pradesh, 2002-04 Number of living children

0 1 2 3 4+ Desire for children Total

Desire for additional child Wants another soon1 54.0 16.3 2.1 1.6 1.6 9.1 Wants another later2 0.4 3.8 0.4 0.0 0.2 0.8 Want another, undecided when 3.0 5.9 0.6 0.4 0.2 1.6 Undecided 0.6 2.7 0.7 0.2 0.3 0.8 Up to God 0.7 0.1 0.2 0.0 0.0 0.1 Want no more 1.8 5.9 10.6 8.5 10.2 8.4 Sterilized 0.4 4.6 50.9 69.3 72.6 46.4 Currently users3 6.9 41.4 30.2 16.8 11.9 23.7 Currently pregnant 30.5 17.2 3.2 1.2 1.3 7.3 Declared infecund 1.3 1.1 1.0 1.2 1.5 1.2 Missing 0.5 0.8 0.3 0.6 0.2 0.5

Total percent 100.0 100.0 100.0 100.0 100.0 100.0

Number of women 806 1,423 2,971 1,983 1,436 8,618

Preferred sex of additional children

Boy 13.6 38.7 60.7 (81.6) (84.1) 33.6 Girl 4.2 9.7 6.5 (6.1) (0.0) 6.4 Doesn’t matter 69.4 40.2 24.4 (6.1) (4.5) 48.5 Upto God 12.5 11.4 6.6 (6.1) (6.8) 10.9 Missing 0.4 0.0 1.8 (0.0) (4.5) 0.5

Total percent 100.0 100.0 100.0 100.0 100.0 100.0

Number of women 473 411 115 46 34 1,079

1 Wants next births within 2 years. 2 Wants to delay next birth for 2 or more years. 3 Other than sterilization. live births ranges from 89 percent in Kangra district to 97 percent in Shimla district. The percentage of pregnancies ending in live birth are higher than that of the state (over 92 percent) in Kullu, Lahul

43 & Spiti, Shimla, Sirmaur, Solan and Una districts while it was lower than that of the state in Bilaspur, Chamba, Hamirpur, Kangra, Kinnaur and Mandi districts. The incidence of stillbirth was the highest in Una district (three percent), followed by Kinnaur district (two percent) and nil in Lahul & Spiti district. Similarly, induced abortion was the highest (five percent) in Kangra district, followed by Mandi districts (over four percent) and nil in Kullu district. The spontaneous abortion was the highest in Chamba district (six percent), followed by five percent in Bilaspur and Kangra districts and the lowest (one percent) in Shimla district. In terms of incidence of induced abortion and spontaneous abortion, Shimla district was moderate.

Table 3.10 OUTCOMES OF PREGNANCY Percent distribution of all pregnancies of currently married women aged 15-44 years by their outcomes three year preceding the survey currently married women, according to districts, Himachal Pradesh, 2002-04

Induced Spontaneous Districts Live birth Stillbirth abortion abortion Missing Total percent

State-Rural 93.4 1.3 2.8 2.4 0.2 100.0 State-Urban 88.8 1.5 3.6 5.2 0.8 100.0 State-Total 92.5 1.3 2.9 2.9 0.3 100.0

Bilaspur 92.0 0.7 2.6 4.7 0.0 100.0 Chamba 90.8 1.6 1.9 5.8 0.0 100.0 Hamirpur 91.8 1.2 2.5 2.6 1.9 100.0 Kangra 88.7 1.5 5.1 4.7 0.0 100.0 Kinnaur 91.4 2.1 4.1 2.4 0.0 100.0 Kullu 94.3 1.7 0.0 3.1 0.9 100.0

Lahul & Spiti 96.5 0.0 0.3 3.2 0.0 100.0 Mandi 92.3 0.3 4.5 2.9 0.0 100.0 Shimla 96.7 0.7 1.3 0.7 0.6 100.0 Sirmaur 94.8 1.2 1.6 2.4 0.0 100.0 Solan 93.3 0.9 1.3 3.3 1.2 100.0 Una 93.0 3.3 1.5 2.2 0.0 100.0

44 CHAPTER IV

MATERNAL HEALTH CARE

Provisions of maternal health care services to ensure safe motherhood is one of the major components of the Reproductive and Child Health (RCH) programme. The RCH programme provides services for antenatal care that includes at least three antenatal care visits, iron prophylaxis for pregnant and lactating women, at least one dose of tetanus toxoid vaccine, detection and treatment of anaemia in mothers, and management and referral of high-risk pregnancies, natal care, post-natal care, and management of unwanted pregnancies. In rural areas, the government delivers reproductive health and other health services through its network of Primary Health Centres (PHCs), Sub-Centres (SCs) and other health facilities. In addition, pregnant women and children can get services from private maternity homes, hospitals, private practitioners, and in some case non-governmental organisations (NGOs) and trust hospitals. In urban areas, reproductive health services are available mainly through government or municipal hospitals, Urban Health Posts (UHPs), Urban Family Welfare Centres (UFWCs), hospitals and nursing homes operated by NGOs, and private nursing and maternity homes.

The National Population Policy (NPP), 2000 adopted by the Government of India (Ministry of Health and Family Welfare, 2000) reiterates the Government’s commitments to the safe motherhood programme within the wider context of reproductive health. Among the national socio-demographic goals for 2010 specified by the policy, several goals pertain to safe motherhood, that 80 percent of all deliveries should take place in institutions by 2010, hundred percent deliveries should be attended by trained personnel, and the maternal mortality ratio should be reduced to a level below 100 per 100,000 live births. Empowering women for improved health and nutrition is one of the 12 strategic themes identified in the policy to be pursued either as stand-alone programmes or as intersectoral programmes.

In Phase-I of DLHS-RCH a separate section on the status of maternal health and utilisation of maternal health care services was canvassed from all the eligible women who had their last pregnancy after January 1, 1999. In Phase-II, the same section was canvassed from all the eligible women who had their last pregnancy after January 1, 2001. The women whose last pregnancy terminated into live/still birth were asked about the details of antenatal, natal and post-natal care they received; complications suffered during pregnancy, delivery and post-delivery period and their treatment seeking behaviour about these complications. Women whose last pregnancy terminated into abortion, either spontaneous or induced, were asked about the utilisation of safe abortion services and the post-abortion complications experienced. This chapter presents information on antenatal, natal and postnatal care received by women whose last pregnancy had terminated during the three years preceding the survey as live birth or as stillbirth.

4.1 Antenatal Check-Up

Women who had given a birth during the three years preceding the survey were asked whether they had gone for antenatal check-ups outside the home, and if they had, what type of service provider had given them the check-ups. They were also asked whether any health worker had visited them at home to provide antenatal check-ups. Table 4.1 gives the percentage of women who received any antenatal check-up during pregnancy by source of antenatal provider according Table 4.1 ANTENATAL CHECK-UP Percentage of women* who received any antenatal check-up (ANC) during pregnancy by source of antenatal provider, according to selected background characteristics, Himachal Pradesh, 2002-04 Antenatal Health personnel providing ANC2 1 Any check-up only antenatal at home by ANM/ Nurse/ Other health Number of 3 Background characteristic check-up ANM Doctor LHV professional Other women Age group Less than 20 years (87.5) (0.0) (52.5) (35.0) (0.0) (0.0) 29 20-34 years 91.7 0.2 61.9 30.1 0.2 0.0 2,521 35 years & above 79.8 3.0 55.6 22.4 0.0 0.1 115 Children ever born 1 94.5 0.5 68.2 26.7 0.1 0.0 957 2 93.8 0.2 64.7 29.4 0.2 0.0 966 3 88.2 0.6 53.6 33.8 0.5 0.0 427 4+ 74.3 0.3 41.6 33.3 0.0 0.0 296 Residence Rural 89.7 0.4 55.9 34.1 0.2 0.0 2,150 Urban 96.2 0.0 84.7 11.4 0.3 0.1 516 Education Non-literate 71.2 0.0 40.4 30.2 0.6 0.0 404 0-9 @ years 90.4 0.5 50.9 39.7 0.1 0.0 942 10 years & above 97.4 0.3 75.4 22.4 0.1 0.0 1,319 Religion Hindu 90.9 0.4 61.1 29.9 0.2 0.0 2,531 Muslim 88.9 0.0 66.1 29.1 0.0 0.0 54 Sikh 94.0 0.0 66.1 27.8 1.3 0.0 59 Caste/tribe# Scheduled caste 89.7 0.4 52.6 37.3 0.1 0.0 647 Scheduled tribe 79.7 0.1 57.5 22.0 0.0 0.1 112 Other backward class 96.9 2.0 57.4 39.0 0.2 0.0 301 Other 91.1 0.0 66.1 25.3 0.2 0.0 1,602 Standard of living index Low 80.7 0.1 42.3 39.1 0.4 0.0 649 Medium 90.5 0.3 56.4 34.1 0.1 0.0 1,086 High 98.6 0.6 80.6 17.9 0.2 0.0 931 Availability of health facility4 in the village No 86.6 0.4 57.1 29.3 0.1 0.0 856 Yes 91.7 0.5 55.1 37.2 0.2 0.0 1,294

Total 91.0 0.4 61.5 29.7 0.2 0.0 2,666 * Women who had their last live/still birth since 1-1-1999/1-1-2001. Note: Total includes 19 women with zero parity and 22 women in other religion who were not shown separately. 1 Antenatal check-ups either at home or outside from home at health facility. 2 Antenatal check-ups outside home and percentage add more than 100.0 due to multiple responses 3 Other also includes trained and untrained dai . # Total figure may not add to N due to do not know and missing cases. @ Literate women with no years of schooling are also included. 4 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village. ( ) Based on less than 50 unweighted cases. to selected background characteristics in the state. The data shows that 91 percent of the pregnant women received antenatal check-up, which is slightly more than RCH Round-I (87 percent). Over 61 percent of the women received antenatal check-up from doctor, 30 percent from the ANM/Nurse/LHV and less than one percent other health professional. Only less than one percent women received antenatal check-ups at home by ANM. Figure 4.1 shows sources of antenatal care in the state.

The percentage of women who had antenatal check-ups was 87 percent for women aged less than 20 years, 92 percent for women aged 20-34 years and 80 percent for women aged 35 years and above. Further, percentage of women who had antenatal check-ups was the highest (94 percent) for women with one or two children ever born and the lowest (74 percent) for women with

46 Figure 4.1 Source of Antenatal Care

Any ANC 91

ANC at home 1

ANC Provider

Doctor 66

ANM/Nurse/LHV 29

Other 4

Note: Based on last live/still 0 20406080100 birth, born during three years preceding the survey PercentHimachal Pradesh, DLHS-RCH, 2002-04

four or more children ever born. The percentage of women who had antenatal check-up was higher in urban areas (96 percent) than in rural areas (89 percent), while it was 91 percent for the state. The percentage of women who received antenatal check-up from doctor was much higher in urban areas (85 percent) than in rural areas (56 percent). On the other hand, more of women in rural areas (34 percent) than in urban areas (11 percent) had antenatal check-ups from ANM/Nurse/LHV.

The percentage of women who had antenatal check-up was the highest (97 percent) for women who had studied for 10 years and above and the lowest (71 percent) for non-literate women, while it was 90 percent for women who had studied for 0-9 years. The percentage of women who received antenatal check-ups from a doctor was the highest (75 percent) for women who had studied for 10 years and above and the lowest (40 percent) for non-literate women, while it was 51 percent for women who had studies for 0-9 years. Further, percentage of women who had antenatal check-up was the highest (99 percent) for women with high SLI and the lowest (81 percent) for women with low SLI, while it was 90 percent for women with medium SLI. These data further show that percentage of women who received antenatal care from the doctor was the highest (81 percent) for women with high SLI, followed by (56 percent) for women with medium SLI and the lowest (42 percent) for women with low SLI. These data have shown that percentage of women who had any antenatal check-up increases with increase with increase in the level of education and the standard of living index of the women. In other words, there exists positive association between percentage of women who had any antenatal check-up and education and the standard of living index of the women.

The percentage of women who had any antenatal check-up was 91 percent for Hindu women, 89 percent for Muslim women and 94 percent for Sikh women. Similarly, percentage of women who had any antenatal check-up from a doctor was 61 percent for Hindu women and 66 percent for Muslim women and Sikh women. Further, percentage of women who had any antenatal check-up was the highest (97 percent) for other backward class women, followed by 91 percent for women from other castes and the lowest (80 percent) for scheduled tribe women. The percentage of women who had antenatal check-ups from a doctor was higher (66 percent) for women from other castes, followed by scheduled tribe women and other backward class women

47 (57 percent), while it was lowest for scheduled caste women (53 percent). Similarly, percentage of women who had antenatal check-up from ANM/Nurse/LHV was the highest (39 percent) for other backward class women, followed by scheduled caste women (37 percent) and the lowest (22 percent) for scheduled tribe women.

The percentage of women who had antenatal check-up was 87 percent for women living in villages having no health facility in the village as against 92 percent for women living in villages having health facility in the village. These data further show that more of women living in villages having no health facility in the village had antenatal care from a doctor and more of the women living in villages having health facility in the village had antenatal care from ANM/Nurse/LHV.

4.2 Antenatal Check-Up at Health Facility

Table 4.2 gives percentage of women who received any antenatal care (ANC) during pregnancy by source and place of antenatal check-up, according to selected background characteristics in the state. During pregnancy, women received antenatal check-up from multiple sources such as, health workers providing ANC at home, Government health facility, private health facility and Indian System of medicine etc. Over 81 percent of the women received antenatal check-up at government health facility, eight percent at private health facility and three from ISM and other health facility.

These data further show that 85 percent women aged less than 20 years had antenatal care from government health facility as against over two percent from private health facility. Similarly, 82 percent women aged 20-34 years had antenatal care from government health facility as against seven percent from private health facility. The percentage of women aged 35 years and above who had antenatal care from government health facility was 64 percent as against nine percent from private health facility. Again, 82-84 percent of women with one to three children ever born as against 67 percent women with four or more children ever born received antenatal care from government health facility. The percentage of women receiving antenatal care from private heath facility was the highest (10 percent) for women with one child ever born, followed by eight percent for women with two children ever born and the lowest (three percent) for women with three children ever born. Eighty two percent women in rural areas as against 80 percent women in urban areas received antenatal care from government health facility. On the other hand, six percent women in rural areas and 15 percent women in urban areas received antenatal care from private health facility. This indicates that maternal services are reaching the target population, particularly through the public sector.

The percentage of women who received antenatal check-up at the government health facility was the highest (85 percent) for women who had studied for 0-9 years and the lowest (68 percent) for non-literate women, while it was over 83 percent for women who had studied for 10 years and above. Further, more of women who had studied for 10 years and above received antenatal care from private health facility than non-literate women. Again, percentage of women who received antenatal check-up at government health facility was the highest (84 percent) for women with medium SLI and the lowest (76 percent) for women with SLI, while it was 82 percent for women with high SLI. More of women with high SLI received antenatal care from private health facility than women with low SLI. Eighty eight percent of Muslim women as against 81 percent of Hindu women received antenatal care from government health facility,

48 Table 4.2 PLACE OF ANTENATAL CHECK-UP Percentage of women* who received any antenatal check-ups (ANC) during pregnancy by source and place of antenatal check- ups, according to selected background characteristics, Himachal Pradesh, 2002-04 Place of antenatal check-ups1 3 Antenatal Private ISM4 facility check-up Government 2 health Number of Background characteristic only at home health facility facility PHC SC Govt. Private Other women Age group Less than 20 years (0.0) (85.0) (2.5) (11.4) (0.0) (0.0) (0.0) (0.0) 29 20-34 years 0.2 82.5 7.3 7.9 2.0 0.4 2.3 0.3 2,521 35 years & above 3.0 64.0 8.7 2.9 2.4 0.0 5.1 0.0 115 Children ever born 1 0.5 82.4 9.6 6.1 0.9 0.2 3.3 0.2 957 2 0.2 84.0 8.0 7.3 2.4 0.8 1.9 0.2 966 3 0.6 83.3 3.2 8.4 1.4 0.0 1.3 0.3 427 4+ 0.3 67.5 4.3 14.6 6.4 0.0 2.0 0.9 296 Residence Rural 0.4 81.9 5.6 9.3 2.5 0.1 2.0 0.3 2,150 Urban 0.0 79.8 14.8 1.4 0.0 1.3 3.9 0.0 516 Education Non-literate 0.0 67.9 1.8 10.5 2.6 0.0 1.4 0.8 404 0-9 @ years 0.5 84.6 3.7 11.5 3.3 0.0 1.5 0.3 942 10 years & above 0.3 83.5 11.6 4.5 1.0 0.7 3.2 0.1 1,319 Religion Hindu 0.4 81.5 7.2 7.8 2.1 0.4 2.4 0.3 2,531 Muslim 0.0 87.8 1.7 8.9 1.9 0.0 1.2 0.0 54 Sikh 0.0 75.4 18.6 4.9 0.0 0.0 0.0 0.0 59 Caste/tribe# Scheduled caste 0.4 83.7 4.1 14.1 2.5 0.0 1.7 0.2 647 Scheduled tribe 0.1 72.6 5.2 9.3 1.5 0.1 0.3 4.2 112 Other backward class 2.0 82.8 7.8 7.6 1.4 0.0 4.6 0.0 301 Other 0.0 81.0 8.7 5.1 1.9 0.6 2.3 0.1 1,602 Standard of living index Low 0.1 76.5 2.6 12.2 5.1 0.0 1.3 0.8 649 Medium 0.3 84.0 5.6 8.8 1.4 0.1 1.0 0.2 1,086 High 0.6 82.2 12.8 3.9 0.9 0.9 4.4 0.0 931 Availability of health facility5 in the village No 0.4 80.8 4.5 7.6 2.2 0.1 1.0 0.5 856 Yes 0.5 82.7 6.3 10.4 2.7 0.2 2.6 0.2 1,294

Total 0.4 81.5 7.4 7.7 2.0 0.4 2.4 0.3 2,666 * Women who had their last live/still birth since 1-1-1999/1-1-2001. Note: Total includes 19 women with zero parity and 22 women in other religion who were not shown separately. # Total figure may not add to N due to do not know and missing cases. @ Literate women with no years of schooling are also included. 1Antenatal check-ups outside home and percentage add more than 100.0 due to multiple responses. 2 Includes sub-centre, primary health centre, community health centre or rural hospital, urban health centre/ urban health post/ urban family welfare centre, government hospital or dispensary. 3 Includes Private hospital/clinic or non-governmental hospital/ trust hospital or clinic. 4 Indian system of medicine. 5 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village. ( ) Based on less than 50 unweighted cases. Total includes 22 other religion cases were not shown separately.

while it was 75 percent for Sikh women. More of Sikh women (19 percent) received antenatal care from private health facility than Hindu (seven percent) or Muslim (two percent) women. Again, percentage of women receiving antenatal care from government health facility was the highest (84 percent) for scheduled caste women, followed by other backward class women (83 percent) and the lowest (73 percent) for scheduled tribe women. The highest (nine percent) percent of women receiving antenatal care from private health facility was for women from other castes, followed by other backward class women (eight percent) and the lowest (four percent) for scheduled caste women. More of women living in villages having health facility in the village than women living in villages having no health facility in the village received antenatal care from government health facility. The scenario was similar in respect of private health facility.

49 4.3 Antenatal Check-Up by District

Table 4.3 gives percentage of women who received any antenatal care by source and place of antenatal check-up by district in Himachal Pradesh. The percentage of women who received any antenatal check-up was the highest (97 percent) in Hamirpur and Kangra districts, followed by 96 percent in Solan district and the lowest (81 percent) in Kullu district. The antenatal coverage was equal to or higher than that of the state (91 percent) in Bilaspur, Hamirpur, Kangra, Kinnaur, Lahul & Spiti, Sirmaur, Solan and Una districts, while in the remaining four districts it was lower than that of the state. However, more than 80 percent of the women got some kind of antenatal check-up for their last births during three years preceding the survey in all the districts of the state. Antenatal check-up done by the doctor were the highest (87 percent) in Solan district, followed by 80 percent in Kinnaur and Lahul & Spiti districts and the lowest (42 percent) in Sirmaur district. The percentage of antenatal check-up done by the doctor were higher than that of the state (61 percent) in Bilaspur, Hamirpur, Kinnaur, Kullu, Lahul & Spiti, Shimla and Solan districts, while in the remaining five districts it was lower than that of the state. The antenatal check-ups done by ANM/Nurse was the highest (50 percent) in Sirmaur district, followed by 42 percent in Chamba district and the lowest (eight percent) in Solan districts, while it was 30 percent for the state.

Table 4.3 ANTENATAL CHECK-UP BY DISTRICT Percentage of women* who received any antenatal care (ANC), by source and place of antenatal check-ups by district, Himachal Pradesh, 2002-04 Antenatal Health personnel providing ANC Place of antenatal check-ups check-up only 1 2 3 Any antenatal at home by Govern ment Private ISM4 District check-up ANM Doctor ANM/ Nurse health facility health facility facility

Bilaspur 92.2 0.0 66.3 26.7 83.6 6.3 2.3 Chamba 86.3 0.0 44.9 41.8 81.0 3.7 0.8 Hamirpur 97.1 0.0 68.6 31.7 91.2 2.6 2.9 Kangra 97.2 0.9 59.5 37.2 78.9 14.5 5.7 Kinnaur 94.9 0.0 80.2 14.3 89.6 5.0 0.7 Kullu 81.1 0.0 71.6 9.5 76.4 1.7 0.8

Lahul & Spiti 91.4 0.8 79.9 10.7 90.1 0.5 0.0 Mandi 87.1 0.0 53.8 34.3 79.4 6.7 1.8 Shimla 85.9 0.0 76.1 9.2 81.2 4.8 1.2 Sirmaur 92.7 0.4 42.5 49.8 85.8 4.7 2.2 Solan 95.6 0.7 87.4 7.9 84.7 7.8 3.1 Una 91.0 0.4 57.4 32.6 80.1 9.3 1.2

Himachal Pradesh 91.0 0.4 61.5 29.7 81.5 7.4 2.5 * Women who had last live/still birth during three years preceding the survey. 1 Antenatal check-ups either at home or health facility. 2 Includes sub-centre, primary health centre, community health centre or rural hospital, urban health centre/ urban health post/ urban family welfare centre, government hospital or dispensary. 3 Includes Private hospital/clinic or non-governmental hospital/ trust hospital or clinic. 4 Either government or private Indian system of medicine.

The extent of utilisation of government health facilities for antenatal check-up was the highest (91 percent) in Hamirpur district, followed by 90 percent in Lahul & Spiti district and the lowest (76 percent) in Kullu district. Similarly, extent of utilization of private health facilities for antenatal check-up was the highest (14 percent) in Kangra district, followed by nine percent in Una district and the lowest (less than one percent) in Lahul & Spiti district, while it was seven percent in the state. The extent of utilization of ISM facility was the highest (six percent) in Kangra district, followed by three percent in Hamirpur and Solan districts and the lowest (zero percent) in Lahul & Spiti district, while it was over two percent in the state.

50

4.4 Components of Antenatal Check-up

Table 4.4 gives women who received an antenatal check-up by specific components of antenatal check-up by residence. Except for X-rays (which are not recommended as a standard component of antenatal care), all of the measurements and tests are part of essential obstetric care or are required for monitoring high-risk pregnancies.

Seventy-four percent women were weighted, 73 percent had blood pressure checked and 75 percent had an abdominal examination as part of the antenatal check-up. Other common components of antenatal check-up done are blood test (80 percent), urine test (77 percent), measurement of height (33 percent), internal examination (44 percent) and breast examination (34 percent). Over 41 percent of women had a sonography/ultrasound, five percent had an X-ray and only nine percent women reported having amniocentesis test. All of these measurements or producers were performed during antenatal check-ups more often in urban areas than in rural areas.

Table 4.4 COMPONENTS OF ANTENATAL CHECK-UP Percentage of women* who received an antenatal check-up by specific components of antenatal check-up, according to residence, Himachal Pradesh, 2002-04 Components of antenatal check-ups Total Rural Urban Antenatal measurements/tests Weight measured 73.8 70.3 87.8 Height measured 33.4 29.0 50.4 Blood pressure checked 73.5 69.2 90.2 Blood tested 80.1 76.6 93.8 Urine tested 77.5 74.3 90.3 Abdomen examined 75.5 72.3 87.9 Internal examined 43.8 38.1 66.1 Breast examined 34.2 30.5 48.5 X-ray 4.8 3.9 8.1 Sonography /ultrasound 41.2 36.9 57.8 Amniocentesis 9.1 5.8 21.6 Antenatal advice Diet 59.6 56.4 72.0 Danger signs of pregnancy 43.0 42.0 46.9 Delivery care 37.8 35.0 48.5 Breast feeding 43.8 40.4 57.1 New born care 35.0 31.6 48.3 Family planning 31.9 28.9 43.6

Number of women who received any antenatal check-up 2,424 1,928 496 * Women who had their last live/still birth since 1-1-1999/1-1-2001

Table 4.4 further gives type of advice received by women who had antenatal check-up for last live/still births during three years preceding the survey. Advice on diet was given to 60 percent women in the state- 56 percent in rural areas and 72 percent in urban area. Forty-three percent women received advice on danger signs of pregnancy and 38 percent on delivery care. Only 44 percent women received advice on breast-feeding and 35 percent on newborn care. However, advice on family planning was given to 29 percent women in rural areas and 44 percent in urban areas, while it was 32 percent in the district.

4.5 Antenatal Care Services

The Reproductive and Child Health Programme in India aims at the registration of all pregnant

51 women in the first 12-16 weeks (Ministry of Health and Family Welfare, 1997). Accordingly the first antenatal check-ups should take place at latest during the first trimester of pregnancy. It also includes the provision of at least three antenatal care visits, at least one tetanus toxoid injection and supplementary iron in the form of IFA tablets daily for 100 days. To assess whether the women had received all the care during pregnancy, information was collected regarding number of antenatal visits, timing of the first visit, tetanus toxoid injection and supplement iron folic acid tablets. The results are presented in Table 4.5. In Himachal Pradesh, 68 percent of the women made atleast three antenatal care visits, while nine percent women made no antenatal care visit. Over 63 percent women made atleast three antenatal care visits in rural areas and 85 percent women in urban areas. The percentage of women who made atleast three antenatal care visits was the highest (83 percent) for women who had studied for 10 years and above and the lowest (37 percent) for non-literate women, while it was 60 percent for women who had studied for 0-9 years. Similarly, percentage of women who made atleast three antenatal care visits was the highest (84 percent) for women with high SLI and the lowest (47 percent) for women with low SLI, while it was 66 percent for women with medium SLI. These data have shown that proportion of women who made atleast three antenatal care visits is positively associated with standard of living index and education of women.

The percentage of women who made atleast three antenatal care visits was the highest (78 percent) for women with one child ever born, followed by 69 percent for women with two children ever born and the lowest (41 percent) for women with four or more children ever born. Sixty eight percent of Hindu women as against 55 percent of Muslim women made atleast three antenatal care visits, while it was 75 percent for Sikhs. Again, percentage of women who made atleast three antenatal care visits was the highest (71 percent) for women from other castes, followed by 64 percent for scheduled caste women and also other backward class women and the lowest (50 percent) for scheduled tribe women. Further, 62 percent of women living in villages having no health facility in the village as against 65 percent of women living in villages having health facility in the village made atleast three antenatal care visits.

Data on timing of first antenatal check-up shows that 53 percent women received their first antenatal check-up in the first trimester of pregnancy, 33 percent in the second trimester, and five percent in the third trimester. A relatively higher proportion of women in the urban areas (64 percent) as compared to those in rural areas (50 percent) had a check-up in the first trimester of pregnancy. The first antenatal check-up in the first trimester was the highest (66 percent) for women who had studied for 10 years and above and the lowest (29 percent) for non- literate women, while it was 44 percent for women who had studied for 0-9 years. Similarly, percentage of women who had first antenatal check-up in the first trimester was the highest (66 percent) for women with high SLI and the lowest (39 percent) for women with low SLI, while it was 49 percent for women with medium SLI. These data have shown that proportion of women having first antenatal check-up in the first trimester increases with increase in education and standard of living index of the women. In other words, there exists positive association between education and standard of living index of the women.

The percentage of women who had first antenatal check-up in the first trimester was the highest (61 percent) for women with one child ever born, followed by 56 percent for women two children ever born and the lowest (33 percent) for women with four or more children ever born. More than one-half of Hindu women as against more than four-tenth of Muslim women had

52 Table 4.5 ANTENATAL CARE Percent distribution of women who had live/still births during three years preceding the survey by number of antenatal check-ups, the stage of pregnancy at the time of first check- up, the number of tetanus toxoid injections received and were given iron folic acid (IFA) tablets/syrup during pregnancy, and percentage who received full antenatal check-ups by some selected background characteristics, Himachal Pradesh, 2002-04 Residence Education Children ever born Non- 0-9@ 10 years & Antenatal care indicators Total Rural Urban literate years above 1 2 3 4+

Number of ANC visits No visit 8.7 9.9 3.7 28.5 9.2 2.4 5.3 5.9 11.1 25.7 1 6.6 7.4 3.3 11.7 9.2 3.2 4.1 6.8 8.1 12.2 2 16.7 18.8 7.6 22.3 21.6 11.4 11.9 17.7 22.4 21.3 3 17.5 18.8 12.1 16.8 20.8 15.3 17.4 17.7 16.3 18.1 4+ 50.2 44.7 73.2 20.4 38.7 67.5 61.1 51.6 41.3 22.6 Missing 0.3 0.4 0.1 0.3 0.5 0.2 0.3 0.3 0.7 0.0

Stage of pregnancy at the time of the first antenatal check-up No antenatal check-up 8.7 9.9 3.7 28.5 9.2 2.4 5.3 5.9 11.1 25.7 First trimester 52.8 50.0 64.1 29.1 44.4 66.0 60.6 55.9 41.2 32.9 Second trimester 32.8 33.6 29.3 32.1 38.7 28.8 30.0 33.1 39.1 32.1 Third trimester 5.4 6.0 2.9 10.0 7.3 2.6 3.8 4.7 7.9 9.3 Missing 0.3 0.4 0.1 0.3 0.5 0.2 0.3 0.3 0.7 0.0

Women who received TT No TT 8.1 8.6 6.1 26.3 7.4 3.0 4.5 6.4 8.9 23.9 1 31.5 33.4 24.0 27.7 41.7 25.5 6.4 48.4 44.0 39.9 2+ 58.1 56.0 66.7 44.7 48.5 69.1 86.6 43.4 43.0 35.5 Do not remember/missing 2.3 2.0 3.3 1.2 2.4 2.5 2.4 1.8 4.1 0.7

Women who received IFA tablets/syrup

No IFA/syrup 13.2 14.4 8.5 30.6 15.6 6.2 7.0 11.6 16.9 33.3 Received but not consumed 2.5 2.7 1.7 2.0 3.3 2.1 2.7 2.1 2.4 3.5 Consumed one IFA per day 55.5 54.7 58.7 41.0 54.0 61.0 58.8 57.9 51.9 41.2

Received 100+ IFA tablets/syrup 42.8 40.1 53.8 30.3 31.9 54.3 50.5 42.1 35.1 29.4

Percentage of women who received full 1 antenatal check-ups 32.5 29.6 44.6 15.8 22.3 44.9 39.3 33.3 24.1 17.9

Number of women 2,666 2,150 516 404 942 1,319 957 966 427 296

Note: Total includes 19 women with zero parity who were not shown separately. @ Literate women with no years of schooling are also included. 1 At least three visits for antenatal check-ups, at least one TT injection received and were given adequate amount of IFA tablets/syrup. Continued…

53 Table 4.5 ANTENATAL CARE (contd) Percent distribution of women who had live/still births during three years preceding the survey by number of antenatal check-ups, the stage of pregnancy at the time of first check-up, the number of tetanus toxoid injections received and iron and were given iron folic acid (IFA) tablets/syrup during pregnancy, and percentage who received full antenatal check-ups by some selected background characteristics, Himachal Pradesh, 2002-04 Availability of health Religion Caste# Standard of living index facility2 in the village Scheduled Scheduled Other backward Hindu Muslim Sikh Other Low Medium High No Yes Antenatal care indicators caste tribe class

Number of ANC visits No visit 8.8 11.1 6.0 9.9 20.3 3.1 8.5 19.3 8.7 1.3 13.1 7.8 1 6.7 11.6 0.0 5.6 6.3 9.1 6.5 10.1 6.8 3.9 7.1 7.6 2 16.4 21.8 18.7 19.6 23.4 24.1 13.6 23.2 17.9 10.6 17.8 19.5 3 18.0 4.3 9.4 20.5 18.3 17.7 16.2 19.0 20.8 12.6 21.7 16.9 4+ 49.9 51.1 65.9 44.0 31.6 45.9 54.8 28.5 44.9 71.5 40.0 47.8 Missing 0.3 0.0 0.0 0.5 0.0 0.0 0.3 0.0 0.7 0.1 0.2 0.5 Stage of pregnancy at the time of the first antenatal check-up No antenatal check-up 8.8 11.1 6.0 9.9 20.3 3.1 8.5 19.3 8.7 1.3 13.1 7.8 First trimester 52.6 42.3 68.0 47.8 43.6 49.2 56.1 39.2 49.5 66.0 47.5 51.7 Second trimester 33.1 33.1 20.0 35.9 31.3 39.1 30.5 32.2 35.0 30.6 33.2 33.9 Third trimester 5.2 13.4 5.9 6.0 4.9 8.7 4.6 9.3 6.0 2.0 5.8 6.1 Missing 0.3 0.0 0.0 0.5 0.0 0.0 0.3 0.0 0.7 0.1 0.2 0.5 Women who received TT No TT 7.9 21.2 5.4 8.0 14.2 2.8 8.7 17.8 5.9 3.9 11.7 6.5 1 31.9 32.1 18.9 37.5 27.2 35.2 28.8 33.7 35.2 25.7 34.5 32.6 2+ 57.9 45.5 75.7 52.8 58.3 61.4 59.6 46.7 56.8 67.6 52.0 58.7 Do not remember/missing 2.3 1.3 0.0 1.7 0.3 0.6 2.9 1.8 2.1 2.7 1.8 2.2 Women who received IFA tablets/syrup

No IFA/syrup 13.3 17.5 8.0 11.8 25.1 12.8 13.1 22.2 13.1 7.2 16.5 12.9 Received but not consumed 2.6 0.7 0.0 3.7 0.2 4.1 1.9 3.2 2.5 2.0 2.8 2.6

Consumed one IFA per day 54.6 68.5 72.4 53.9 54.0 60.6 55.4 47.2 56.5 60.2 51.6 56.8

Received 100+ IFA tablets/syrup 42.6 37.6 59.4 39.2 35.1 35.1 46.2 30.6 39.3 55.2 39.6 40.4

1 Percentage of women who received full 32.3 22.5 53.6 29.8 23.8 25.0 35.6 19.7 28.5 46.1 29.8 29.5 antenatal check-ups

Number of women 2,531 54 59 647 112 301 1,602 649 1,086 931 856 1,294 Note: Total includes 22 women in other religion who were not shown separately. # Total figure may not add to N due to don’t know and missing cases. 1 At least three visits for antenatal check-ups, at least one TT injection received and was given adequate amount of IFA tablets/syrup. 2 Includes sub-center, primary health center, community health center or referral hospital, government hospital, and government dispensary within the village.

54 first antenatal check-up in the first trimester, while it was 68 percent for Sikh women. The percentage of women who had first antenatal check-up in the first trimester was the highest (56 percent) for women from other castes, followed by other backward class women (49 percent) and the lowest (44 percent) for scheduled tribe women. Further, 47 percent of women living in villages having no health facility in the village as against 52 percent of women living in villages having health facility in the village had their first antenatal check-up in the first trimester of their pregnancy.

Nutritional deficiencies in women are often exacerbated during pregnancy because of the additional nutrient requirements of foetal growth; therefore a pregnant woman needs six times more iron than a non-pregnant woman. The information on receiving iron folic acid tablets/syrup during pregnancy was collected in the survey. These data further show that 87 percent women received IFA tablets/syrup in the state - 86 percent in rural areas and 91 percent in urban areas. IFA coverage was quite low (69 percent) for non-literate women and high (94 percent) for women who had studied for 10 years and above. Similarly, IFA coverage was quite low (78 percent) for women with low SLI and high (93 percent) for women with high SLI. The percentage of women who received IFA tablets/syrup was the highest (93 percent) for women with one child ever born, followed by 88 percent for women with two children ever born and the lowest (67 percent) for women with four or more children ever born.

Eighty seven percent of Hindu women as against 82 percent of Muslim women received IFA tablets/syrup, while it was 92 percent for Sikh women. The percentage of women who received IFA tablets/syrup was the highest (88 percent) for scheduled caste women, followed by other backward class women (87 percent) and the lowest (75 percent) for scheduled tribe women. Again, only 43 percent of women received 100+ IFA tablets/syrup in the state – 40 percent in rural areas and 54 percent in urban areas. Further, distribution of women who received 100+ IFA tablets/syrup shows that it decreases with increase in the parity of women. Fifty four percent of the women who had studied for 10 years and above received 100+ IFA tablets/syrup, followed by 32 percent women who had studied for 0-9 years and it was the lowest (30 percent) for non-literate women. Intake of 100+ IFA tablets/syrup was the highest (55 percent) for women with high SLI and the lowest (31 percent) for women with low SLI, while it was 39 percent for women with medium SLI. The percentage of women who received 100+ IFA tablets/syrup was the highest (59 percent) for Sikh women and the lowest (38 percent) for Muslim women, while it was 43 percent for Hindu women. More women from other castes than scheduled caste women received 100+ IFA tablets/syrup, while it was the lowest for scheduled tribe and other backward class women. However, proportion of women living in villages having no health facility and those having health facility in the village who received 100+ IFA tablets/syrup is similar.

For the last live birth or stillbirth during the three years preceding the survey, women were asked whether they were given tetanus toxoid injection to prevent them and their baby from getting tetanus. The data shows that 31 percent of the women received one TT injection and 58 percent women received two or more TT injections, while eight percent of the women did not receive any TT injection in the state. The percentage of women who received at least one tetanus toxoid injection was 90 percent in the state - 89 percent in rural areas and 91 percent in urban areas. Further, percentage of women who did not receive any TT injection was the highest (26 percent) for non-literate women and the lowest (three percent) for women who

55 had studied for 10 years and above, while it was seven percent for women who had studied for 0-9 years. The percentage of women who received atleast one tetanus toxoid injection was the highest (95 percent) for women who had studied for 10 years and above and the lowest (72 percent) for non-literate women, while it was 90 percent for women who had studied for 0-9 years. Similarly, percentage of women who received atleast one tetanus toxoid injection was the highest (93 percent) for women with high SLI and the lowest (80 percent) for women with low SLI, while it was 92 percent for women with medium SLI.

The coverage of women who received TT injections varies by parity. At least one tetanus toxoid injection was received by 93 percent women of parity-1 compared with 75 percent of parity- 4 and above. Ninety percent of Hindu women as against 78 percent of Muslim women received atleast one tetanus toxoid injection, while it was 95 percent for Sikh women. The percentage of women who received atleast one tetanus toxoid injection was the highest (97 percent) for other backward class women, followed by schedule caste women (90 percent), while it was the lowest (85 percent) for schedule tribe women.

The percentage of women who received full antenatal care (Atleast three ANC visits and 100+ IFA tablets and atleast one TT injection) is given in Table 4.5. The data shows that only 32 percent of women in Himachal Pradesh received full antenatal care – 30 percent in rural areas and 45 percent in urban areas. Coverage of full antenatal care was the highest (45 percent) for women who had studied for 10 years and above and the lowest (16 percent) for non-literate women, while it was 22 percent for women who had studied for 0-9 years. Similarly, coverage of full antenatal care was the highest (46 percent) for women with high SLI and the lowest (20 percent) for women with low SLI, while it was 28 percent for women with medium SLI. These data have shown that proportion of women who received full antenatal care increases with increase in standard of living index and education of women. In other words, there exists positive association between proportion of women who received full antenatal care and their education and standard of living index.

The percentage of women who received full antenatal care was the highest (39 percent) for women with one child ever born, followed by 33 percent for women with two children ever born and the lowest (18 percent) for women with four or more children ever born. Coverage of full antenatal care was 32 percent for Hindu women as against 22 percent for Muslim women, while it was 54 percent for Sikh women. Again, percentage of women who received full antenatal care was the highest (36 percent) for women from other castes, followed by 30 percent for scheduled caste, while it was the lowest (24 percent) for scheduled tribe women. Figure 4.2 gives full antenatal care by background characteristics.

4.6 Antenatal Care Indicator by District

Table 4.6 shows the percentage of women who had given live/still birth during three years preceding the survey who received different types of antenatal care; (the percentage who received antenatal check-up in the first trimester of pregnancy, the percentage who received at least three antenatal check-ups, the percentage who received at least one tetanus toxoid injection, the percentage given 100 or more iron folic acid tablets/syrup and the percentage who received full antenatal care services) by district. The utilisation of antenatal care services differs from district to district. The utilisation of antenatal care services was the highest (66 percent) in

56 Figure 4.2 Full Antenatal Care by Background Characteristic

Total 32 Rural 30 Urban 45 EDUCA TION Non-literate 16 0-9 years@ 22 10 & above 45 CA STE Schedulde tribe 24 Schedulde caste 30 Other backw ard class 25 Other 36 STANDARD OF LIVING Low 20 Medium 29 High 46

0 5 10 15 20 25 30 35 40 45 50 Percent

@ Literate mothers with no years of schooling are also included. Himachal Pradesh, DLHS-RCH, 2002-04

Table 4.6 ANTENATAL CARE INDICATORS BY DISTRICT Percentage of women* who received different type of antenatal care by district, Himachal Pradesh, 2002-04 Percentage that Percentage that Percentage that Percentage Percentage that received an antenatal received three or received at least that received received full2 check-up in the first more antenatal one tetanus adequate antenatal check- District trimester of pregnancy check-ups toxoid injection amount of IFA1 ups Bilaspur 63.0 70.1 91.8 66.7 49.4 Chamba 29.4 53.0 83.9 37.1 24.9 Hamirpur 66.5 80.4 97.6 52.0 45.4 Kangra 60.5 76.0 90.5 40.7 31.8 Kinnaur 60.4 64.8 92.6 53.7 41.1 Kullu 47.7 66.2 79.7 46.5 35.0

Lahul & Spiti 57.8 63.4 88.6 41.7 31.9 Mandi 45.7 60.7 91.6 40.0 29.2 Shimla 56.6 70.1 85.7 46.5 34.2 Sirmaur 53.9 57.0 83.6 39.3 28.2 Solan 61.4 73.0 93.8 49.4 38.9 Una 44.9 67.7 93.3 33.1 25.6

Himachal Pradesh 52.8 67.7 89.6 42.8 32.5 * Women who had their last live/still birth since 1-1-1999/1-1-2001 1 100 or more iron folic acid tablets including syrup 2 At least three visits for antenatal check-ups, at least one TT injection received and adequate amount of IFA

Hamirpur district, followed by 63 percent in Bilaspur district and the lowest (29 percent) in Chamba district. Further, utilisation of antenatal care services was higher than that of the state (53 percent) in Bilaspur, Hamirpur. Kangra, Kinnaur, Lahul & Spiti, Shimla, Sirmaur and Solan districts and in the remaining four districts it was lower than that of the state.

57 The percentage of women who made atleast three visits for antenatal check-ups was the highest (80 percent) in Hamirpur district, followed by 76 percent in Kangra district and the lowest (53 percent) in Chamba district. The utilisation of antenatal check-ups was equal to or higher than that of the state (68 percent) in Bilaspur, Hamirpur, Kangra, Shimla, Solan and Una districts and in the remaining six districts it was lower than that of the state. Again, percentage of women who received atleast one TT injection was the highest (98 percentage) in Hamirpur district, followed by 94 percent in Solan districts and the lowest (80 percent) in Kullu district. The percentage of women who received atleast one TT injection was higher than that of the state (90 percent) in Bilaspur, Hamirpur, Kangra, Kinnaur, Mandi, Solan and Una districts, while in five districts it was lower than that of the state. There has been good coverage of tetanus toxoid injection in the all districts, ranging from 80 to 98 percent, but, on the other hand, performance regarding receipt of 100 or more IFA was quite unsatisfactory. It varies between 33 percent in Una district to 67 percent in Bilaspur district. The percentage of women who received full antenatal care was the highest (49 percent) in Bilaspur district, followed by 45 percent in Hamirpur district and the lowest (25 percent) in Chamba district. The percentage of women who received full antenatal care was higher than that of the state (32 percent) in Bilaspur, Hamiepur, Kinnaur, Kullu, Shimla and Solan and in the remaining six districts it was lower than that of the state (see Map-3).

4.7 Pregnancy Complications and Treatment

Complications during pregnancy may adversely affect both women’s health and the outcome of the pregnancy. Early detection of complications during pregnancy and their management are important components of the safe motherhood programme. In the survey, all the eligible women who had given last live/still birth during three years preceding the survey were asked if at any time during the pregnancy, they had experienced any of the following pregnancy-related problems such as swelling of hands and feet, paleness, visual disturbance, vaginal bleeding, convulsions, weak or no movement of foetus, abnormal position of foetus, and other problems. All of the information is based on women’s self-reporting which is presented in Table 4.7. These data shows that 28 percent women experienced at least one pregnancy related problem in the state- 27 percent in rural areas and 32 percent in urban areas. Coverage of such women was higher for women who had ANC (30 percent) than those who had no ANC (14 percent). The percentage of women who experienced at least one pregnancy related problem was the highest (37 percent) for women aged 35 years and above, followed by 30 percent for women aged 30- 34 years and the lowest (20 percent) for women aged 15-19 years. The percentage of women who experienced at least one pregnancy related problem varies from 26 percent to 30 percent irrespective of parity of the women. This proportion is relatively higher among women with medium and high SLI than women with low SLI.

The major problems reported were ‘swelling of hand and feet’ (13 percent), ‘paleness’ (10 percent) and ‘visual disturbance’ (over nine percent). The other problems reported were ‘abnormal position of foetus’ (three percent), ‘vaginal bleeding’ (two percent), ‘convulsions’ (one percent), and ‘weak or no movement of foetus’ (over one percent). Only five percent women reported other problems related to pregnancy. Swelling of hands and feet was more common among older women (30+ years), women with parity-1 and parity-2, and women with high standard of living index. The percentage of women who were more anaemic belonged to the age group 20-24 years and 30-34 years, women from rural areas, women with

58 Table 4.7 PREGNANCY COMPLICATIONS Percentage of women who had live/still births during three years preceding the survey by pregnancy complication and type of complication during pregnancy by some selected background characteristics, Himachal Pradesh, 2002-04 Percentage Type of pregnancy complication; of women with any Swelling of Weak or no Abnormal Number pregnancy hands and Visual movement position of of Background characteristic complication feet Paleness disturbances Bleeding Convulsion of foetus foetus Other women

Age group (years)

15-19 (20.0) (12.5) (7.5) (5.0) (0.0) (2.5) (0.0) (0.0) (0.0) 29 20-24 28.1 11.7 11.3 10.0 1.7 1.0 1.6 2.2 6.8 978 25-29 27.2 13.3 9.7 9.7 2.3 0.2 1.2 4.1 4.4 1,118 30-34 30.0 15.4 10.9 7.9 3.2 0.7 2.1 2.8 2.3 425 35-39 37.2 13.2 8.7 13.1 4.9 0.7 0.0 0.0 10.9 96

Children ever born 13.9 10.8 11.3 2.0 0.6 2.1 2.6 7.0 957 1 29.8 13.4 8.9 7.2 1.9 0.5 1.4 3.3 3.5 966 2 26.8 10.9 10.1 8.8 1.5 1.2 0.7 2.5 3.3 427 3 26.0 9.4 12.3 11.2 5.6 0.3 0.5 1.9 7.3 296 4+ 29.2

Residence

Rural 27.4 10.8 11.7 10.4 2.5 0.6 1.2 2.8 5.6 2,150 Urban 31.6 21.9 4.7 5.8 1.2 0.6 2.4 3.8 3.5 516

Standard of living index Low 23.7 8.0 11.2 10.4 2.0 0.7 1.0 1.9 5.3 649 Medium 29.8 12.2 10.7 10.2 1.6 0.6 1.7 3.3 6.7 1,086 High 29.5 17.4 9.4 8.1 3.1 0.5 1.5 3.3 3.4 931

Received any ANC

Yes 29.7 13.5 11.0 10.2 2.3 0.6 1.5 3.2 5.5 2,424 No 14.1 8.0 3.6 2.6 1.7 0.6 0.8 0.4 1.8 233

Total 28.2 13.0 10.4 9.5 2.2 0.6 1.4 3.0 5.2 2,666

Note1: Total include 19 women with zero parity, 9 with missing information on whether received any ANC category who were not shown separately. Note2: Total includes 19 women in the age group 40-44 who were not shown separately. @ Literate women with no years of schooling are also included. ( ) Based on less than 50 unweighted cases.

59 a low and medium standard of living index and women who received any antenatal care during the pregnancy. Anaemia was higher among parity-1 women and women with parity 3+. Similarly, visual disturbance was high for women aged 20-24 years and 35-39 years. Vaginal bleeding was high among women aged 35-39 years and women with four and more children ever born. Figure 4.3 gives distribution of women with pregnancy complications by symptom.

Figure 4.3 Percentage of women with Pregnancy Complication and by Symptoms Any pregnancy complication 28

Sw elling of hands and feet 13

Paleness 10

Visual disturbance 10

Bleeding 2

Convulsion 1

Weak or no movement of fetus 1

Abnormal postion of fetus 3

Other 5

0 5 10 15 20 25 30

Himachal Pradesh, DLHS-RCH, 2002-04 Percent

Women who reported at least one pregnancy related complication were asked whether they had consulted someone or had sought treatment for their problem and also the source of treatment. Table 4.8 shows the percentage of women who had any pregnancy complications, who sought treatment by source of treatment according to residence and availability of health facility in the village. Sixty-nine percent of the women reported that they sought treatment in the state – 68 percent in rural areas and 70 percent in urban areas. The percentage of women who sought treatment of their pregnancy complication was higher (70 percent) for women living in villages having no health facility in the village than women (68 percent) living in villages having health facility in the village.

Among women who sought treatment for pregnancy complications, 83 percent visited government health facility including a primary health centre (eight percent) and sub-centre (one percent) and 13 percent visited private health facility, while four percent women visited ISM and other health facility. The proportion of women who visited private health facility was 14 percent in urban areas and 13 percent in rural areas. Among women who sought treatment, 78 percent sought treatment from a doctor, 21 percent from ANM/Nurse/LHV and one percent from other. The percentage of women who sought treatment from the doctor was 95 percent in urban areas as against 73 percent in rural areas. Similarly, percentage of women who sought treatment from ANM/Nurse/LHV was 26 percent in rural areas as against five percent in urban areas.

60 Table 4.8 TREATMENT FOR PREGNANCY COMPLICATIONS Percentage of women* who had any pregnancy complication, sought treatment and source of treatment according to residence and availability of health facility in the village, Himachal Pradesh, 2002-04 Availability of health Residence facility5 in the village Treatment and source Total Rural Urban No Yes

Percentage of women sought treatment who had any pregnancy complication 68.8 68.5 70.0 69.6 68.0

Number of women 752 589 163 193 396

Percentage sought treatment at health facility

Government health facility1 83.1 83.8 80.6 85.0 83.1 Primary health centre 7.8 10.0 0.2 8.7 10.6 Sub centre 0.9 0.4 2.5 1.2 0.1

Private health facility2 13.1 12.8 13.9 10.6 13.9

ISM3 facility 3.7 3.2 5.8 4.7 2.4

Other 0.1 0.0 0.4 0.0 0.0

Percent distribution of women who obtained treatment from

Doctor 77.9 73.2 94.7 70.5 74.5 ANM/nurse/midwife/LHV 21.0 25.6 4.9 28.0 24.3 Other4 0.7 0.8 0.0 0.3 1.1 Missing 0.4 0.4 0.4 1.3 0.0

Total percent 100.0 100.0 100.0 100.0 100.0

Number of women 518 404 114 134 269

1 Include municipal hospital, dispensary, urban health centre/urban health post/urban family welfare centre, community health centre/rural hospital, primary health centre and sub centre 2 Include private hospital/clinic and non-governmental organization/ trust hospital 3 Either government or private Indian system of medicine 4 Other include Dai trained or untrained, other health professional and ISM practitioner 5 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village

4.8 Delivery Care

4.8.1 Place of Delivery

One of the important thrusts of the Reproductive and Child Health Programme is to encourage deliveries under proper hygienic conditions under the supervision of trained health professionals. The provision of delivery services in the government health institutions is one of the components of the RCH programme. For each live/still birth during three years preceding the survey, women were asked about the place of delivery, who assisted the home delivery by selected back- ground characteristics are given in Table 4.9. More than one-third (37 percent) deliveries took place in government health institutions, eight percent in private health institutions and 54 percent at home. Thirty two percent of the deliveries in rural areas and 58 percent in urban areas took place in health institutions. The percentage of institutional deliveries increased from 32 percent in Round-1 to 45 percent in Round-11 in Himachal Pradesh. The proportion of births occurring in health institutions was higher (46 percent) for women aged 25-34 years, than for women aged 35 years and above (29 percent). The percentage of institutional deliveries

61 Table 4.9 PLACE OF DELIVERY Percent distribution of women who had given live/still births during three years preceding the survey, by place of delivery, according to selected background characteristics, Himachal Pradesh, 2002-04 Health institutions Number Total of Background characteristics Public Private Home Other Missing percent women

Age group (in years) Below 20 (25.0) (2.5) (70.0) (2.5) (0.0) 100.0 29 20-34 37.6 8.3 53.6 0.2 0.3 100.0 2,521 35 and above 23.3 5.9 69.4 1.4 0.0 100.0 115 Children ever born 1 49.0 13.1 37.2 0.4 0.3 100.0 957 2 37.0 6.5 56.2 0.1 0.1 100.0 966 3 26.7 3.9 67.7 0.6 1.0 100.0 427 4+ 12.4 3.3 84.0 0.3 0.0 100.0 296 Residence Rural 31.8 6.3 61.2 0.4 0.3 100.0 2,150 Urban 58.2 16.0 25.5 0.1 0.2 100.0 516 Education Non-literate 14.6 2.4 82.7 0.3 0.0 100.0 404 0-9@ years 26.6 4.1 68.2 0.6 0.6 100.0 942 10 years & above 51.2 12.8 35.7 0.1 0.2 100.0 1,319 Religion Hindu 37.0 8.0 54.4 0.3 0.3 100.0 2,531 Muslim 33.8 5.7 60.5 0.0 0.0 100.0 54 Sikh 38.6 18.1 43.3 0.0 0.0 100.0 59 Caste# Scheduled caste 28.1 4.3 67.1 0.1 0.5 100.0 647 Scheduled tribe 19.0 6.6 73.5 1.0 0.0 100.0 112 Other backward class 37.1 10.0 52.9 0.0 0.0 100.0 301 Other 41.6 9.5 48.1 0.4 0.3 100.0 1,602 Standard of living index Low 21.5 2.5 75.5 0.3 0.3 100.0 649 Medium 30.5 5.2 63.3 0.6 0.4 100.0 1,086 High 55.2 15.5 29.0 0.0 0.3 100.0 931 Number of antenatal check- ups No check-up 8.7 0.8 89.1 1.3 0.0 100.0 233 1 17.8 2.2 79.7 0.0 0.3 100.0 176 2 24.1 5.1 70.1 0.6 0.1 100.0 444 3 33.3 4.0 62.5 0.2 0.0 100.0 466 4+ 49.8 12.7 37.0 0.1 0.3 100.0 1,338 Delivery characteristics Normal 34.6 3.7 61.3 0.3 0.1 100.0 2,263 Caesarean 49.3 37.6 12.9 0.3 0.0 100.0 277 Assisted 54.9 25.9 19.2 0.0 0.0 100.0 118 Availability of health facility1 in the village No 27.2 5.6 66.3 0.6 0.3 100.0 856 Yes 34.9 6.7 57.8 0.2 0.3 100.0 1,294

Total 36.9 8.2 54.3 0.3 0.3 100.0 2,666

Note: Total includes 19 women with zero parity, 9 cases with missing information on number of ANC visits and 8 missing case on delivery characteristics who were not shown separately. # Total figure may not add to N due to do not know and missing cases. @ Literate women with no years of schooling are also included. 1 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village ( ) Based on less than 50 unweighted cases.

was the highest (64 percent) for women who had studied for 10 years and above and the lowest (17 percent) for non-literate women, while it was 31 percent for women who had studied for 0-9 years. Accordingly, home deliveries were the highest for non-literate women and the lowest for women who had studied for 10 years and above. Institutional deliveries conducted at government

62 health facility and also at the private health facilities were the highest for women who had studied for 10 years and above. Further, percentage of institutional deliveries was the highest (71 percent) for women with high SLI and the lowest (24 percent) for women with low SLI, while it was 36 percent for women with medium SLI. Accordingly, home deliveries were the highest for women with low SLI and the lowest for women with high SLI. Further, percentage of institutional deliveries conducted at government health facility and also at the private health facility was the highest for women with high SLI. These data have shown that there exists positive association between proportions of institutional deliveries and education and standard of living index of the women. Figure 4.4 gives distribution by place of delivery.

Figure 4.4 Place of Delivery and Assistance During Delivery

Assistance During Home Delivery Place of Delivery Relative/ Home Other/ friends 54% Missing 17% 0.6% Untrained None Dai 2% 39% Doctor 5%

ANM/ Nurse 6%

Public 37% Private TBA 8% 31%

Note: Percentage may add more than 100.0 due to rounding Himachal Pradesh, DLHS-RCH, 2002-04

The proportion of institutional deliveries decreases with increase in parity of the women. This is apparent from the fact that percentage of institutional deliveries was the highest (62 percent) for women with one child ever born, followed by 43 percent for women with two children ever born and the lowest (16 percent) for women with four or more children ever born. Institutional deliveries were 45 percent for Hindu women as against 39 percent for Muslim women, while it was 57 percent for Sikh women. The percentage of institutional delivery was the highest (51 percent) for other castes women, followed by other backward class women (47 percent, and the lowest (26 percent) for scheduled-tribe women.

Institutional deliveries should be more common among women who had three or more antenatal check-up and less common among women who had one or no antenatal check up. The percentage of institutional delivery was the highest (62 percent) for women who had four or more antenatal check up, followed by 37 percent for women who had three antenatal check- up and the lowest (nine percent) for women who had no antenatal check up. On the other hand, percentage of home deliveries was the highest (89 percent) for women who made no visit for

63 antenatal check-up, followed by 80 percent for women who made only one visit for antenatal check-up, while it was the lowest (37 percent) for women who made four or more visits for antenatal check-up. These data have shown that percentage of institutional deliveries increases with increase in antenatal check-up visits, while it is just the reverse for home deliveries. Further, home deliveries were higher among women who had normal delivery, while institutional deliveries were higher among women who had caesarean/assisted deliveries. One-third of the women living in villages having no health facility in the village as against more than four-tenth of the women living in villages having health facility in the village had institutional delivery.

4.8.2 Assistance During Home Delivery

Table 4.10 shows distribution of women who had given live/still births during three years preceding the survey, by assistance during home delivery and percentage of safe delivery, according to selected characteristics. If more than one type of attendant assisted during the delivery, then only the most qualified person has been considered. The data shows that only over five percent of home deliveries were attended by doctors, six percent by ANM/Nurse/LHV, 31 percent by trained birth attendants, 39 percent by untrained dais, 17 percent by relatives and friends, while more than one percent of home deliveries were un-attended (Figure 4.4). Forty three percent of the home deliveries were attended by trained health personnel and 57 percent deliveries by untrained persons. The percentage of home delivery attended by health personnel was higher for women below 35 years than those 35 years and more. The health personnel attended 41 percent of the home deliveries in rural areas as against 56 percent in urban areas. The percentage of home deliveries attended by health personnel was 50 percent for women with one child ever born, followed by 45 percent for women with three ever born children and 27 percent for women with four or more children ever born.

The percentage of home deliveries attended by health personnel was the highest (58 percent) for women who had studied for 10 years above and the lowest (20 percent) for non- literate women, while it was 43 percent for women who had studied for 0-9 years. Similarly, percentage of home deliveries attended by health personnel was the highest (59 percent) for women with high SLI and the lowest (24 percent) for women with low SLI, while it was 49 percent for women with medium SLI. Health personnel attended 43 percent of home deliveries of Hindu women as against 17 percent of Muslim women, while it was 52 percent for Sikh women. Again, health personnel attended 44 percent of home deliveries of scheduled caste women as against 20 percent of scheduled tribe women, while it was 57 percent for other backward class women. Twenty two percent of home deliveries to women who did not have any antenatal check-up were attended by health personnel compared to 57 percent of home deliveries to women who had four or more antenatal check-ups. Health personnel attended 41 percent of normal home deliveries as against 56 percent of caesarean home deliveries. Again, health personnel attended 36 percent of home deliveries in villages having no health facility in the village as against 45 percent in villages having health facility in the village.

4.8.3 Delivery Assisted by Skilled Persons

Table 4.10 further shows that 51 percent of the deliveries were safe deliveries in the state – 45 percent in rural areas and 79 percent in urban areas. The percentage of safe deliveries was 52 percent for women aged 25-34 years as against 35 percent for women aged 35 years and above.

64 Table 4.10 ASSISTANCE DURING HOME DELIVERY AND SAFE DELIVERY Percent distribution of women who had given live/still births during three years preceding the survey, by assistance during home delivery, and percentage of safe delivery, according to selected background characteristics, Himachal Pradesh, 2002-04 Attendant assisting during home delivery1 ANM/ Un- Number Nurse/ trained Relative/ of Percentage of Background characteristics Doctor LHV TBA dai friends None women safe2 delivery

Age group (in years) 20-34 5.7 6.2 31.5 39.0 15.7 1.4 1,351 52.3 35 and above 0.0 7.9 26.0 31.7 29.8 4.0 80 34.6 Children ever born 1 6.7 11.8 31.6 34.7 13.5 1.1 356 69.0 2 5.3 4.2 33.3 40.6 14.6 1.5 543 48.9 3 5.2 4.9 35.4 38.6 13.6 1.9 289 37.5 4+ 1.9 4.3 20.5 41.4 29.4 2.0 249 20.9 Residence Rural 5.5 5.6 30.3 39.4 17.2 1.6 1,315 44.9 Urban 4.8 12.9 38.4 31.2 10.1 1.0 132 78.6 Education Non-literate 3.0 2.8 14.6 42.3 35.5 1.8 334 21.8 0-9@ years 5.0 4.9 33.1 40.3 15.1 1.4 642 37.4 10 years & above 7.7 10.5 39.9 33.9 5.2 1.6 471 70.5 Religion Hindu 5.6 6.1 31.1 38.8 16.3 1.6 1,377 51.3 Muslim 0.0 0.0 17.0 56.5 26.5 0.0 33 39.5 Sikh (0.0) (13.0) (39.1) (34.8) (8.7) (4.3) 25 (13.0) Caste# Scheduled caste 6.0 5.0 32.8 40.2 13.5 2.1 434 39.8 Scheduled tribe 1.6 4.1 14.6 49.8 28.5 0.7 83 29.8 Other backward class 4.4 20.3 32.8 33.4 8.3 0.3 159 60.2 Standard of living index Low 2.8 2.3 19.3 46.0 28.4 1.1 489 27.8 Medium 7.1 6.9 35.3 37.5 11.1 1.9 687 44.6 High 5.7 11.8 41.4 28.5 9.2 1.4 270 75.8 Number of antenatal check-ups No check-up 1 2.5 3.3 15.9 48.0 29.2 1.0 207 14.7 2 4.8 6.4 20.1 43.9 23.3 1.2 140 29.0 3 3.3 4.4 29.9 44.0 16.5 1.8 311 34.6 4+ 7.3 7.4 28.8 36.3 18.1 1.1 291 46.5 Delivery characteristics 7.0 7.9 42.5 31.1 8.6 1.9 495 68.1 Normal Caesarean 3.1 6.0 32.1 40.1 17.2 1.0 1,388 43.9 Assisted (46.0) (4.0) (6.0) (6.0) (2.0) (28.0) 36 (50.0) * * * * * * 23 98.8 Availability of health facility3 in the village No 6.9 5.2 24.2 44.4 16.8 1.8 567 40.9 Yes 4.4 5.9 34.9 35.6 17.6 1.4 748 47.5

Total 5.4 6.2 31.0 38.7 16.6 1.5 1,447 51.4 Note1: Total includes 9 women with zero parity, 2 cases with missing information on number of ANC visits and 1missing case on delivery characteristics who were not shown separately. @ Literate women with no years of schooling are also included. # Total figure may not add to N due to do not know and missing cases 1 If the respondent mentioned more than one attendant, only the most qualified attendant is shown 2 Either institutional delivery or home delivery assisted by doctor/ANM/Nurse/LHV 3 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village ( ) Based on less than 50 unweighted cases. * Percentage not shown: Based on few cases. Note2: Total includes 15 cases of below 20 years of age group and 12 cases of other religion were not shown separately.

The percentage of safe deliveries was 51 percent for Hindu women as against 39 percent for Muslim women and 13 percent for Sikh women. Forty percent of the deliveries were safe deliveries for scheduled caste women as against 30 percent for scheduled-tribe women, while

65 it was 60 percent for other backward class women. The percentage of safe deliveries was the highest (69 percent) for women with one child ever born, followed by 49 percent for women with two children ever born and the lowest (21 percent) for women with four or more children ever born. Safe deliveries were the highest (68 percent) among women who had four or more antenatal check-up, followed by 46 percent among women who had three antenatal check-ups and the lowest (15 percent) among women who no antenatal check-up.

The percentage of safe deliveries was the highest (70 percent) for women who had studied for 10 years and above and the lowest (22 percent) for non-literate women, while it was 37 percent for women who had studied for 0-9 years. Similarly, percentage of safe deliveries was the highest (76 percent) for women with high SLI and the lowest (28 percent) for women with low SLI, while it was 45 percent for women with medium SLI. These data have shown that there exists positive association between proportion of safe deliveries and education and standard of living index of the women. Further, percentage of safe deliveries was 41 percent for women living in villages having no health facility in the village as against 47 percent for women living in villages having health facility in the village. Figure 4.5 shows delivery assisted by skilled person by background characteristics.

Figure 4.5 Delivery Assisted by Skilled Person by Background Characteristic

Total 51 Rural 45 Urban 79 EDUCATION Non-literate 22 0-9 years@ 38 10 & above 71 CASTE Schedulde tribe 30 Schedulde caste 40 Other backward class 60 STANDARD OF LIVING Low 28 Medium 45 High 76

0 153045607590

Himachal Pradesh, DLHS-RCH, 2002-04 Percent

4.9 Reasons for Not Going to Health Institutions for Delivery

Table 4.11 gives percentage distribution of women who had given last live/still birth at home during three years preceding the survey by the main reason for not going to health institutions for delivery, according to residence and availability of health facility in the village. More than one-fifth (23 percent) of the women said that it was not considered necessary to deliver at the

66 Table 4.11 REASONS FOR NOT GOING TO HEALTH INSTITUTIONS FOR DELIVERY Percent distribution of women who had given last live/still birth at home during three years preceding the survey by the main reason for not going to health institution for delivery, according to residence and availability of health facility in the village, Himachal Pradesh, 2002-04 Availability of health facility1 in Residence the village Reason Total Rural Urban No Yes

Not Necessary 22.9 22.7 24.9 22.7 22.7 Not customary 2.0 2.0 2.2 1.7 2.1 Cost too much 2.3 2.3 1.7 1.8 2.7 Health facility too far/ No transport 4.8 5.2 0.7 7.0 3.9 Poor quality service 1.0 1.0 1.2 0.2 1.6 No time to go 12.8 12.9 11.6 10.6 14.6 Family did not allow 1.3 1.2 2.5 0.8 1.5 Better care at home 12.9 13.5 6.8 9.8 16.4 Lack of knowledge 0.5 0.6 0.0 0.9 0.3 Other 1.1 1.2 0.8 0.1 2.0

Total percent 100.0 100.0 100.0 100.0 100.0

Number of women 1,447 1,315 132 567 748

1 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village. health institution. It is surprising to see that a higher proportion of urban women (25 percent) than rural women (23 percent) felt this way. Further, two percent of the women said that it was not customary to deliver in health institutions. Other factors contributing for not going to health institution for delivery were, ‘cost too much’ (two percent), ‘no transportation’ or ‘health facility is too far’ (five percent), ‘no time to go’ (13 percent), ‘family did not allow’ (over one percent), ‘better care at home’ (13 percent), while less than one percent reported lack of knowledge regarding the delivery facilities. One percent women did not opt for institutional delivery due to poor quality of services.

4.10 Delivery Characteristics by District

Table 4.12 shows the delivery characteristics by district; institutional delivery (delivery in government or private health institutions), home delivery and attendant assistance during home delivery for last live/still births to women during the three years preceding the survey. The percentage of institutional delivery was the highest (62 percent) in Bilaspur and Shimla districts, followed by 55 percent in Kangra district and the lowest (25 percent) in Chamba district. Further, percentage of institutional deliveries was higher than that of the state (45 percent) in Bilaspur, Hamirpur, Kangra, Kullu, Shimla and Solan districts and in the remaining six districts it was lowers than that of the state.

The percentage of women who had delivery at home was the highest (75 percent) in Chamba district, followed by 69 percent in Sirmaur district and it was the lowest (36 percent) in Shimla district. The percentage of women who had delivery at home was lower than that of the state (54 percent) in Bilaspur, Hamirpur, Kangra, Kullu, Shimla and Solan districts and in the remaining six districts it was higher than that of the state. Again, percentage of home deliveries assisted by skilled persons was the highest (26 percent) in Hamirpur district, followed by 24 percent in Kangra district and the lowest (five percent) in Chamba district. The percentage of home deliveries assisted by skilled persons was the higher than that of the state (12 percent) in Hamirpur, Kangra, Lahul & Spiti, Solan and Una districts and in the

67 Table 4.12 DELIVERY CHARACTERISTICS BY DISTRICT Place of delivery, assistance during home deliveries, and percentage of safe deliveries by district, Himachal Pradesh, 2002-04 Percentage of Percentage of Home delivery women who had women who had assisted by skilled1 Percentage of safe2 Districts institutional delivery delivery at home persons delivery

Bilaspur 62.0 38.0 7.5 64.9 Chamba 25.0 74.7 4.6 28.5 Hamirpur 48.0 51.3 26.4 61.5 Kangra 55.0 44.7 23.6 65.5 Kinnaur 33.5 65.6 7.4 38.4 Kullu 48.0 50.5 5.5 50.8

Lahul & Spiti 35.4 63.5 19.9 48.0 Mandi 31.4 67.2 5.3 34.9 Shimla 62.5 36.2 7.6 65.2 Sirmaur 31.0 68.7 5.0 34.4 Solan 53.8 45.9 12.0 59.3 Una 40.2 59.3 20.3 52.2

Himachal Pradesh 45.1 54.3 11.6 51.4

Note: Table includes last live/still birth since 1-1-1999/1-1-2001. 1 Includes Doctor/ANM/Nurse. 2 Either institutional delivery or home delivery assisted by skilled person. remaining seven districts it was lower than that of the state. The percentage of safe deliveries was the highest (65 percent) in Bilaspur, Kangra and Shimla districts, followed by 61 percent in Hamirpur district and the lowest (28 percent) in Chamba district. The percentage of safe deliveries was higher than that of the state (51 percent) in Bilaspur, Hamirpur, Kangra, Shimala and Solan districts and in the remaining seven districts it was lower than that of the state. (See Map-4).

4.11 Complications During Delivery

Complications during delivery include ‘premature labour’, ‘obstructed labour’, ‘prolonged labour (more than 12 hours)’, ‘breech presentations’, ‘excessive bleeding during delivery’ and ‘other problems’ at the time of delivery reported by women during the three years preceding the survey. Table 4.13 gives percentage of women who had given last live/still birth during three years preceding the survey by delivery complication, according to selected background characteristics. Data shows that more than one-fourth (28 percent) women experienced at least one problem during delivery. The percentage of delivery complications was higher among urban women (29 percent) than among rural women (27 percent). The percentage of women reporting atleast one delivery related problem was lowest (25 percent) for younger women below 20 years and it was highest (30 percent) for women aged 35 years and above. The percentage of women reporting atleast one delivery related problem was 33 percent for women with one child ever born, followed by 26 percent for women with three children ever born and the lowest (23 percent) for women with two children ever born. This proportion was relatively high among women who had received some kind of antenatal care during pregnancy than those who had no antenatal check-up. Thirty two percent of women who had four and more antenatal check-up reported at least one problem during their pregnancy when compared to 17 percent for women who had no antenatal check-up. Among women who had assisted or caesarean delivery, 54-55 percent reported experiencing atleast one problem during pregnancy as against 23 percent women with normal delivery. A relatively higher proportion of women

68 Table 4.13 DELIVERY COMPLICATIONS Percentage of women who had given last live/still births during three years preceding the survey by delivery complication, according to selected background characteristics, Himachal Pradesh, 2002-04

Any Type of delivery complication; delivery Prematu Excessi Prolong- Obstruct Breech Number complic re ve ed -ed present of Background characteristics ation labour bleeding labour labour ation Other women

Age group (in years) Below 20 (25.0) (17.5) (0.0) (10.0) (12.5) (5.0) (0.0) 29 20-34 27.8 15.1 4.9 9.9 9.3 4.3 2.0 2,521 35 and above 29.6 15.0 2.8 11.3 9.6 3.2 2.6 115

Children ever born 1 33.1 17.1 3.6 14.4 12.0 4.8 3.0 957 2 23.5 13.6 4.7 7.6 6.2 4.4 1.5 966 3 25.7 16.2 4.9 5.3 10.2 2.7 1.5 427 4+ 24.6 10.9 6.1 9.7 9.4 2.5 2.2 296

Residence Rural 27.4 15.7 4.9 10.7 9.9 3.9 1.5 2,150 Urban 29.1 12.2 4.0 6.8 6.9 5.6 4.6 516

Number of antenatal check-ups No check-up 16.7 6.3 4.4 6.2 2.4 2.1 0.0 233 1 27.9 15.8 4.5 16.0 8.0 2.3 1.8 176 2 24.5 13.7 3.8 8.4 12.0 3.4 0.2 444 3 23.8 12.4 4.8 12.7 10.0 2.4 0.7 466 4+ 32.2 17.7 5.0 9.4 9.6 5.8 3.6 1,338

Delivery characteristics Normal 23.2 14.0 4.3 8.2 8.2 2.2 0.8 2,263 Caesarean 54.4 23.1 7.6 15.8 13.9 18.0 10.1 277 Assisted 54.6 16.1 7.1 30.8 19.9 10.9 8.6 118

Place of delivery Government sector 32.6 16.9 5.2 13.0 9.1 4.7 2.1 985 Private sector 49.4 25.5 6.1 14.4 13.5 12.5 12.2 217 Home 21.2 12.2 4.2 7.3 8.7 2.6 0.6 1,447

Total 27.8 15.0 4.7 10.0 9.3 4.2 2.1 2,666

Note1: Total includes 19 women with zero parity, 9 missing cases on number of ANC visits, 8 missing cases on delivery characteristic and 8 on place of delivery who were not shown separately. Note2: Total include 9 women in other place of delivery and 8 cases missing who were not shown separately. ( ) Based on less than 50 unweighted cases.

who delivered in health institutions (32-50 percent) experienced atleast one delivery complication compared to those who delivered at home (21 percent).

The major problems reported were ‘premature labour’ (15 percent), ‘prolonged labour’ (10 percent), ‘obstructed labour’ (nine percent), and ‘excessive bleeding (five percent). Only four percent women reported ‘breech presentation’, and two percent reported ‘other’ problems related to delivery. Twenty three percent women who had caesarean delivery as against 16 percent women who had assisted delivery reported ‘premature labour’ problem, while it was 14 percent for normal deliveries. Excessive bleeding was more common among women who had caesarean/assisted delivery than those who had normal delivery. Prolonged labour problem reported was the highest (31 percent) for women who had assisted delivery, followed by 16 percent for women who had caesarean delivery and the lowest (eight percent) for women with normal delivery. Similarly, obstructed labour problem reported was 20 percent for women

69 who had assisted delivery as against 14 percent for women who had caesarean delivery, while it was eight percent for women with normal delivery. Further, breach presentation problem reported was the highest (18 percent) for women who had caesarean delivery, followed by 11 percent for women who had assisted delivery and the lowest (two percent) for women with normal delivery. These data have shown that delivery complications are associated with delivery characteristics and that most of the women who caesarean/assisted delivery had experienced one or the other complication. These data further show that chances of women experiencing delivery complications are more for those delivering at private health facility than at government health facility. Figure 4.6 gives women with delivery complication and by symptoms.

Figure 4.6 Percentage of women with Delivery Complication and by Symptoms

Any Delivery complication 28

Premature labor 15

Excessive bleeding 5

Prolnged labor 10

Obstructed labor 9

Breech presentation 4

Other 2

0 5 10 15 20 25 30 Himchal Pradesh, DLHS-RCH, 2002-04 Percent

4.12 Post Delivery Complications and Treatment

Table 4.14 present information about women who experienced post-delivery complications according to selected background characteristics. The incidence of post-delivery complications is judged by any of the following complications occurring during the first six-weeks of delivery- ‘high fever’, ‘lower abdominal pain’, ‘foul smelling vaginal discharge’, ‘excessive bleeding’, ‘convulsion’, ‘severe headache’, and ‘other’ problems. Twenty six percent women reported that they faced any of the problems during the first six weeks after their delivery. The proportion of women who cited at least one post delivery complication was higher in rural areas (28 percent) than in urban areas (17 percent). The percentage of women who experienced any post- delivery complications was the highest (29 percent) for women with one child ever born, followed by 27 percent for women with four or more children ever born and the lowest (22 percent) for women with two children ever born. The percentage of women who experienced any post-delivery complication was 48 percent for assisted deliveries as against 29 percent for caesarean deliveries, while it was 24 percent for normal deliveries. The data have shown that chances of experiencing any post-delivery complications are more when conducted at home or private health facility than when conducted at the government health facility. The percentage of women who delivered at home and experienced any post-delivery complications attended

70 Table 4.14 POST DELIVERY COMPLICATIONS Percentage of women who had given last live/still births during three years preceding the survey by post delivery complication, according to selected background characteristics, Himachal Pradesh, 2002-04 Type of post delivery complication; Any post Lower Foul smelling Background delivery High abdominal vaginal Excessive Severe Number characteristics complication fever pain discharge bleeding Convulsion headache Other of women

Age Below 20 (30.0) (12.5) (12.5) (5.0) (7.5) (2.5) (15.0) (0.0) 29 20-34 25.4 10.3 14.0 5.1 9.4 1.1 7.8 1.9 2, 521 35 and above 28.2 7.7 12.1 11.6 7.6 0.0 14.9 3.9 115

Children ever born 1 29.2 10.6 14.5 6.1 12.2 0.4 7.7 2.3 957 2 21.9 8.6 13.7 3.4 7.4 0.9 6.1 1.1 966 3 23.5 10.3 11.6 5.8 5.8 1.7 9.4 3.4 427 4+ 26.6 12.5 14.5 8.9 10.9 1.8 12.4 2.2 296

Residence Rural 27.6 11.6 15.6 5.8 10.4 1.1 9.1 1.9 2,150 Urban 17.2 4.1 6.9 3.8 5.1 0.7 4.4 2.6 516

Delivery characteristics Normal 24.1 9.8 13.3 5.3 8.5 1.0 7.3 1.6 2,263 Caesarean 29.4 10.2 12.1 6.3 9.6 1.5 11.7 1.0 277 Assisted 47.7 19.0 31.9 5.0 25.5 1.1 17.5 12.4 118

Place of delivery Government sector 22.3 6.7 11.2 4.3 7.3 0.9 6.2 2.2 985 Private sector 27.3 10.7 10.5 6.5 13.3 1.6 11.9 2.3 217 Home 27.8 12.6 16.4 5.9 10.2 1.0 9.1 1.8 1,447

Assistance during home delivery Doctor 43.1 23.3 21.8 5.8 19.0 0.0 14.7 9.8 78 ANM/Nurse/LHV 29.2 9.2 19.2 4.8 8.5 0.0 10.1 0.0 90 TBA 31.2 13.9 21.1 8.3 12.9 1.3 11.3 1.2 449 Untrained dai 23.2 11.1 11.0 2.9 6.7 0.7 6.3 1.6 560 Relative/friends 27.9 12.3 18.0 9.5 12.0 2.1 9.9 1.6 240

Total 25.6 10.2 13.9 5.4 9.4 1.0 8.2 2.0 2,666

Note1: Total includes 19 women with zero parity, 8 missing cases on delivery characteristics, 8 on place of delivery and 8 on assistance during home delivery who were not shown separately. Note2: Total include 9 women in other place of delivery and 22 assisted by none during home delivery who were not shown separately. ( ) Based on less than 50 unweighted cases by the doctor was the highest (43 percent), followed by 31 percent by TBA and the lowest (23 percent) by untrained dai. ANM/TBA are generally attending normal home deliveries and the complicated one are attended by the doctor. It is perhaps for that reason that post-delivery complications are the highest for deliveries attended by the doctor.

Women who reported delivery complications as ‘high fever’ (10 percent), ‘lower abdominal pain’ (14 percent), ‘severe headache’ (eight percent), ‘foul smelling vaginal discharge’ (five percent), ‘excessive vaginal bleeding’ (nine percent), and ‘convulsion’ (one percent). Only two percent women reported other problems. Rural-urban differences in all symptoms of postpartum complication were large favouring urban areas. All the postpartum complications, except convulsions, are more prevalent among women who had caesarean/assisted delivery than those with normal delivery. Similarly, all the postpartum complications are more prevalent

71 among women who delivered at home/private health facility than at the government health facility. Figure 4.7 gives distribution of women with post-delivery complication and by symptom.

Figure 4.7 Percentage of women with Post Delivery Complication and by Symptoms

Any Post Delivery complication 26

High fever 10

Lower abdominal pain 14

Foul smelling vaginal discharge 5

Excessive bleeding 9

Convulsion 1

Severe headache 8

Other 2

0 5 10 15 20 25 30 Himachal Pradesh, DLHS-RCH, 2002-04 Percent

Women who reported at least one complication during the postpartum period were asked, whether they had consulted or sought treatment for their problems and also the source of treatment. Table 4.15 shows the percentage of women who had post delivery complications and sought treatment by source of treatment according to residence and availability of health facility in the village. Fifty-two percent of the women sought treatment of their post-delivery complication in the state – 50 percent in rural areas and 68 percent in urban areas. Fifty percent women living in villages, irrespective of the status of health facility in the village, sought treatment of their post-delivery complications. Among women who sought treatment of their post-delivery complications in the postpartum period, 71 percent visited government health facility including primary health centre (seven percent) and sub-centre (less than one percent each), 20 percent women visited private health facility and over nine percent visited ISM and other health facility.

The proportion of women who visited government health facility was relatively higher in urban areas (76 percent) than in rural areas (70 percent). On the other hand, the proportion of women seeking treatment from private health facility was more in rural areas than in urban areas. Again, 18 percent of women living in villages having no health facility in the village as against 23 percent women living on villages having health facility in the village sought treatment of post delivery complication from private health facility. The percentage of women who sought treatment from the doctor was 78 percent, 16 percent from the ANM/Nurse/LHV, three percent from other health personnel and three percent from others. Sixty eight percent women living in villages having no health facility in the village as against 82 percent women living in villages having health facility in the village sought treatment from a doctor. Similarly, 26 percent women living in villages having no health facility in the village as against 14 percent women living in villages having health facility in the village sought treatment from ANM/Nurse/LHV.

72 Table 4.15 TREATMENT FOR POST DELIVERY COMPLICATIONS Percentage of women who had last live/still births during three years preceding the survey and who had any post delivery complication, sought treatment for the problems, and source of treatment according to residence and availability of health facility in the village, Himachal Pradesh, 2002-04 Availability of health Residence facility5 in the village Treatment and source Total Rural Urban No Yes

Percentage of women sought treatment who had any post delivery complication 52.5 50.1 68.5 50.5 49.9

Number of women 682 594 89 186 407

Percentage sought treatment at health facility 70.9 69.8 76.0 65.0 72.1

Government health facility1 6.7 8.1 0.0 9.7 7.4 Primary health centre 0.1 0.1 0.0 0.3 0.0 Sub centre 20.4 21.3 15.9 18.5 22.6 Private health facility2 3.9 3.4 6.7 4.5 2.9 ISM3 facility 5.6 6.4 1.5 12.2 3.7 Other

Percent distribution of women who obtained treatment from

Doctor 78.5 77.7 82.5 68.2 82.1 ANM/nurse/midwife/LHV 16.1 17.6 8.6 25.6 13.8 Other health professionals4 2.6 2.9 1.1 5.1 1.9 Other 2.8 1.8 7.8 1.1 2.2

Total percent 100.0 100.0 100.0 100.0 100.0

Number of women 358 297 61 94 203

1 Include municipal hospital, dispensary, urban health centre/urban health post/urban family welfare centre, community health centre/rural hospital, primary health centre and sub centre 2 Include private hospital/clinic and non-governmental organization/ trust hospital 3 Either government or private Indian system of medicine 4 Other health professionals include Dai (trained or untrained), relative/friends and ISM practitioner 5 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village

4.13 Obstetric Morbidity by District

The extent of health problems/complications women suffer during pregnancy, delivery and post delivery period indicates the state of obstetric morbidity. Table 4.16 gives extent of pregnancy, delivery and post-delivery complications and treatment seeking behaviour by district in Himachal Pradesh. The percentage of women who experienced pregnancy complication was the highest (47 percent) in Kangra district, followed by 46 percent in Sirmaur district and the lowest (14 percent) in Hamirpur and Solan districts. The percentage of women who experienced pregnancy complication was higher than that of the state (28 percent) in Kangra, Kinnaur and Sirmaur districts, while it was lower than that of the state in nine districts. The percentage of women who sought treatment of pregnancy complications was the highest (82 percent) in Hamirpur district, followed by 77 percent in Bilaspur district and the lowest (54 percent) in Kullu district. Further, percentage of women who sought treatment of pregnancy complication was higher than that of the state (69 percent) in Bilaspur, Hamirpur, Kangra, Kinnaur, Lahul & Spiti, Shimla and Solan districts and in the remaining five districts it was lower than that of the state.

The percentage of women who had delivery complications was the highest (56 percent) in Lahu & Spiti district, followed by 43 percent in Kangra district and the lowest

73 Table 4.16 PREGNANCY, DELIVERY AND POST DELIVERY COMPLICATIONS Extent of pregnancy, delivery and post delivery complications and treatment seeking behaviour by districts, Himachal Pradesh, 2002-04 Percentage of women1 2 3 Who had Sought treatment Who had Who had post Sought treatment complication for pregnancy delivery delivery for post delivery District during pregnancy complication complication complication complication

Bilaspur 23.5 77.3 40.1 22.1 81.4 Chamba 25.5 56.4 33.2 28.7 53.2 Hamirpur 13.8 81.9 16.4 11.5 68.6 Kangra 46.8 75.5 43.2 45.0 55.4 Kinnaur 30.7 73.4 37.1 33.6 42.0 Kullu 14.6 (53.8) 18.4 16.4 37.9

Lahul & Spiti 14.7 73.4 56.0 22.5 62.4 Mandi 21.2 56.9 12.8 14.9 35.9 Shimla 23.7 71.9 24.8 19.0 58.4 Sirmaur 45.9 61.6 35.7 39.2 47.4 Solan 13.7 73.4 12.5 10.2 (46.9) Una 17.9 67.8 17.0 12.2 56.7

Himachal Pradesh 28.2 68.8 27.8 25.6 52.5

1 Women who had last live/still birth during three years preceding the survey. 2 Women who reported at least one complication of pregnancy. 3 Women who reported at least one post delivery complication. ( ) Based on less than 50 unweighted cases

(12 percent) in Solan district. The percentage of women who had delivery complications was higher than that of the state (28 percent) in Bilaspur, Chamba, Kangra, Kinnaur, Lahul & Spiti and Sirmaur districts, while in the remaining six districts it was lower than that of the state.

Again, the percentage of women who had post-delivery complications was the highest (45 percent) in Kangra district, followed by 39 percent in Sirmaur district, and the lowest (10 percent) in Solan district. The percentage of women who had post-delivery complications was higher than that of the state (26 percent) in Chamba, Kangra, Kinnaur and Sirmaur districts and in the remaining eight districts it was lower than that of the state. The percentage of women who had post-delivery complications and sought treatment was the highest (81 percent) in Bilaspur district, followed by 69 percent in Hamirpur district and the lowest (36 percent) in Mandi district. The percentage of women who had post-delivery complications and sought treatment was higher than that of the state (52 percent) in Bilaspur, Chamba, Hamirpur, Kangra, Lahul & Spiti, Shimla and Una districts and in the remaining five districts it was lower than the state.

74 Map-3

Percentage of Women Received Three or More Antenatal Check-Up

75 Map-4

Percentage of Delivery Attended by Skilled Person

76 CHAPTER V

CHILD CARE AND IMMUNIZATION

Child health services under the Reproductive and Child Health (RCH) programme include health education to mothers on breast-feeding and services for immunization, Vitamin A supplements and Iron prophylaxis, treatment of diarrhoea and Acute Respiratory Infections (ARIs). The District Level Household Survey (DLHS) covered all the currently married women whose last surviving child was born during the three years preceding the survey, and information on those breastfeeding currently and duration of breastfeeding. They were also asked about their awareness of diarrhoea management and danger signs of pneumonia and practices followed in case of episodes of diarrhoea and ARI among the children. Data on immunization, administering Vitamin-A supplements and Iron prophylaxis was collected for the last two living children born after January 1, 1999/2001. This chapter presents an analysis of the data collected on the above aspects.

5.1 Breastfeeding

Educating mothers on correct breastfeeding practices and child nutrition is one of the components of the RCH programme. Infant feeding practices have significant effects on the health of both mothers and children. Mothers are affected through the influences of breastfeeding on the period of postpartum infertility, and hence on fertility levels and the length of birth intervals. These effects vary according to the duration and intensity of breastfeeding. Proper infant feeding, starting from the time of birth, is important for the physical and mental development of the child. Breastfeeding improves the nutritional status of young children and reduces morbidity and mortality. Breast milk not only provides important nutrients, but also protects the child against infection. The timing and type of supplementary foods introduced in an infant’s diet have significant effects on the child’s nutritional status.

As recommended by the World Health Organization (WHO), breastfeeding should be initiated immediately after birth and should be continued upto a minimum of six months. The WHO also suggests that the yellowish milk, known as colostrums, should be given to the baby because it provides protection against certain infections. Afterwards, it has to be supplemented with other semi-solid and solid foods at the proper time intervals.

Table 5.1 gives percentage of children under age three years whose mother started breastfeeding within two hours of births, within one day of birth and percentage whose mother squeezed the first breast milk from her breast before breastfeeding by selected background characteristics. Although, the practice of breastfeeding is common in Himachal Pradesh, the initiation of breastfeeding within two hours of the birth of the child is not always followed. Only 41 percent of the children were breastfed within two hours of birth and 64 percent were breastfed within one day of birth (including those who were breastfed within two hours of birth), while 35 percent children were breastfed after one day of birth. As shown in Figure 5.1, over 22 percent of the children were breastfed after two hours, but same day, 24 percent were breastfed after the first day of birth but before 3 days and over 10 percent children were breastfed after three days, while over one percent children were never breastfed. Forty eight percent of the women, who gave birth to children during the reference period, squeezed out the first breast milk before breastfeeding the child. Forty three percent of non-literate women and those who had studied for Table 5.1 INITIATION OF BREASTFEEDING Percentage of children under age 3 whose mother started breastfeeding within two hours of births, within one day of birth, and after one day of birth and percentage whose mother squeezed the first milk from her breast before breastfeeding by selected background characteristics, Himachal Pradesh , 2002-04 Percentage started breastfeeding Percentage whose Within two hours Within one After one mother squeezed first Number of Background characteristic of birth day of birth1 day of birth milk from breast children

Residence Rural 41.5 63.9 34.9 46.9 1,946 Urban 41.0 63.5 33.7 53.2 459

Mother’s education Non-literate 42.7 65.2 34.0 43.4 360 0-9@ years 38.6 62.1 35.8 45.8 839 10 and above 43.0 64.6 34.0 51.1 1,205

Religion Hindu 41.9 64.4 34.1 47.7 2,281 Muslim 17.0 37.3 57.7 56.9 50 Sikh 42.1 64.1 35.9 56.5 53

Caste/tribe# Scheduled caste 40.6 61.0 37.8 44.9 570 Scheduled tribe 44.9 60.3 38.4 47.7 98 Other backward class 32.5 56.2 41.7 54.1 272 Other 43.1 66.5 31.9 48.3 1,462

Standard of living index Low 41.2 67.0 32.5 45.5 590 Medium 40.9 63.8 34.8 49.5 969 High 42.1 61.6 36.0 48.4 846

Total 41.4 63.8 34.7 48.1 2,405

Note-1: Table based on youngest living child born during the three years preceding the survey Note-2: Table includes 20 case for other religion were not shown separately 1 Includes children whose mother started breastfeeding within two hours of births @ Literate mother with no years of schooling are included. #Total figure may not add to N due to do not know and missing cases.

10 years and above as against 39 percent women who had studied for 0-9 years breastfed the child within two hours of birth. Further, 42 percent of Hindu women and also Sikh women as against only 17 percent of Muslim women breastfed the child within two hours of births. The percentage of women who breastfed the child within two hours of birth was the highest (45 percent) for scheduled tribe women, followed by other women (43 percent) and the lowest (32 percent) for other backward class women. The SLI of the women do not appear to influence their breastfeeding practices as 41- 42 percent of women breastfed the child within two hours of birth. Again, 34 percent non-literate women and also those who had studied for 10 years and above as against 36 percent women who had studied for 0-9 years started breastfeeding the children after one day of birth. Fifty-eight percent of Muslim women as against 34 percent of Hindu women breastfed the child after one day of birth, while it was 36 percent for Sikh women. These data do not suggest any serious gaps in breastfeeding practices between different socio-economic strata of the population in Himachal Pradesh.

The custom of squeezing the first breast milk before initiating breastfeeding is widely practised in every group. The percentage of women who squeezed out the first breast milk was 48 percent in the state – 47 percent in rural areas and 53 percent in urban areas. The percentage of women

78 Figure 5.1 Initiation of Breastfeeding Never/ Missing 2% After 3 days 10%

Within 2 hours 41% 1-3 days 24%

After 2 hours, but same day 22% Himachal Pradesh, DLHS-RCH, 2002-04

who squeezed out the first breast milk was 51 percent for women who had studied for 10 years and above, 46 percent for women who had studied for 0-9 years and 43 percent for non-literate women. Forty-nine percent of the women with medium SLI as against 48 percent women with high SLI squeezed out the first breast milk, while it was 45 percent for women with low SLI. The percentage of women who squeezed out the first breast milk was the highest (54 percent) for other backward class women, followed by 48 percent for other caste women and the lowest (45 percent) for scheduled caste women.

Mother of children born in the three years preceding the survey were asked whether the child had been fed breast milk exclusively and if so, what was the duration? Here it needs to be mentioned that, exclusive breastfeeding includes breastfeeding the child without giving it anything including water. Table 5.2 gives distribution of children under age three years by exclusive breast- feeding by child’s age in months. Only 62 percent of the children under four months of age were exclusively breastfed in Himachal Pradesh. The percentage of exclusively breastfed infants drops steadily from 68 percent for children under 2 months of age to 11 percent for children who were 6-7 months. Over 45 percent children in the age group 4-5 months were exclusively breastfed up to four months. Fifty five percent of the children aged 6-7 months were exclusively breastfed for four months and 16 percent of them were exclusively breastfed for atleast six months. Similarly, 57 percent children in the age group 7-9 months were exclusively breastfed for four months, while only 18 percent of them were exclusively breastfed for six months.

5.1.1 Breastfeeding by Districts

Table 5.3 shows that percentage of women who started breastfeeding the child within two hours of birth was the highest (67 percent) in Bilaspur district, followed by 63 percent in Kinnaur district and the lowest (32 percent) in Chamba district. The percentage of women who started breastfeeding the child within two hours of birth was higher than that of the state (41 percent) in Bilaspur, Hamirpur, Kinnaur, Kullu, Lahul & Spiti, Mandi, Shimla and Sirmaur districts, while in four districts it was lower than the state. The percentage of women who started breastfeeding the child within one day of birth was the highest (83 percent) in Kullu district, followed by 77 percent in Hamirpur and Kinnaur districts and the lowest (51 percent) in Solan district. The percentage

79 Table 5.2 EXCLUSIVE BREASTFEEDING BY CHILD’S AGE Percentage of children under age 3 years by exclusive breastfeeding and child’s age in month, Himachal Pradesh, 2002-04 Status of exclusive breastfeeding Age in months Exclusive breastfeeding At least 4 months At least 6 months Number of children

<2 68.5 * * 120 2-3 57.5 * * 160 4-5 17.0 45.2 * 177 6-7 10.6 55.0 16.2 190 8-9 2.2 58.8 20.1 164 10-11 0.5 61.5 11.8 149 12-13 1.4 51.1 22.3 185 14-15 4.1 54.8 18.5 166 16-17 0.1 42.3 8.0 119 18-19 0.0 58.8 15.3 145 20-21 0.0 49.6 17.1 142 22-23 0.0 56.0 13.3 96 24-25 3.1 57.7 17.9 121 26-27 0.0 50.6 17.6 113 28-29 3.0 54.8 17.9 107 30-31 0.0 30.4 7.3 68 32-33 0.0 47.0 12.1 95 34-35 0.0 54.6 14.4 89

< 4 months 62.2 * * 280 4-6 months 16.4 48.6 * 274 7-9 Months 3.4 57.5 18.3 256

Note: Table based on youngest living child born during the three years preceding the survey

Table 5.3 BREASTFEEDING BY DISTRICT Percentage of children under age 3 whose mother started breastfeeding within two hours of births, within one day of birth and after one day of birth, percentage whose mother squeezed the first milk from her breast before breastfeeding and percentage of children who were exclusively breastfed by district, Himachal Pradesh, 2002-04 Percentage Percentage started breastfeeding whose mother squeezed first Within two hours Within one After one milk from Exclusive District of birth day of birth1 day of birth breast breastfeeding2

Bilaspur 66.8 73.7 26.4 63.2 28.9 Chamba 32.5 55.4 44.6 51.7 11.5 Hamirpur 47.9 76.7 22.5 52.9 7.2 Kangra 35.7 56.0 40.7 54.9 4.6 Kinnaur 63.3 77.1 22.3 52.4 9.9 Kullu 45.9 82.8 17.2 26.0 60.1

Lahul & Spiti 45.3 70.4 29.6 56.6 9.0 Mandi 42.9 73.7 26.3 43.5 30.4 Shimla 43.4 73.1 24.9 43.0 11.7 Sirmaur 51.8 66.2 32.2 45.2 9.7 Solan 35.9 50.8 48.1 49.5 9.7 Una 33.0 54.8 43.1 38.5 11.8

Himachal Pradesh 41.4 63.8 34.7 48.1 16.0

Note: Table based on youngest living child born during the three years preceding the survey 1 Includes children whose mother started breastfeeding within two hours of births. 2 Based on youngest children age 6 moths and older at the time of survey and breastfed exclusively 6 months or more as mother reported. of women who started breastfeeding the child within one day of birth was higher than that of the state (64 percent) in Bilaspur, Hamirpur, Kinnaur, Kullu, Lahul & Spiti, Mandi, Shimla and Sirmaur

80 districts, while it was lower than that of the state in four districts of Chamba, Kangra, Solan and Una. The percentage of women who started breastfeeding the child after one day of birth was the highest (48 percent) in Solan district, followed by 45 percent in Chamba district and the lowest (17 percent) in Kullu district. The percentage of women who started breastfeeding the child after one day of birth was higher than that of the state (35 percent) in Chamba, Kangra, Solan and Kinnaur districts and in the remaining eight districts it was lower than that of the state.

There is a great deal of variation in the proportion of women who squeezed out the breast milk before breastfeeding the child. It was the highest (63 percent) in Bilaspur district, followed by 57 percent in Lahul & Spiti district and the lowest (26 percent) in Kullu district. The percentage of women who squeezed out the breast milk before breastfeeding the child was higher than that of the state (48 percent) in Bilaspur, Chamba, Hamirpur, Kangra, Kinnaur, Lahul & Spiti and Solan districts and in the remaining five districts it was lower than that of the state. Between the districts variation is 55 percentage points in the extent of exclusive breastfeeding for six months of children aged 6+ months. It was the highest (60 percent) in Kullu district, followed by 30 percent in Mandi district and the lowest (five percent) in Kangra district.

5.2 Immunization of Children

The immunization of children against six preventable diseases namely, tuberculosis, diphtheria, pertusis, poliomyelitis and measles is the main component of the child survival programme. As part of the National Health Policy, the National Immunization Programme is being implemented on a priority basis. The Government of India initiated the Expanded Programme on Immunization (EPI) in 1978 with the objective of reducing morbidity, mortality and disabilities among children from these six diseases.

The Universal Immunization Programme (UIP) was introduced in 1985-86 with the objective of covering at least 85 percent of all infants against the six vaccine preventable diseases by 1990. This scheme has been introduced in every district of the country. The standard immunization schedule developed for the child immunization programme specifies the age at which each vaccine should be administrated and the number of doses to be given. Routine vaccinations received by infants and children are usually recorded on a vaccination card that is issued for the child.

In the first phase of Round-II, all the women with last and last but one living child born after January 1, 1999 were asked whether the child/children had received the vaccination against polio, tuberculosis (BCG), diphtheria, whooping cough (pertusis), tetanus (DPT) and measles, and reference period for the second phase was from January 1, 2001. For Polio and DPT, further information on polio at birth and number of doses was asked. Children who received BCG, three doses of DPT and polio (excluding polio 0) and measles were considered fully vaccinated. Information on the source of immunization for the last dose and in cases where immunization was not given, the reason for not giving immunization was also sought. Table 5.4 gives distribution of children aged 12-23 months who received vaccination by selected background characteristics. Data shows that 79 percent of the children were fully vaccinated and two percent children did not at all receive any vaccination. In other words, 19 percent children were partially vaccinated. The percentage of children who were protected against all the six killer diseases shows that BCG vaccine was given to96 percent children, while 89 percent children received Measles vaccine in the state. Ninety one percent of the children received three doses of DPT, while 88 percent children received three doses

81 Table 5.4 VACCINATION OF CHILDREN Percentage of children age 12-23 months who received vaccination according to selected background characteristics, India, 2002-04 DPT Polio Number Full 1 No of

Background characteristic Polio 0 BCG 1 2 3 1 2 3 Measles vaccination vaccination children

Residence Rural 46.2 96.1 96.2 94.5 90.6 92.3 91.1 88.0 87.8 78.3 2.1 768 Urban 74.3 96.3 94.3 93.2 91.9 92.8 91.6 88.1 91.9 83.7 2.1 163 Sex of the child Male 50.1 97.6 96.8 96.1 92.9 95.0 93.8 90.4 89.3 82.0 1.3 508 Female 52.3 94.4 94.6 92.1 88.4 89.2 88.1 85.1 87.8 75.9 3.1 423 Birth order 1 64.1 97.0 97.5 95.4 93.4 95.7 94.5 92.1 91.2 85.7 1.6 394 2 48.9 97.0 96.2 95.4 90.5 91.4 90.1 86.1 89.2 77.8 2.3 314 3 36.7 96.1 94.5 92.8 88.6 87.2 86.7 83.0 88.1 72.3 2.4 134 4+ 22.9 89.2 89.4 87.4 84.0 88.7 87.4 84.1 76.1 66.3 3.4 89 Mother’s education Non-literate 25.1 87.0 87.5 86.1 79.8 85.7 84.7 77.4 76.7 63.2 6.6 132 0-9@ years 36.0 96.4 95.7 93.5 89.8 89.4 88.8 87.2 87.8 75.6 2.2 342 10 years and above 69.9 98.5 98.4 97.2 94.8 96.5 94.9 91.7 92.7 86.7 0.7 457 Religion Hindu 50.1 96.2 95.8 94.5 91.0 92.4 91.2 88.0 88.5 79.4 2.1 882 Caste/tribe# Scheduled caste 38.3 94.9 93.5 92.1 88.4 86.7 85.6 82.7 87.7 72.6 3.5 213 Scheduled tribe (37.8) (97.6) (95.3) (91.3) (86.6) (74.8) (74.0) (70.1) (88.2) (61.4) (0.8) 35 Other backward class 64.9 98.1 99.8 97.6 92.7 94.1 94.1 93.9 89.1 79.1 0.2 118 Other 53.7 96.1 96.1 84.7 92.0 94.4 93.1 89.2 89.0 82.1 2.0 564 Standard of living index Low 32.2 92.5 92.8 89.8 86.3 86.9 85.7 82.3 81.6 67.1 5.2 222 Medium 41.5 96.7 96.8 95.7 90.8 92.5 91.7 89.1 88.1 79.7 1.5 374 High 74.4 97.8 96.8 95.7 93.8 95.8 94.2 90.7 93.9 86.9 0.8 335

Total 51.1 96.1 95.8 94.3 90.8 92.4 91.2 88.0 88.6 79.3 2.1 931

Note: Table includes only last and last but one living child born since 1.1.1999/1.1.2001. @ Literate mothers with no years of schooling are included. # Total figure may not add to N due to do not and missing cases. Total includes 23,18 & 7 cases for Muslim, Sikh & Other religion were not shown separately. 1 BCG, three injection of DPT, three doses of Polio (excluding Polio 0) and measles. ( ) Based on less than 50 unweighted case.

82 pf Polio vaccine in the state. The percentage of children who received BCG vaccination was the highest (98 percent) for children whose mother had studied for 10 years and above and the lowest (87 percent) for children having non-literate mother, while it was 96 percent for children whose mother had studied for 0-9 years. Similarly, percentage of children who received BCG vaccination was the highest (98 percent) for children with high SLI and the lowest (92 percent) for children with low SLI, while it was 97 percent for children with medium SLI. Further, BCG coverage of children does not show any caste differentials. The percentage of children who received three doses of DPT vaccination was the highest (95 percent) for children whose mother had studied for 10 years and above and the lowest (80 percent) for children having non-literate mother, while it was 90 percent for children whose mother had studied for 0-9 years. Similarly, percentage of children who received three doses of DPT vaccination was the highest (94 percent) for children with high SLI and the lowest (86 percent) for children with low SLI, while it was 91 percent for children with medium SLI. The percentage of children who received three doses of Polio vaccine was the highest (92 percent) for children whose mother had studied for 10 years and above and the lowest (77 percent) for children having non-literate mother, while it was 87 percent for children whose mother had studied for 0-9 years. Ninety one percent of children with high SLI as against 89 percent of children with medium SLI received three doses of Polio vaccine, while it was 82 percent for children with low SLI. Again, percentage of children who received Measles vaccination was the highest (93 percent) for children whose mother had studied for 10 years and above and the lowest (77 percent) for children having non-literate mother, while it was 88 percent for children whose mother had studied for 0-9 years. Ninety four percent of children with high SLI as against 88 percent children with medium SLI received Measles vaccination, while it was 82 percent for children with low SLI Figure 5.2 shows percentage of children age 12-23 months who have received specific vaccination.

Figure 5.2 Percentage of Chidren Age 12-23 months who have Received Specific Vaccinations, Himachal Prdesh

BCG 96

DPT1 96 DPT2 94 DPT3 91

Polio1 92 Polio2 91 Polio3 88

Measles 89

All 79

None 2

0 1938577695 Himachal Pradesh, DLHS-RCH, 2002-04 Percent

The percentage of fully immunized children was 79 percent in the state – 78 percent in rural areas and 84 percent in urban areas. Eighty two percent of male children as against 76 percent for

83 female children were fully immunized- difference being six percentage points. The sex differential in the vaccination of children exists in favour of male children. Coverage of full immunization of children steadily declines with increase in the birth order of the child. It declines from 86 percent for first order birth to 66 percent for four or higher birth order. These data further shows that coverage of full immunization of children increases with increase in the education and standard of living index of the mother. Further, proportion of children fully immunized was the lowest (61 percent) for scheduled tribe children and the highest (82 percent) for children from other castes. Figure 5.3 shows percentage of children aged 12-23 months who have received all vaccination in the state.

Figure 5 .3 Percentage of Children Age 12-23 months Who Have Received All Vaccination, Himachal Pradesh

TOTAL 79

Rural 78

Urban 84 SEX OF THE CHILD

Male 82 Female 76 CASTE

Scheduled caste 73 Scheduled tribe 61 Other backward class 79 Other 82 EDUCATION Non-literate 63 0-9 years@ 76 10 & above 87 STANDARD OF LIVING Low 67 Medium 80 High 87

Percent @ Literate women with no years of schooling are also included Himachal Pradesh, DLHS-RCH.2002-04

There has been some improvement in full vaccination coverage in Himachal Pradesh since the time of Round-I in 1998-99. These data indicate that despite the progress that has been made in immunization coverage for children in Himachal Pradesh, coverage levels are still low and a large proportion of children who received some early vaccinations dropped out of the programme before receiving all of the recommended vaccinations. However, coverage of full vaccination of children has increased from 74 percent in 1998-99 to 79 percent in 2002-04. In other words, coverage of full immunization has marginally improved during this period.

Table 5.5 shows the percentage of children in the age group 12-23 months and 24-35 months with a vaccination card, and the percentage who received various vaccinations during the first year of life by current age of children and place of residence. The interviewer was shown this vaccination card.

84 Table 5.5 CHILDHOOD VACCINATION RECEIVED BY 12 MONTHS OF AGE Percentage of children age 12-23 months and 24-35 months with a vaccination card shown to the interviewer and percentage who received specific vaccinations by 12 months of age according to residence, Himachal Pradesh , 2002-04 Total Rural Urban 12-23 Vaccination status months 24-35 months 12-23 months 24-35 months 12-23 months 24-35 months Vaccination card shown to interviewer 59.7 48.9 60.0 48.9 58.1 49.1

Percentage vaccinated by 12 months of age

Polio 0 51.1 47.9 46.2 42.2 74.3 74.4

BCG 96.1 96.1 96.1 95.5 96.3 98.5

DPT injection No DPT 3.0 4.0 2.8 4.1 4.2 3.9 1 1.6 1.2 1.7 1.2 1.2 1.2 2 3.4 2.0 3.9 2.3 1.3 0.5 3 90.8 91.6 90.6 91.3 91.9 93.1 Don’t remember/missing 1.1 1.2 1.0 1.2 1.5 1.3

Polio doses No Polio 2.9 3.1 2.8 3.4 2.9 1.4 1 1.2 2.0 1.7 1.5 1.2 3.9 2 3.3 3.2 3.9 3.7 3.7 1.3 3 90.7 87.6 90.6 86.9 92.0 90.9 Don’t remember/missing 1.9 3.9 2.3 4.2 0.2 2.5

Measles 88.6 91.0 87.9 91.9 91.9 86.9

Full 1 vaccination 79.3 79.6 78.3 79.6 83.7 79.5

No vaccination at all 2.1 1.5 2.1 1.7 2.1 0.6

Number of children 931 845 768 695 163 150 Note: Table includes only last and last but one living child born since 1.1.1999/1.1.2001 1 BCG, three injection of DPT, three doses of Polio (excluding Polio 0) and measles

The interviewers were shown vaccination card for 60 percent children aged 12-23 months and for 49 percent children aged 24-35 months in the state. It has increased by 11 percentage points. The coverage of BCG vaccination was 96 percent in the state. The percentage of children who received three doses of DPT vaccine was 91 percent for children aged 12-23 months as against 88 percent for children aged 24-35 months in the state. Similarly, percentage of children who received three doses of Polio vaccine was 91 percent for children aged 12-23 months as against 92 percent for children aged 24-35 months in the state. Further, percentage of children who received Measles vaccine was 89 percent for children aged 12-23 months as against 91 percent for children aged 24-35 months in the state. These data show that there have been minor changes in the coverage of BCG, DPT, Polio and Measles for the age group 12-23 months and 24-35 months. Accordingly, coverage of full immunization has remained unchanged at 79 percent (see Figure 5.4).

5.3 Source of Immunization

Table 5.6 gives the percent distribution of children under age three years who have received any vaccination by the source of last vaccination, according to place of residence and availability of health facilities in the village. The percentage of children who received last vaccination from government health facility was 94 percent, from private health facility two percent and four percent

85 Figure 5.4 Child vaccination by age 83.7

79.3 79.6 79.6 79.5 78.3 Percent

Age 12-23 monthsHimachal Pradesh, DLHS-RCH.2002-04 Age 24-35 months Total Rural Urban

Table 5.6 SOURCE OF CHILDHOOD VACCINATION Percent distribution of children under age 3 who have received any vaccination by source of last vaccination, according to place of residence and availability of health facilities in the village, Himachal Pradesh, 2002-04 Residence Availability of health facility1 in the village Source of vaccination Total Rural Urban No Yes Government health sector Government/municipal hospital 56.5 51.6 77.2 60.8 45.4 Community/primary health centre 29.3 34.4 7.6 27.5 39.1 Sub-centre 8.0 8.6 5.2 5.5 10.7 RCH/MCP camp 0.1 0.0 0.5 0.0 0.0

Private health sector Private hospital 1.2 0.9 2.1 0.7 1.1 Private doctor 1.0 0.4 3.6 0.2 0.6

ISM2 health facility 0.6 0.6 0.6 0.2 1.0 Other 3.1 3.1 2.9 4.9 2.0

Missing 0.2 0.2 0.3 0.3 0.1

Total percent 100.0 100.0 100.0 100.0 100.0

Number of children 2,572 2,080 492 834 1,246 Note: Table includes last and last but one living children born in the three years preceding the survey 1 Includes sub-centre, primary health centre, Community health centre or referral hospital, government hospital, and government dispensary within the village 2 Either government or private health facility of Indian System of Medicine at ISM and other health facility. Among the children who were immunized at the government health facility, eight percent of them received vaccination from the sub-centre, 29 percent from community/primary health centre and 56 percent from government/municipal hospital. The percentage of children who received vaccination from the private sector was considerably lower in rural areas (one percent) than in urban areas (six percent). Even immunization coverage of children living in villages was 94-95 percent from government health facility irrespective of the status of health facility in the village.

5.4 Vitamin A and IFA Supplements

Vitamin A deficiency is one of the most common nutritional deficiency disorders in the world, affecting more than 250 million children worldwide (Bolem et. al., 1997). The child survival programme also includes administration of five doses of Vitamin-A for prevention of night blindness

86 and distribution of IFA for iron supplement. In Round-II, mothers of children born during the three years preceding the survey were asked whether their children had received a dose of Vitamin-A and IFA tablets/syrup. Those who said that their children had received a dose of Vitamin- A and IFA tablets/syrup were further asked how many doses were given. Table 5.7 gives percentage of children age 12-35 months who have received at least one dose of Vitamin-A and IFA tablets/ syrup, according to selected background characteristics. The percentage of children who received at least one dose of Vitamin-A was 68 percent and four percent children received IFA tablets/syrup. In other words, one-third of the children did not receive Vitamin-A supplement and very few children received IFA tablets/syrup supplementation in the state.

Table 5.7 VITAMIN A AND IFA SUPPLEMENTATION FOR CHILDREN Percentage of children age 12-35 months who have received at least one dose of Vitamin A and iron folic acid tablets/syrup, according to selected background characteristics, Himachal Pradesh, 2002-04 Percentage who received at least Percentage who received Background characteristic one dose of vitamin A iron folic acid tablets/syrup Number of children Age of the child 12-23 months 67.8 4.5 931 24-35 months 68.4 2.8 845

Sex of the child Male 68.9 3.2 964 Female 67.2 4.2 812

Birth order 1 71.8 3.7 756 2 68.2 5.1 573 3 67.5 3.2 256 4+ 54.6 0.2 188

Residence Rural 67.2 3.4 1,463 Urban 72.0 5.3 313

Mother’s education Non-literate 55.6 2.9 286 0-9 years@ 64.0 2.7 650 10 years and above 75.5 4.7 841

Religion Hindu 68.2 3.8 1,675 Muslim (56.8) (4.5) 42 Sikh (70.3) (5.4) 45

Caste/tribe # Scheduled caste 63.0 2.9 414 Scheduled tribe 64.0 1.5 68 Other backward class 69.7 2.6 206 Other 70.0 4.4 1,085

Standard of living index Low 58.7 3.8 443 Medium 69.2 2.7 705 High 73.4 4.7 628

Availability of health facility in the village1 Yes 67.8 3.2 874 No 66.4 3.6 588

Total 68.1 3.7 1,776 Note -1: Table includes last and last but one living children born in the three years preceding the survey. Note-2: Total includes 3 children with missing information on Birth order and 14 children for other religion were not shown separately. @ Literate mother with no years of schooling are also included here. # Total figure may not add to N due to do not know and missing cases. 1 Includes sub-centre, primary health centre, Community health centre or referral hospital, government hospital, and government dispensary within the village. ( ) Based on less than 50 unweighted cases.

87 Male children are more likely to receive Vitamin-A than female children but in case of IFA tablets/syrup the pattern is reverse. Children living in urban areas, children whose mother had studied for 10 years and above, children living in households with a high standard of living index, and children living in villages having health facility in the village are more likely to receive a dose of Vitamin-A and IFA tablets/syrup. Children of birth order 4 or above are much less likely than children of birth order three or less to receive any dose of vitamin-A and IFA tablets/syrup. Similarly, schedule caste/schedule tribe children are less likely to receive at least one dose of Vitamin-A than other backward and other caste category.

5.5 Immunization Coverage by District

Table 5.8 gives percentage of the children who received specific vaccination and Vitamin-A supplementation by district in Himachal Pradesh. There are inter-district differentials in the coverage for different vaccinations, and for children receiving all vaccinations and those who did not receive any vaccination at all. The percentage of children who received Polio-0 at birth was the highest (92 percent) in Bilaspur district, followed by 68 percent in Kangra district and the lowest (31 percent) in Sirmaur district. Further, coverage of Polio-0 at birth was higher than that of the state (51 percent) in Bilaspur, Kangra, Shimla and Solan districts and in eight districts it was lower than the state. The percentage of children who received BCG was the highest (100 percent) in Bilaspur district, followed by 99 percent in Kangra district and the lowest (91 percent) in Sirmaur district. The percentage of children who received three doses of DPT was the highest (97 percent) in Shimla district, followed by 96 percent in Una district and the lowest (79 percent) in Sirmaur district. The percentage of children who received three doses of Polio vaccine was the highest (95 percent) in Solan and Una districts, followed by 94 percent in Kullu district and the lowest (61 percent) in Bilaspur district. The percentage of children who received Measles vaccine was the highest (95 percent) in Hamirpur district, followed by 94 percent in Kangra district and the lowest (76 percent) in Chamba district. Again, percentage of children who were fully vaccinated was the highest (92 percent) in Hamirpur and Una districts, followed by 86 percent in Solan district and the lowest (38 percent) in Bilaspur district. The percentage of children

Table 5.8 CHILDHOOD VACCINATION BY DISTRICT Percentage of children who received specific vaccinations and Vitamin A supplementation by district, State, 2002-04 Percentage vaccinated1 Percentage received at District Polio 0 BCG DPT3 Polio3 Measles Full2 None least one dose of Vitamin A3 Bilaspur 92.1 100.0 66.8 61.0 77.7 38.5 0.0 51.6 Chamba 29.1 84.9 80.2 83.8 76.5 68.7 6.7 56.5 Hamirpur 39.1 96.6 94.6 92.4 95.5 92.4 2.3 84.9 Kangra 68.5 99.0 93.8 87.8 94.3 81.1 1.0 59.5 Kinnaur 43.6 97.7 87.8 72.6 86.0 65.9 0.6 71.9 Kullu 47.3 94.0 93.8 94.0 85.3 78.6 2.0 77.1

Lahul & Spiti 46.4 96.3 80.4 59.1 92.2 48.2 0.0 44.3 Mandi 37.5 96.1 92.2 90.5 88.4 82.8 3.9 72.6 Shimla 66.0 98.6 96.6 91.1 89.7 81.8 1.4 77.1 Sirmaur 30.8 90.7 78.6 80.0 79.7 67.3 3.7 53.3 Solan 54.9 94.8 95.2 95.2 86.1 86.1 3.1 79.1 Una 39.9 98.8 96.4 95.2 93.1 91.8 0.0 76.1

Himachal Pradesh 51.1 96.1 90.8 88.0 88.6 79.3 2.1 68.1 Note: Table includes only last and last but one living child born since 1.1.1999/1.1.2001 1 Children age 12-23 months, 2 BCG, three injection of DPT, three doses of Polio (excluding Polio 0 ) and measles. 3 Children age 12-35 months.

88 who received full vaccination was higher than that of the state (79 percent) in Hamirpur, Kangra, Mandi, Shimla, Solan and Una districts and in six districts it was lower than the state (see Map-5).

District wise variations in the percentage of children who received at least one dose of Vitamin-A are also shown in Table 5.8. The percentage of children in the age group 12-35 months who received at least one dose of Vitamin-A supplement ranges from 44 percent in Lahul & Spiti district to 85 percent in Hamirpur district. Further, Bilaspur (52 percent), Chamba (56 percent), Kangra (59 percent), Lahul & Spiti (44 percent) and Sirmaur (53 percent) districts are having below the state average of 68 percent children who received at least one dose of Vitamin-A.

5.6 Child Morbidity and Treatment

This section discusses the awareness, prevalence and treatment of diarrhoea and acute respiratory infection (ARI). Mothers of surviving children born during the three years preceding the survey were asked if their children suffered from cough and cold or diarrhoea during the two weeks preceding the survey, and if so, the type of treatment that had been given. Accuracy of all these measures is affected by the reliability of the mother’s recall of when the diseases occurred.

5.6.1 Awareness of Diarrhoea

Diarrhoea is a major killer disease of children under five years of age. Deaths from acute diarrhoea are mostly due to dehydration resulting from loss of water and electrolytes. An attempt was made to collect data on awareness of diarrhoea management and the practice followed during the diarrhoea episode.

Table 5.9 gives percentage of women aware of diarrhoea management, type of practices followed if child gets diarrhoea, and percentage of women whose child suffered during last two weeks prior to survey from diarrhoea by selected background characteristics. In Himachal Pradesh, 80 percent of the mothers were aware of what to do when a child had diarrhoea as compared to 87 percent in Round-I, which is seven percentage points down from Round-I. The awareness of ORS has increased from 49 percent in Round-I to 64 percent in Round-II, which is 15 percent point up from Round-I. Fifty-eight percent of the women were aware of salt and sugar solution. The percentage of the women who reported that they would continue normal food was 17 percent, continue breastfeeding (11 percent), and give plenty of fluids (24 percent), while 20 percent of women said did not know what to give a child who had diarrhoea. The knowledge of ORS was higher among urban women (66 percent) than rural women (56 percent). The knowledge of ORS was the highest (83 percent) among women who had studied for 10 years above and the lowest (27 percent) among non-literate women, while it was (51 percent) among women who had studied for 0-9 years. The knowledge of ORS was the highest (69 percent) for other castes women, followed by 59 percent for women belonging to schedule caste and the lowest (38 percent) for scheduled tribe women. The extent of ORS was the highest (85 percent) for women with high SLI and the lowest (35 percent) for women with low SLI, while it was 62 percent for women with medium SLI. The extent of ORS was 65 percent for women living in villages having health facility in the village as against 51 percent of women living in villages having no health facilities in the village.

5.6.2 Treatment of Diarrhoea

Table 5.10 gives percentage of women who sought treatment whose child suffered from diarrhoea

89 Table 5.9 AWARENESS OF DIARRHOEA Percentage of women who are aware of diarrhoea management, type of practice followed if child gets diarrhoea, and percentage of women whose child suffered1 from diarrhoea by selected background characteristics, Himachal Pradesh, 2002-04 Type of practices to be followed if child gets diarrhoea* Knowledge Salt and Continue Continue Give Background of diarrhoea Give sugar normal breast- plenty of Do not Number characteristic management ORS solution food feeding fluids know of women Age 15-24 74.9 58.7 50.4 12.5 7.7 18.8 25.2 977 25-34 83.0 67.6 62.7 19.7 14.0 28.7 17.1 1,532 35-44 80.6 57.2 64.1 13.0 3.9 17.5 19.3 111

Residence Rural 77.6 59.5 56.2 15.5 11.1 23.1 22.4 2,101 Urban 89.0 81.3 66.2 21.5 11.7 30.1 11.3 519

Mother’s education Non-literate 52.2 27.0 32.1 8.5 5.7 10.5 47.1 396 0-9@ years 73.0 51.5 48.0 14.5 9.6 21.6 27.3 917 10 and above 93.0 83.5 73.1 20.7 14.1 30.8 6.9 1,306

Religion Hindu 80.3 64.3 58.9 17.0 11.5 24.9 19.7 2,487 Muslim 61.7 45.2 45.6 12.7 8.0 16.8 40.9 53 Sikh 80.6 68.2 42.5 10.9 6.2 19.8 19.4 58

Caste/tribe# Scheduled caste 79.2 59.2 55.5 16.9 10.3 23.9 21.1 620 Scheduled tribe 61.9 38.1 43.1 11.8 4.1 11.9 38.5 109 Other backward class 75.5 54.9 56.6 18.8 13.8 25.6 24.5 291 Other 82.1 68.9 60.5 16.6 11.6 25.4 17.9 1,598

Standard of living index Low 60.6 34.9 38.8 11.2 8.3 16.7 38.9 633 Medium 80.1 62.5 57.9 13.4 9.1 21.7 20.1 1,054 High 92.6 84.9 71.6 24.1 15.7 33.0 7.5 933

Availability of health facility 2 in the village Yes 83.6 65.0 62.8 18.3 13.2 27.2 16.7 1,263 No 68.6 51.2 46.2 11.4 8.0 17.0 30.9 838

Total 79.8 63.8 58.2 16.7 11.2 24.5 20.2 2,620

Note: Table based on women with living children born since 01.01.1999 for phase - I /01.01.2001 for phase - II. 1 Last two weeks prior to survey. @ Literate mother with no years of schooling are included. # Total figure may not add to N due to do not know and missing cases. 2 Includes sub-centre, primary health centre, Community health centre or referral hospital, government hospital, and government dispensary within the village. Total includes 22 other religion cases were not shown separately.

diarrhoea and by source of treatment, according to place of residence and availability of health facility in the village. Over 10 percent women reported that their children suffered from diarrhoea in the state – 11 percent in rural areas and eight percent in urban areas. The percentage of women whose children suffered from diarrhoea treated with ORS was 51 percent in the state – 48 percent in rural areas and 60 percent in urban areas. Further, 46 percent women living in villages having health facility in the village as against 53 percent women living in villages having no health facility in rural areas whose child suffered from diarrhoea treated with ORS. Extent of women whose child suffered from diarrhoea sought treatment was 70 percent in the state – 68 percent in rural areas and 77 percent in urban areas. The percentage of women who sought treatment from government health facility was 62 percent, 31 percent from private health facility, 36 percent from ISM facility and over three percent from other health facility, while one percent women used home remedy.

90 Table 5.10 TREATMENT OF DIARRHOEA Percentage of women who sought treatment whose child suffered from diarrhoea and by source of treatment, according to place of residence and availability of health facility in the village, Himachal Pradesh, 2002-04 Availability of health fcaility2 in the Residence village Sought treatment/ source of treatment Total Rural Urban Yes No

Percentage of women whose child suffered1 from diarrhoea 10.4 10.9 8.0 12.7 8.3

Number of women 2,620 2,101 519 1,263 838

Percentage of women whose child suffered1 from diarrhoea treated with 50.9 47.9 (60.5) 45.8 52.9 ORS

Percentage of women whose child suffered1 from diarrhoea sought 70.0 68.2 (76.7) 685 67.7 treatment

Number of women 271 230 41 160 70

Source of treatment

Government health facility Hospital/dispensary 44.7 44.8 (57.6) 44.1 (53.3) UHC/UHP/UFWC 0.9 1.1 (0.0) 0.5 (2.2) CHC/ Rural hospital 1.9 2.2 (0.0) 2.6 (2.2) Primary health centre 11.8 14.3 (0.0) 10.5 (11.1) Sub centre 2.8 3.4 (0.0) 1.8 (4.4)

Private health facility Private hospital clinic 30.6 28.3 (33.3) 32.5 (24.4)

3 ISM facility 35.8 33.6 (54.5) 31.1 (44.4) Home remedy 0.7 0.9 (0.0) 1.3 (0.0) Other 3.4 2.3 (3.0) 3.3 (0.0)

Percent distribution of women who seek treatment by

Doctor 88.3 88.1 (90.9) 89.1 (84.4) ANM/Nurse/LHV 9.3 10.8 (6.1) 9.9 (13.3) Relative/friends 0.6 0.7 (0.0) 0.5 (2.2) ISM practitioner 1.5 0.0 (3.0) 0.0 (0.0) Missing 0.3 0.4 (0.0) 0.5 (0.0)

Total percent 100.0 100.0 100.0 100.0 100.0

Number of women 190 157 33 110 47

Note: Table based on women with living children born since 01.01.1999 for phase - I /01.01.2001 for phase - II. 1 Last two weeks prior to survey. 2 Includes sub-centre, primary health centre, Community health centre or referral hospital, government hospital, and government dispensary within the village. 3 Either government or private health facility of Indian System of Medicine. ( ) Based on less than 50 unweighted cases.

In other words, one third of the women who sought treatment of the child had it from more than one health facility. Among the women whose children suffered from diarrhoea who sought treatment and consulted the doctor was 88 percent, nine percent consulted ANM/Nurse/LHV, over one percent consulted ISM practitioner and one percent consulted relatives/friends.

5.6.3 Awareness of Pneumonia

Another major killer disease among infants and children is Acute Respiratory Infections (ARI)

91 including pneumonia. Early diagnosis and treatment with antibiotics can prevent a large proportion of ARI/pneumonia deaths. An attempt was made to understand the awareness level of pneumonia, and the percentage of children who had suffered from pneumonia during the last two weeks before the survey and their health seeking behaviour. Table 5.11 gives percentage of women who are aware of danger signs of pneumonia by signs by selected background characteristics and availability of health facility in the village. Only 27 percent of women were aware of danger signs of pneumonia in the state – 24 percent in rural areas and 40 percent in urban areas. The figure was slightly down from 29 percent in Round-I. Knowledge of danger signs of pneumonia was low among women (19 percent) aged below 25 years, while it was 32 percent among women aged 25 years and more. Level of awareness of danger signs of pneumonia was the highest (35 percent) for women who had studied for 10 years and above and the lowest (14 percent) for non-literate women, while it was 22 percent for women who had studied for 0-9 years. Similarly, aware of danger signs of pneumonia was the highest (40 percent) for women with high SLI and the lowest (17 percent) for women with low SLI, while it was 22 percent for women with medium SLI. The level of awareness of danger signs of pneumonia was 27 percent for Hindu women as against 24 percent for Muslim women and 27 percent for Sikh women. The awareness level of danger signs of pneumonia was the highest (32 percent) among other backward class women, followed by 29 percent among women from other castes and the lowest (20 percent) among scheduled tribe women. Twenty seven percent of women living in villages having health facility in the village as against 20 percent of women living in villages having no health facility in the village were aware of danger sign of pneumonia.

Women, who were aware of the danger signs of pneumonia, were further asked about different types of danger signs of pneumonia. Main danger signs of pneumonia reported by women were ‘difficulty in breathing’ (62 percent), ‘pain in chest and productive cough’ (71 percent), ‘wheezing /whistling’ (37 percent), ‘chest in drawing’ (62 percent), ‘not able to drink or take a feed’ (17 percent), ‘rapid breathing’ (23 percent), ‘condition get worse than before’ (20 percent) and ‘excessive drowsy and difficulty in keeping awake’ (10 percent).

5.6.4 Treatment of Pneumonia

Table 5.12 gives percentage of women whose child suffered from cough and cold who sought treatment and source of treatment, according to place of residence and availability of health facility in the village. The percentage of women whose child suffered from cough and cold and difficulty in breathing was 15 percent in the state – 14 percent in rural areas and 18 percent in urban areas. The percentage of women whose child suffered from cough and cold and difficulty in breathing was 16 for women living in villages having health facility in the village as against 12 percent for women living in villages having no health facility in the village.

The percentage of women whose child suffered from cold, cough and difficulty in breathing who sought treatment was 78 percent in the district – 74 percent in rural areas and 91 percent in urban areas. Similarly, 73 percent of women living in villages having health facility in the village as against 77 percent of women living in villages having no health facility in the village sought treatment of children who suffered from cold and cough. Further, percentage of women who sought treatment from government health facility was 57 percent, 32 percent from private health facility and about six percent from ISM and other health facility, while five percent of the women treated the children with home remedy. Further, percentage of who sought treatment from the doctor

92 Table 5.11 AWARENESS OF PNEUMONIA Percentage of women who are aware of danger signs of pneumonia by signs by selected background characteristics and availability of health facility in the village, Himachal Pradesh, 2002-04 Danger signs of ARI Percentage of women aware Not able to Excessive drowsy Pain in chest Conditions Background of danger signs Number of Difficulty in Chest in- drink or take a and difficulty in and productive get worse Wheezing/ Rapid Number of characteristic of pneumonia women breathing drawing feeding keeping awake cough than before whistling breathing women

Age 15- 24 19.4 977 58.4 57.1 14.0 4.1 77.9 14.1 38.4 24.2 190 25-34 32.1 1,532 63.8 64.7 19.2 11.9 67.0 22.0 34.8 21.7 491 35-44 31.8 111 (63.2) (60.5) (7.9) (13.2) (86.8) (15.8) (44.7) (26.3) 35 Residence Rural 24.1 2,101 59.6 58.6 16.2 5.3 76.9 19.2 37.4 21.5 506 Urban 40.5 519 67.2 72.0 20.1 21.8 55.3 21.2 35.9 25.2 211 Mother’s education Non-literate 14.1 396 42.1 44.3 13.0 1.2 89.9 19.0 34.2 20.3 56 0-9@ years 22.5 917 60.9 58.9 18.0 4.3 74.5 20.6 42.0 16.7 207 10 and above 34.7 1,306 64.7 66.4 17.6 13.9 66.4 19.5 35.0 25.6 454 Religion Hindu 27.1 2,487 60.6 63.1 17.6 10.6 71.4 20.3 37.5 22.7 673 Muslim 24.3 53 * * * * * * * * 13 Sikh 44.4 58 (83.3) (55.6) (16.7) (5.6) (44.4) (11.1) (50.0) (22.2) 26 Caste/tribe# Scheduled caste 23.1 620 58.6 54.7 16.1 8.6 80.3 10.6 43.3 19.3 144 Scheduled Tribe 19.8 109 * * * * * * * * 21 Other backward class 32.1 291 58.6 60.1 16.0 5.7 79.8 16.4 44.2 23.1 94 Other 28.6 1,598 63.3 65.1 17.9 12.0 65.2 23.8 34.4 24.1 457 Standard of living index Low 17.4 633 49.4 46.9 13.4 4.4 86.4 16.8 40.4 21.7 110 Medium 22.0 1,054 61.3 66.2 21.3 5.7 74.5 21.1 33.4 12.9 232 High 40.2 933 65.8 64.9 16.0 14.6 63.5 19.9 38.2 28.8 374 Availability of health facility 2 in the village Yes 26.7 1,263 57.1 62.9 17.7 4.9 79.2 21.3 37.1 21.6 337 No 20.2 838 64.6 49.9 13.2 6.0 72.3 15.0 38.2 21.4 169

Total 27.3 2,620 61.8 62.5 17.3 10.1 70.6 19.8 37.0 22.6 717

Note: Table based on women with living children born since 01.01.1999 for phase - I /01.01.2001 for phase - II. 1 Last two weeks prior to survey. Table includes 22 women with awareness of pneumonia and 4 women with danger signs of ARI on other religion were not shown separately. * Percentage not shown: Based on few cases. @ Literate mother with no years of schooling are included. # Total figure may not add to N due to ‘do not know’ and ‘missing’ cases. 2 Includes sub-centre, primary health centre, Community health centre or referral hospital, government hospital, and government dispensary within the village. () Based on less than 50 unweighted cases

93 Table 5.12 TREATMENT OF PNEUMONIA Percentage of women who sought treatment whose child suffered1 from cough and cold and source of treatment, according to place of residence and availability of health facility in the village, Himachal Pradesh, 2002-04 Availability of health fcaility2 in the Residence village Sought treatment/ source of treatment Total Rural Urban Yes No Percentage of women whose child suffered from cough, cold and difficulty 15.1 14.4 17.9 16.2 11.8 in breathing

Number of women 2,620 2,101 519 1,263 838

Percentage of women sought treatment whose child suffered from cough and 78.3 74.3 91.2 73.1 767 cold

Number of women 395 302 93 204 98

Source of treatment

Government health facility Hospital/dispensary 47.0 45.2 51.7 44.5 46.5 UHC/UHP/UFWC 0.6 0.8 0.0 0.3 1.6 CHC/ Rural hospital 0.3 0.4 0.0 0.4 0.2 Primary health centre 5.9 8.1 0.0 8.6 7.2 Sub centre 3.3 4.6 0.0 3.0 7.7 Private health facility

Private hospital clinic 32.1 32.9 29.8 36.1 26.6

ISM3 facility 3.3 3.5 2.9 2.1 6.2 Home remedy 5.3 3.5 10.3 3.7 3.0 Other 2.3 1.1 5.3 1.1 1.1

Percent distribution of women who seek treatment by

Doctor 84.5 82.8 89.0 85.5 77.5 ANM/Nurse/LHV 9.1 12.5 0.2 9.5 18.4 Relative/friends 1.2 0.5 3.0 0.0 1.6 Chemist 1.2 1.5 0.5 1.3 1.9 ISM Practitioner 0.9 0.0 3.4 0.0 0.0 Other 3.0 2.6 3.9 3.7 0.5

Total percent 100.0 100.0 100.0 100.0 100.0

Number of women 309 224 84 149 75

Note: Table based on women with living children born since 01.01.1999 for phase - I /01.01.2001 for phase - II. 1 Last two weeks prior to survey. 2 Includes sub-centre, primary health centre, Community health centre or referral hospital, government hospital, and government dispensary within the village 3 Either government or private health facility of Indian System of Medicine was 87 percent, over nine percent from ANM/Nurse/LHV, over one percent from ISM practitioners and over one percent from relatives and friends.

5.6.5 Knowledge of Diarrhoea Management and Pneumonia by District

Table 5.13 presents distribution of women by awareness of diarrhoea management, ORS, danger signs of pneumonia and whose child had suffered from diarrhoea and pneumonia during last two weeks prior to survey by district. The level of awareness of diarrhoea management among women was the highest (97 percent) in Kangra district, followed by 89 percent in Bilaspur district

94 and the lowest (60 percent) in Kullu district. The level of awareness of diarrhoea management among women was higher than that of the state (80 percent) in Bilaspur, Kangra, Kinnaur, Lahul & Spiti, Shimla and Sirmaur districts and in the remaining six districts it was lower than that of the state.

The level of awareness about ORS among women was the highest (82 percent) in Kangra district, followed by 74 percent in Bilaspur district and the lowest (42 percent) in Lahul & Spiti district. The level of awareness about ORS among women was higher than that of the state (64 percent) in Bilaspur, Hamirpur, Kangra, Shimla, Sirmaur and Solan districts and in the remaining six districts it was lower than that of the state. The percentage of women whose child suffered from diarrhoea was the highest (16 percent) in Bilaspur district, followed by 14 percent in Kangra district and the lowest (two percent) in Solan district. The percentage of women whose child suffered from diarrhoea was higher than that of the state (10 percent) in Bilaspur, Kangra, Kullu, Mandi, Shimla and Sirmaur districts and in the remaining six districts it was lower than that of the state.

The level of awareness of danger signs of pneumonia among women was the highest (53 percent) in Kangra district, followed by 43 percent in Sirmaur district and the lowest (eight percent) in Kullu district. The level of awareness of danger signs of pneumonia among women was the higher than that of the state (27 percent) in Bilaspur, Chamba, Kangra, Kinnaur and Sirmaur districts and in the remaining seven districts it was lower than that of the state.

The percentage of women whose child suffered from pneumonia was the highest (22 percent) in Sirmaur district, followed by 20 percent in Kangra district and the lowest (over two percent) in Solan district. The percentage of women whose child suffered from pneumonia was higher than that of the state (15 percent) in Bilaspur, Chamba, Kangra, Shimla and Sirmaur districts and in the remaining seven districts of Hamirpur, Kinnaur, Kullu, Lahul & Spiti, Mandi, Solan and Una it was lower than that of the state.

Table 5.13 KNOWLEDGE OF DIARRHOEA MANAGEMENT AND PNEUMONIA BY DISTRICT Percentage of women by awareness of diarrhoea management, ORS, danger signs of pneumonia and whose child had suffered from diarrhoea and pneumonia during last two weeks prior to survey by district, Himachal Pradesh, 2002-04 Percentage of women aware of Percentage of women Percentage of women Percentage of women whose child suffered1 Diarrhoea whose child suffered1 aware of danger signs of from pneumonia District Management ORS from diarrhoea pneumonia Bilaspur 89.3 74.1 16.4 29.0 18.9 Chamba 71.1 45.3 7.0 35.6 16.9 Hamirpur 76.6 68.4 6.3 19.6 9.2 Kangra 96.9 82.1 14.2 52.8 20.1

Kinnaur 84.0 62.0 9.3 29.8 4.6 Kullu 60.3 45.2 12.3 8.3 10.1 Lahul & Spiti 83.4 42.3 4.0 13.8 7.5 Mandi 65.5 44.9 13.7 13.3 14.3

Shimla 81.1 71.2 10.6 15.5 18.4 Sirmaur 87.1 68.0 11.6 43.0 21.6 Solan 75.9 69.4 1.7 13.9 2.5 Una 77.3 59.0 4.4 11.8 5.0

Himachal Pradesh 79.8 63.8 10.4 27.3 15.1

Note: Table based on women with last and last but one living children born since 01.01.1999 /01.01.2001. 1 Last two weeks prior to survey.

95 Map-5

Percentage of Children (age 12-23 months) Who Have Received Full Vaccination

96 CHAPTER VI

FAMILY PLANNING

The Reproductive and Child Health Programme has been implemented with a new philosophy and direction to meet the health care needs of women and children. It envisages for the couples to control their fertility and have sexual relations free from the fear of pregnancy. Provision of free contraceptive services to all the needy couples is one of the components of the RCH programme. In DLHS-RCH a separate section on family planning was canvassed to all the eligible women to assess the knowledge and practice of various family planning methods. The information on source of currently adopted contraceptive method, source of supply of the method and health problems related to contraceptive use were collected from current users. The current non-users were asked about the past status of contraceptive use, reason for not using contraceptives currently and future intention to adopt a family planning method.

An attempt was made to understand why male methods of family planning especially that of vasectomy was not in common use. The husbands of sampled eligible women were asked about the contraceptive method they would recommend to a couple who was not desirous of any additional children. They were also asked about the reasons for not preferring male methods and their knowledge about the no-scalpel vasectomy. This chapter presents the results of data on contraceptive practices collected from both the sampled women and their husbands.

6.1 Knowledge of Family Planning Methods

Lack of knowledge of various contraceptive choices can be a major barrier to promote the use of contraceptives among couples. In DLHS-RCH information on knowledge of contraceptives was obtained by asking a question, “Which are the family planning methods are you aware of?” to each sampled eligible women. The knowledge of no-scalpel vasectomy was also asked to the husbands of eligible women. The DLHS-RCH assesses the knowledge of female sterilisation, male sterilisation including NSV, IUD, Pills, condom and traditional methods along similar lines.

Table 6.1 gives percentage of currently married women age 15-44 years who know any contraceptive method by specific method and selected background characteristics. The data shows that almost all of the currently married women were having knowledge of any of the contraceptive methods irrespective of residence. Knowledge of any modern method was almost universal in the state. Further, knowledge of any modern spacing method among currently married women was 96 percent in the state – 95 percent in rural areas and 99 percent in urban areas. On the other hand, knowledge about all modern methods was 80 percent in the state – 79 percent in rural areas and 87 percent in urban areas. The difference in the knowledge of any modern method and all modern method is 19 percentage points, which is quite high. Similarly, rural-urban differential in the knowledge of all modern methods is nine percentage points.

The extent of knowledge about female sterilisation was 98 percent – 88 percent for Tubectomy and 70 percent for Laparoscopy. Similarly, knowledge about male sterilization was 92 percent – 77 percent for vasectomy and 65 percent for No-scalped vasectomy. The extent of knowledge among currently married women about spacing methods was 87 percent for IUD/Loop, Table 6.1 KNOWLEDGE OF CONTRACEPTIVE METHODS Percentage of currently married women age 15-44 years who know any contraceptive method by specific method and selected background characteristics, Himachal Pradesh, 2002-04. Availability of health facility in the Residence 3 Total village Contraceptive methods Rural Urban No Yes

Any method 99.4 99.3 99.5 99.4 99.2 Any modern method 99.3 99.3 99.5 99.4 99.2 Any modern spacing method1 95.6 94.7 98.9 93.5 95.6 All modern methods2 80.4 78.6 87.2 76.5 80.0

Female sterilization 98.3 98.5 97.7 98.5 98.5 Tubectomy 88.2 87.5 90.8 87.6 87.5 Laparoscopy 69.8 67.1 79.6 64.9 68.6

Male sterilization 92.5 92.4 92.9 93.1 91.9 Vasectomy 77.2 75.6 82.7 80.0 72.6 No-scalpel vasectomy 64.7 61.5 76.2 61.8 61.3

IUD/Loop 87.5 85.7 94.2 83.1 87.4

Pills 93.7 92.6 98.0 91.2 93.5 Daily 82.1 80.2 88.8 79.1 81.0 Weekly 64.0 59.3 81.1 62.9 56.9 Condom/Nirodh 90.2 88.8 95.1 87.5 89.7 Sponge (today) 16.5 12.7 30.0 13.2 12.4 Injectables 33.3 32.5 36.2 30.9 33.7 Norplant 4.2 3.4 7.1 3.4 3.5 Contraceptive herbs 25.1 25.5 23.5 19.7 29.5 Any traditional method 57.3 57.0 58.5 51.8 60.5 Any other Indian system of medicinal contraceptives 22.2 23.6 17.2 17.2 28.0

Number of women 8,618 6,748 1,870 2,730 4,018

1 Include IUD, pills and condom. 2 Include Female sterilization, Male sterilization, IUD, pills and condom 3 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village.

94 percent for Pills and 90 percent for condom/nirodh. Knowledge about Daily pills was 82 percent as against 64 percent for weekly pills-difference being 18 percentage points. Knowledge about other contraceptive methods was 16 percent for Sponge (today), 33 percent for Injectables and four percent for Norplant. Further, extent of use of any traditional method was 57 percent, contraceptive herbs 25 percent and any other Indian System of Medicinal contraceptives 22 percent. Figure 6.1 gives knowledge of family planning method.

6.1.1 Knowledge of Family Planning Methods by Districts

Table 6.2 shows the knowledge of contraceptive methods by districts in Himachal Pradesh. In all districts more than 98 percent women knew about any contraceptives method/any modern method. Further, more than 92 percent women knew about any spacing method in all the districts. The scenario in respect of all modern methods is somewhat different. The level of awareness of all modern methods among women was the highest (92 percent) in Hamirpur and Kangra districts, followed by 87 percent in Lahul & Spiti district and the lowest (35 percent) in Bilaspur district. The level of awareness of all modern methods among women was higher than that of the state (80 percent) in Hamirpur, Kangra, Kullu, Lahul & Spiti, Mandi, Sirmaur, Solan and Una district and it was lower than that of the state in four districts. The percentage of women having knowledge of

98 Figure 6.1 Knowledge of Family Planning Method

Any modern 99 Any modern spacing 96 All modern 80 Any tradtional 57

Female sterilization 98 Male sterilization 93 IUD 88 Pills 94 Condom 90

0 20 40 60 80 100 120 Himachal Pradesh, DLHS-RCH, 2002-04 Percent

Table 6.2 KNOWLEDGE OF CONTRACEPTIVE METHODS BY DISTRICT Percentage of currently married women age 15-44 years who know any contraceptive method by specific method and district, Himachal Pradesh, 2002-04 Any Any modern All Any Any modern1 spacing2 modern3 Male Female Condom traditional Districts method method method methods sterilization sterilization IUD Pill /Nirodh method

Bilaspur 99.8 99.6 96.2 34.8 51.3 96.6 64.4 93.4 79.8 24.9 Chamba 99.9 99.7 92.9 65.3 97.2 98.9 68.5 88.9 86.0 64.4 Hamirpur 99.1 99.0 97.5 92.5 97.8 98.7 96.4 97.1 94.2 53.0 Kangra 100.0 100.0 99.8 92.6 98.3 99.9 94.6 98.5 98.9 94.5 Kinnaur 100.0 100.0 100.0 78.7 99.8 100.0 89.4 99.7 86.6 23.4 Kullu 99.1 99.1 93.3 81.4 95.8 97.6 88.1 91.2 87.5 42.1

Lahul & Spiti 100.0 100.0 99.7 87.1 100.0 100.0 92.6 98.2 94.1 42.9 Mandi 98.7 98.7 92.0 80.9 95.2 98.0 88.1 90.5 85.4 51.2 Shimla 98.7 98.6 94.5 78.6 89.3 97.5 86.2 89.7 89.7 38.8 Sirmaur 100.0 100.0 99.8 85.8 93.9 98.7 91.4 99.1 95.8 78.9 Solan 98.8 98.8 94.7 84.6 92.9 97.4 92.6 93.7 89.1 40.8 Una 98.9 98.8 93.6 82.5 94.4 98.4 91.5 91.9 84.9 41.5

Himachal Pradesh 99.4 99.3 95.6 80.4 92.5 98.3 87.5 93.7 90.2 57.3 1 Includes Female sterilization, Male sterilization, IUD, Pills and Condom. 2 Includes IUD, Pills and Condom. 3 Includes Female sterilization & Male sterilization & IUD & Pills and Condom.

male sterilization was the highest (100 percent) in Lahul & Spiti and Kinnaur districts, followed by 98 percent in Kangra and Hamirpur district and the lowest (51 percent) in Bilaspur district. On the other hand, more than 97 percent women were having knowledge of female sterilization in all the districts of Himachal Pradesh. The level of knowledge of IUD/Loop among women was the highest (96 percent) in Hamirpur district, followed by 95 percent in Kangra district and the lowest (64 percent) in Bilaspur district. More than 88 percent women were having knowledge about Pill in all the districts of the state. Knowledge about condom was more than 79 percent in all the districts of the state. Further, knowledge of any traditional method among women was the highest (94 percent), in Kangra district, followed by 79 percent in Sirmaur district and the lowest (23 percent) in Kinnaur district, while it was 57 percent in the state.

99 6.1.2 Knowledge of No-Scalpel Vasectomy (NSV)

Knowledge of no-scalpel vasectomy among the husbands of currently married women in Himachal Pradesh is shown in Table 6.3. Level of knowledge about No-scalpel vasectomy among husbands was 54 percent in the state - 52 percent in rural areas and 63 percent in urban areas. Further, 49 percent of the husbands living in villages having no health facility in the village as against 54 percent of the husbands living in villages having health facility in the village were aware of No-scalpel vasectomy. Among the husbands who knew about NSV, 75 percent reported that NSV is simpler than conventional vasectomy, 66 percent feel that NSV does not lead to any complication and 55 percent feel that NSV does not affect a man’s sexual performance. Only 55 percent of the husbands living in villages having no health facility in the village as against 67 of the husbands living in villages having health facility in the village feel that NSV does not affect man’s sexual performance.

Table 6.3 KNOWLEDGE OF NO-SCALPEL VASECTOMY (NSV) Husbands knowledge of NSV by residence and availability of health facility in the village, Himachal Pradesh, 2002-04 Availability of health Residence 1 facility in the village Knowledge of NSV Total Rural Urban No Yes

Percentage of husband who had knowledge about NSV 54.4 51.8 62.9 48.8 53.8

Number of husbands 4,550 3,489 1,061 1,410 2,079

Who know that NSV is simpler than conventional vasectomy 75.2 79.1 64.7 76.7 80.6

Who feel that NSV does not lead to any complication 66.3 66.8 64.9 68.1 66.0

Who feel that NSV does not affect man’s sexual performance 54.9 56.3 51.0 54.8 57.3

Number of husbands 2,474 1,806 668 689 1,117

1 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village.

6.1.3 Knowledge of No-Scalpel Vasectomy (NSV) by Districts

Table 6.4 gives percentage of husbands of eligible women by knowledge of No-scalpel vasectomy awareness by districts in Himachal Pradesh. The level of knowledge of NSV among husbands was the highest (64 percent) in Kangra district, followed by 63 percent in Hamirpur district and the lowest (44 percent) in Mandi district, while it was 54 percent in the state. Further, percentage of husbands who said NSV is simpler than conventional method was the highest (88 percent) in Lahul & Spiti district, followed by 87 percent in Chamba and Kinnaur districts and the lowest (62 percent) in Bilaspur district, while it was 75 percent fir the state. Again, percentage of husbands who reported NSV does not lead to any complication was the highest (86 percent) in Kullu district, followed by 84 percent in Lahul & Spiti district and the lowest (47 percent) in Sirmaur district, while it was 66 percent for the state. The percentage of husbands who said NSV does not affect man’s sexual performance was the highest (82 percent) in Lahul & Spiti district, followed by 80 percent in Kinnaur district and the lowest (36 percent) in Bilaspur district, while it was 55 percent for the state.

100 Table 6.4 NO-SCALPEL VASECTOMY BY DISTRICT Percentage of husband of eligible women by knowledge of NSV by district, Himachal Pradesh, 2002-04 Who reported NSV Who reported NSV does Knowledge about NSV is simpler than does not lead to any not affect man’s sexual Districts NSV conventional method complication performance

Bilaspur 56.9 62.4 55.0 36.4 Chamba 47.4 87.5 64.7 63.8 Hamirpur 62.8 84.3 72.4 67.7 Kangra 64.1 83.3 66.3 53.4 Kinnaur 58.9 86.9 80.4 79.6 Kullu 46.4 73.8 85.7 64.3

Lahul & Spiti 52.7 88.3 84.1 82.0 Mandi 43.6 78.1 69.9 66.7 Shimla 55.5 67.9 78.6 55.3 Sirmaur 53.4 70.0 47.3 43.0 Solan 52.1 69.1 48.4 42.0 Una 56.2 82.8 66.3 55.4

Himachal Pradesh 54.4 75.2 66.3 54.9

6.2 Current Use of Family Planning Methods

Table 6.5 gives percentage distribution of currently married women age 15-44 years currently using any contraceptive method by selected background characteristics. The percentage of women using any modern contraceptive method was 65 percent in the state – 65 percent in rural areas and 68 percent in urban areas. The current use of modern contraception brought out by Round-I of DLHS-RCH was 62 percent, which shows that it has increased by three percentage points. Use of modern method was reported by 65 percent of the women – 19 percent women were using any spacing method and 46 percent any permanent method. The most preferred method among the users of sterilization was female sterilization (41 percent), while only five percent males were using male sterilization. The use of any traditional methods by women was over four percent – over three percent women were using withdrawal method and over one percent rhythm or periodic abstinence method. The rural-urban differential is in the use of any modern spacing method is 20 percentage points. Figure 6.2 gives practices of family planning methods.

Figure 6.2 Practice of Family Planning Methods

IUD/Loop Missing Pills 2% 0.2% 4% Condom Not using any 13% method 30% Male sterilization 5%

Any tradional Female sterilization method/other 41% method 5% Note: Total percent may add more than 100.0 due to rounding Himachal Pradesh, DLHS-RCH, 2002-04

101 Table 6.5 CONTRACEPTIVE PREVALENCE RATE Percentage of currently married women age 15-44 years currently using any contraceptive method by selected background characteristics, Himachal Pradesh, 2002-04 Any modern Any Rhythm/ Any Any modern1 spacing Any Male Female IUD/ Condom traditional periodic Number of Method method method method2 sterilization sterilization sterilization Loop Pill / Nirodh method3 abstinence Withdrawal women

Residence Rural 69.0 64.6 14.4 50.0 5.9 44.0 1.3 3.3 9.8 4.1 1.2 2.9 6,748 Urban 74.2 68.3 34.5 33.6 3.0 30.6 4.7 5.7 24.2 5.9 1.3 4.5 1,870

Education Non-literate 77.0 73.5 6.0 67.3 11.5 55.8 0.4 1.8 3.7 3.3 1.0 2.3 1,874 0-9@ years 73.2 69.1 11.7 57.3 5.2 52.2 1.3 3.4 7.0 3.8 1.1 2.7 3,326 10 years & above 63.4 57.4 32.7 24.3 2.0 22.3 3.6 5.3 23.8 5.9 1.4 4.4 3,415

Religion Hindu 70.4 65.8 18.5 47.1 5.4 41.7 1.9 3.8 12.8 4.5 1.1 3.3 8,267 Muslim 56.3 49.8 21.3 28.6 1.4 27.2 4.4 6.0 10.8 6.5 4.8 1.6 124 Sikh 64.3 59.6 25.8 32.7 1.8 30.8 3.7 2.2 19.9 4.7 1.4 3.3 156 Buddhist 70.7 68.7 32.3 35.6 13.3 22.3 4.2 9.5 18.5 1.9 1.4 0.5 54

Caste/tribe# Scheduled caste 68.1 64.2 13.1 50.8 5.4 45.4 1.0 3.1 9.0 3.8 0.8 2.8 1,876 Scheduled tribe 61.2 57.0 16.6 39.8 6.8 33.0 1.9 4.4 10.2 3.9 1.3 2.6 348 Other backward class 71.6 65.6 17.0 48.5 1.8 46.7 0.8 4.6 11.5 5.9 2.7 3.2 856 Other 71.2 66.4 21.1 45.0 5.7 39.3 2.6 3.9 14.7 4.6 1.1 3.5 5,524

Standard of living index Low 68.1 63.4 7.8 55.4 9.6 45.8 0.9 2.6 4.3 4.6 1.4 3.2 1,888 Medium 69.7 66.4 13.6 52.6 4.3 48.3 1.0 3.5 9.1 3.1 0.8 2.2 3,583 High 71.8 65.5 31.2 34.0 3.8 30.1 3.8 4.9 22.5 6.2 1.5 4.5 3,147

Availability of health facility in the village4 No 68.4 64.6 12.2 52.0 6.2 45.8 1.4 3.1 7.6 3.5 0.6 2.9 2,730 Yes 69.4 64.7 15.9 48.6 5.8 42.8 1.2 3.4 11.3 4.5 1.5 3.0 4,018

Total 70.1 65.4 18.8 46.4 5.3 41.1 2.0 3.8 12.9 4.5 1.2 3.3 8,618

1 Include Female sterilization, Male sterilization, IUD, Pills and Condom. 2 Include IUD, Pills and Condom. 3 Include Rhythm/Periodic abstinence, Withdrawal and Other traditional method. @ Literate women with no years of schooling are also included. #Total figure may not add to N due to don’t know and missing cases. 4 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village. Note: Total includes 18 cases for other religions and 3 cases of education missing that were not shown separately.

102 Current use of contraception was 72 percent for other backward class women as against 71 percent for other caste women and 68 percent for scheduled caste women, while it was 61 percent for scheduled tribe women. The current use of any modern method was the highest (73 percent) for non-literate women and the lowest (57 percent) for women who had studied for 10 years and above, while it was 69 percent for women who had studied for 0-9 years. The current use of any modern method was the highest (66 percent) for women with medium SLI and the lowest (63 percent) for women with low SLI, while it was 65 percent for women with high SLI. Again, use of any modern method was the highest (69 percent) for Buddhist women, followed by 66 percent for Hindu women and the lowest (50 percent) for Muslim women, while it was 60 percent for Sikh women. Again, current use of female sterilization was the highest (56 percent) for non-literate women and the lowest (22 percent) for women who had studied for 10 years and above, while it was 52 percent for women who had studied for 0-9 years. The current use of female sterilization was the highest (48 percent) for women with medium SLI and the lowest (30 percent) for women with high SLI, while it was 46 percent for women with low SLI. The use of condom was also high among women who had studied for 10 years and above and women with high standard of living index.

6.2.1 Current Use of Family Planning Methods by Districts

Table 6.6 gives percentage of currently married women age 15-44 years currently using any contraceptive method by district. The percentage of women currently using any modern method was the highest (77 percent) in Shimla district, followed by 72 percent in Kullu district and the lowest (55 percent) in Una district, while it was 70 percent for the state. Further, current current use of any spacing method among women was the highest (24 percent) in Lahul & Spiti district, followed by 22 percent in Shimla and Solan districts and the lowest (12 percent) in Sirmaur district, while it was 19 percent for the state. The use of male sterilization was the highest (22 percent) in Kinnaur district, followed by 21 percent in Kullu district and the lowest (one percent)

Table 6.6 CONTRACEPTIVE PREVALENCE RATES BY DISTRICT Percentage of currently married women age 15-44 years currently using any contraceptive method by district, Himachal Pradesh, 2002-04 Any Any modern Any 1 Any modern spacing2 Male Female Condom/ traditional3 Districts method method method sterilization sterilization IUD Pill Nirodh method

Bilaspur 68.9 67.8 14.4 5.0 48.5 1.7 3.5 9.2 1.1 Chamba 66.2 56.8 17.5 14.2 24.3 1.2 1.7 14.6 9.4 Hamirpur 66.2 62.2 16.7 3.4 41.9 1.5 2.3 12.8 3.7 Kangra 70.5 60.3 21.8 1.1 37.4 1.1 4.1 16.6 10.1 Kinnaur 68.8 64.5 19.4 22.1 22.8 3.9 8.1 7.5 4.3 Kullu 75.3 71.7 18.5 20.8 32.1 3.0 4.9 10.6 3.5

Lahul & Spiti 65.3 62.2 23.6 18.5 20.0 6.8 6.2 10.5 2.9 Mandi 72.7 69.0 15.3 3.8 49.2 2.4 3.3 9.5 3.3 Shimla 79.2 76.7 22.3 3.4 51.0 3.4 7.0 11.9 2.2 Sirmaur 70.9 66.4 12.3 2.8 51.4 1.0 1.8 9.5 4.3 Solan 69.2 68.3 22.5 4.7 41.2 2.9 3.1 16.5 0.9 Una 58.3 55.5 21.7 2.3 30.7 2.4 3.4 15.9 2.6

Himachal Pradesh 70.1 65.4 18.8 5.3 41.1 2.0 3.8 12.9 4.5

1 Include Female sterilization, Male sterilization, IUD, Pills and Condom 2 Include IUD, Pills and Condom 3 Include Rhythm/Periodic abstinence, Withdrawal and Other traditional method

103 in Kangra district, while it was five percent for the state. Similarly, use of female sterilization was the highest (51 percent) in Shimla and Sirmaur districts, followed by 49 percent in Mandi district and the lowest (20 percent) in Lahul & Spiti district, while it was 41 percent for the state (see Map-6). The use of spacing methods was two percent for IUD/Loop, four percent for Pill and 13 percent for Condom/Nirodh in the state. The use of IUD/Loop varies from one percent in Chamba, Kangra and Sirmaur districts to seven percent in Lahul & Spiti district. Similarly, use of Pill varies from less than two percent in Chamba and Sirmaur districts to eight percent in Kinnaur district. The use of Condom/Nirodh was the highest (17 percent) in Kangra and Solan districts, followed by 16 percent in Una district and the lowest (seven percent) in Kinnaur district, while it was 13 percent for the state. The variation in contraceptive prevalence at the district level is basically due to the variation in the use of spacing methods while both modern and traditional contraceptive users do not show much variation across districts. Further, use of any traditional method was the highest (10 percent) in Kangra district, followed by nine percent in Chamba district and the lowest (one percent) in Solan district, while it was over four percent for the state.

6.2.2 Current Use and Ever Use of Family Planning Methods by Women

Table 6.7 gives percentage of currently married women aged 15-44 years by current use and ever use of contraception according to selected demographic characteristics in Himachal Pradesh. The percentage of the currently married women using any modern method was eight percent in the age group 15-19 years, 31 percent in the age group 20-24 years, 59 percent in the age group 25-29 years, 80 percent in the age group 30-34 years, 81 percent in the age group 35-39 years and 80 percent in the age group 40-44 years. These data have shown that use of contraception increases with increase in age of the women and it attains its peak of 81 percent in the age group 35-39 years. The use of any traditional method was the lowest (one percent) in the age group 15-19 years and the highest (five percent) in the age group 40-44 years. However, percentage of never users was 90 percent in the age group 15-19 years that steadily declined to 11 percent in the age group 40 – 44 years.

Further, percentage of women having never used any contraception was 86 percent for women having no surviving children, over 42 percent for women having one surviving child, 13 percent for women having two surviving children and 11 percent for women having three or more surviving children. These data have shown that percentage of women never using contraception decreases with increase in the number of surviving children. In other words, percentage of women using contraception increases with increase in the number of surviving children.

The percentage of women never using contraception was 62 percent for women having no surviving sons as against 36 percent for women having no surviving daughters. ce5.8(e) 003 Tc[(r.7(e)Ce)-0.4()-1.5(,)4421 Twvcon8.93having no se19r m 0.4-6.8su819rv819iv819in81915 T819D -0.19i/65 -1.w3

104 Table 6.7 USE OF CONTRACEPTION BY WOMEN Percentage of currently married women in 15-44 years by current use and ever use of contraception according to selected demographic characteristics, Himachal Pradesh, 2002-04 Percentage of women/ husbands Percentage of women/husbands using by contraceptive status Demographic Any modern1 Any traditional2 Not using any Number of Characteristic method method Any method method Ever used Never used women

Age-group 15-19 8.3 1.4 9.7 90.3 10.2 89.8 104 20-24 30.6 4.3 34.8 65.2 42.4 56.8 1,506 25-29 59.3 3.9 63.2 36.8 71.4 28.3 2,185 30-34 79.7 4.8 84.8 15.1 88.0 11.8 1,912 35-39 81.1 4.8 86.2 13.7 88.1 11.2 1,698 40-44 80.3 5.3 85.9 14.1 88.8 10.8 1,213

Surviving children 0 5.9 1.9 7.8 92.2 13.7 85.9 854 1 42.3 4.7 47.0 52.7 56.7 42.5 1,500 2 76.6 5.5 82.4 17.6 86.9 12.7 3,175 3 or more 81.6 4.1 85.9 14.1 88.6 11.0 3,089

Surviving sons 0 24.4 4.2 28.7 71.3 37.3 61.9 2,002 1 70.8 5.3 76.3 23.6 81.4 18.0 3,749 2 or more 87.1 3.7 91.0 9.0 92.9 7.0 2,867

Surviving daughters 0 54.9 3.5 58.5 41.3 63.1 36.5 3,123 1 70.9 4.7 75.9 24.1 81.1 18.4 3,297 2 or more 72.1 5.6 77.9 22.1 82.7 16.7 2,197

All women 65.4 4.5 70.1 29.8 75.0 24.5 8,618

1 Include Female sterilization, Male sterilization, IUD, Pills and Condom. 2 Include Rhythm/Periodic abstinence, Withdrawal and Other traditional method.

selected demographic characteristics are given in Table 6.8. The current use of any modern method of contraception among the husbands was 29 percent in the age group below 25 years, 53 percent in the age group 25-34 years, 81 percent in the age group 35-44 years and 83 percent in the age group 45 years and above. These data have shown that use of contraception increases steadily with increase in the age of the husband

Further, percentage of husbands having never used contraception was 91 percent for husbands having no surviving children, 46 percent for husbands having one surviving child, 16 percent for husbands having two surviving children and 13 percent for husbands having three and more surviving children. These data have shown that percentage of husbands never using any modern contraception decreases with increase in the number of surviving children. In other words, percentage of husbands using any modern contraception increases with increase in the number of children surviving. The percentage of husbands using any contraception was 29 percent for husbands having no surviving son as against 57 percent for husbands having no surviving daughters. Further, use of any contraception among husbands was 88 percent for husbands having two or more surviving sons as against 74 percent for husbands having two or more surviving daughters. The low level of contraception among husbands having no surviving sons is perhaps due to their desire to have a male progeny.

105 Table 6.8 USE OF CONTRACEPTION BY MEN Percentage of husband of currently married women by current use and ever use of contraception by selected demographic variables, Himachal Pradesh, 2002-04. Demographic Percentage of husbands/women using

Characteristic Any modern1 method Any traditional2 method Any method Not using any method Number of men

Age-group Below 25 28.9 1.9 30.8 69.2 148 25-34 52.8 4.1 57.1 42.7 1,697 35-44 80.8 4.1 84.8 15.1 1,944 45+ 83.2 4.9 88.1 11.9 760

Surviving children 0 6.6 1.0 7.9 91.4 413 1 49.0 4.3 53.3 46.5 754 2 78.6 5.6 84.2 15.8 1,718 3 or more 83.8 3.4 87.2 12.7 1,665

Surviving sons 0 29.0 3.1 32.3 67.3 1,002 1 74.2 5.3 79.5 20.5 1,953 2 or more 87.9 3.5 91.4 8.6 1,595

Surviving daughters 0 56.6 3.2 59.9 39.9 1,592 1 77.0 4.9 81.8 18.1 1,767 2 or more 74.1 4.5 78.4 21.5 1,190

All men 69.1 4.2 73.3 26.6 4,550

1 Include Female sterilization, Male sterilization, IUD, Pills and Condom. 2 Include Rhythm/Periodic abstinence, Withdrawal and Other traditional method.

6.3 Reasons for Not Using Male Methods

The DLHS-RCH asked husbands of currently married women about the contraceptive methods that he or his wife was using currently. The husbands who were not using male methods were further asked the reasons for it. Table 6.9 gives percentage of husbands with their choice of family planning methods and reasons for not using male methods by residence in Himachal Pradesh. Among the husbands interviewed, 63 percent reported their choice of female methods in the state – 67 percent in rural areas and 52 percent in urban areas. The reasons cited for not preferring the male methods are ‘fear of weakness’ (31 percent), ‘female methods are more popular’ (53 percent), ‘lack of sexual pleasure’ (one percent), ‘fear of method failure’ (two percent) and ‘fear of operation’ (over three percent). Only less than one percent husbands reported fear of impotency as one of the reasons for not using male methods. However, there is not much rural-urban differential in the reasons for not using male methods, except in the case of ‘fear of weakness’ and ‘female methods are more popular’.

6.4 Source of Contraceptive Methods

Table 6.10 gives percentage distribution of current users of modern contraceptive methods by method and source of supply in Himachal Pradesh. These services are provided by the government health institutions, private hospitals and clinics, as well as by non-governmental organisations (NGOs). The data shows that 97 percent of the female sterilizations were performed at the government health facility, two percent at private health facility and one percent at other health facility. The female sterilization performed at the government health facility was performed at

106 Table 6.9 REASONS FOR NOT USING MALE METHODS Percentage of husbands with their choice of family planning methods and reasons for not accepting male methods according to residence, Himachal Pradesh, 2002-04 Residence Female method users and reason for not accepting male methods Total Rural Urban

Percentage of husband who have reported female methods 63.2 66.9 51.8

Number of men 3,333 2,521 812

Reasons for not accepting male methods* Fear of impotency 0.3 0.3 0.3 Lack of sexual pleasure 0.6 0.5 0.9 Fear of method failure 1.6 1.6 1.7 Fear of operation 3.3 3.7 1.4 Fear of weakness 31.5 34.7 18.5 Female methods are more popular 53.0 49.2 68.2 Other 11.0 11.2 10.3

Number of men 2,106 1,686 421

* Percentages may add to more than 100.0 because multiple responses could be recorded.

Table 6.10 SOURCE OF MODERN CONTRACEPTIVE METHODS Percent distribution of current users of modern contraceptive methods by method and source of supply, Himachal Pradesh, 2002- 04 Contraceptive method Female Male Condom/ All modern IUD/ Loop Pills 1 Source sterilization sterilization Nirodh methods Government medical centre 97.4 97.8 70.3 52.7 26.0 79.8 Government/Municipal hospital 63.6 60.4 61.6 23.5 12.7 50.8 CHC/PHC 4.1 3.3 5.2 19.8 7.2 5.6 Sub-centre 0.7 0.1 2.2 5.8 2.3 1.3 Government doctor 0.0 0.0 0.0 2.0 1.4 0.4 Government nurse/ ANM 0.0 0.0 1.1 0.9 1.0 0.3 Family planning/RCH camp 28.5 33.9 0.1 0.0 0.1 20.7 Out reach/MCP clinic in village 0.0 0.0 0.0 0.0 0.1 0.0 Mobile clinic 0.4 0.0 0.0 0.7 1.1 0.5

Private medical centre 1.8 0.2 26.2 5.2 0.5 2.4 Private hospital 1.4 0.0 11.3 3.3 0.2 1.4 Private doctor 0.3 0.0 13.7 1.9 0.4 0.8 Private nurse 0.2 0.2 1.1 0.0 0.0 0.2

Chemist NA NA NA 38.4 66.5 15.4 Other 0.7 1.8 3.6 2.8 1.3 1.1 Do not know 0.0 0.3 0.0 0.5 5.4 1.1 Missing 0.1 0.0 0.0 0.4 0.2 0.1

Total percent 100.0 100.0 100.0 100.0 100.0 100.0

Number of users 3,545 455 174 328 1,115 5,617 1 Includes female sterilization, male sterilization, IUD, Pills or condom. Note: CHC: Community health centre, PHC: Primary health centre. NA: Not applicable.

‘Government/Municipal hospital’ (64 percent), ‘CHC/PHC’ (four percent), ‘Sub-Centre’ (one percent) and Family planning/RCH camp/Mobile clinic’ (29 percent). Similarly, 98 percent of male sterilizations were performed at the government health facility, less than one percent at private health facility and two percent at other health facility. Government/Municipal hospitals are the main source for male sterilization (60 percent), CHC/PHC (three percent), Family planning/ RCH camp (34 percent). Among the IUD/Loop users, 70 percent reported the source as government

107 health facility, 26 percent private health centres and four percent other health facility. Fifty-three percent of the Pill users received their supplies and services from the government health facility, five percent from the private health facility, 38 percent from the chemist and three percent from other sources. However, chemist is the main source for condom (66 percent) and 26 percent from government health facility. Further, percentage of current users who received their supply and services from the government health facility was 80 percent, followed by 16 percent chemist and three percent from private health facility and other. These data have shown that eight-tenth of the current users received their supply and services in respect of sterilization and spacing methods from the Government health facility and one-sixth from chemist, while role of private and other health facility was nominal in Himachal Pradesh. Figure 6.3 gives source of family planning among current users of modern contraceptive methods.

Figure 6.3 Source of Family Planning Among Current Users of Modern Contraceptive Methods Other Don't know /missing 1% Chemist 1% 15%

Pr iv ate 2%

Government 81%

Note: Total percent may add more than 100.0 due to rounding Himachal Pradesh, DLHS-RCH, 2002-04

6.5 Problems with Current Use of Contraceptive Methods

Women who were using a modern contraceptive method were asked if they had experienced any problems related with the use of method. Table 6.11 gives percentage of women informed about side effects, had side effects with the use of method in Himachal Pradesh. Only one-third of the women using female sterilization reported having been informed about all the available methods. Further, percentage of women who were informed about the side effect before adoption of the method was 35 percent for female sterilization, 43 percent each for IUD/Loop and Pill. The percentage of women who had side effect/health problem due to use of contraceptive method was 17 percent for female sterilization, 12 percent for IUD/Loop and eight percent for Pill.

The most common problems experienced by sterilized women were 'weakness/inability to work’ (40 percent),’body ache/backache’ (73 percent),’cramps’ (six percent),’weight gain’ (14 percent),’white discharge’ (16 percent),’dizziness’ (19 percent),’irregular periods’ (31 percent),’ nausea or vomiting’ (seven percent),’excessive bleeding’ (13 percent) and ‘spotting’ (three percent). The common problems experienced by women using Pill were ‘weakness or inability to work’ (19 percent),’white discharge’ (19 percent), ‘dizziness’ (35 percent),’body ache or backache’ (13 percent), ‘cramps’ (three percent),’irregular periods’ (26 percent),’nausea/vomiting’ (16 percent), ‘excessive bleeding’ (six percent),’weight gain’ (six percent) and other (48 percent).

108 Table 6.11 HEALTH PROBLEMS WITH CURRENT USE OF CONTRACEPTION Percentage of women informed about side effects, had side effects with the method by use of method, Himachal Pradesh, 2002-04 Type of method Health problems/side effect Female sterilizations IUD/loop Pill

Women who were informed about all the available methods 32.7 N.A N.A

Women who were informed about the side effects before adoption of the method 35.5 43.4 43.3

Women who had side effect/health problem due to use of contraceptive method 16.8 12.0 8.4

Number of current users 3,545 174 328

Type of health problems/side effects1 Weakness/inability to work 39.8 * (19.4) Body ache/ backache 73.3 * (12.9) Cramps 5.7 * (3.4) Weight gain 13.8 * (6.5) Dizziness 18.9 * (35.5) Nausea/vomiting 7.4 * (16.1) Breast tenderness 4.6 * (0.0) Irregular periods 30.8 * (25.8) Excessive bleeding 13.2 * (6.5) Spotting 2.9 * (0.0) White discharge 15.8 * (19.4) Other 0.0 * (0.0)

Number of users with side effects 596 21 28 1 Percentages may add to more than 100.0 because multiple problems could be recorded. () Based on less than 50 unweighted cases * Percentage based on few cases not shown. NA: Not Applicable

6.6 Treatment for Health Problems with Current Use of Contraception

Table 6.12 gives percentage of women who had follow-up visit, satisfied with method of current use and sought treatment of side effect due to use of method in the state. Twenty-four percent users of female sterilization and four percent Pill users had follow up visit by the health worker after adoption of method. The percentage of women who were satisfied with method of current use was 96 percent for users Pills and female sterilization. Further, percentage of women who sought treatment was 61 percent for female sterilization and 45 percent for Pill.

Those women who sought treatment of contraceptive use related problems, 83 percent of them had treatment from government health facility, 19 percent from private health facility, over two percent from ISM facility and one percent from chemist/medical shop, while one percent women sought treatment from other health facility.

6.7 Advice to Non-Users to Use Contraception

Information about non-users who were advised by the ANM/health worker to adopt contraceptives and their future intention to use by preferred method according to their background characteristics are given in Table 6.13. Sixteen percent of the current non-users were advised by ANM/health worker to use any contraceptive method in the state – 15 percent in rural areas and 17 percent in urban areas. Similarly, 12 percent of the current non-users living in villages having no health facility in the village as against 18 percent current non-users living in villages having health facility in the village were advised by the ANM/health worker to use any contraceptive method.

109 Table 6.12 FOLLOW-UP VISIT AND SOUGHT TREATMENT FOR HEALTH PROBLEMS WITH CURRENT USE OF CONTRACEPTION Percentage of women who had follow-up visit, satisfied with method of current use and sought treatment of side effects due to use of method, Himachal Pradesh, 2002-04

Type of method Health problems/side effect Female sterilizations Pill

Women who had follow up visit by health worker after adoption of method 23.7 3.7

Women who are satisfied with method of current use 95.7 95.8

Number of current users 3,545 328

Women who sought treatment for the health problem 61.2 (45.2)

Number of women with side effects 596 28

Source of treatments Government health facility Government hospital/dispensary 76.4 * UHC/UHP/UFWC 0.0 * CHC/Rural hospital 0.9 * PHC 5.2 * Sub-centre 0.5 * Out reach/MCP clinic in village 0.0 *

Private health facility NGO/trust hospital clinic 0.0 * Private hospital/clinic 18.8 *

ISM health facility1 2.3 * Chemist/Medical shop 0.6 * Home remedy 0.0 * Other 0.7 *

Number of women with side effects 365 14

1 Either government or Private. * Percentage not shown: Based on few cases. Note: Total includes 21 cases of women with side effects of contraception and 14 cases of women with side effect treatment for IUD/loop were not shown separately. () Based on less than 50 cases.

The contraceptive methods recommended by the ANM/health worker were female sterilization (33 percent), male sterilization (four percent), IUD/Loop (17 percent), Pill (25 percent) and condom/nirodh (19 percent). Further, more of the women in rural areas than in urban areas were advised to use female sterilization and it was just the reverse in case of male sterilization. More of the women in rural areas than in urban areas were advised to use spacing methods.

6.7.1 Future Intentions

Table 6.14 gives percentage of current non-users who intended to use contraception in future by preferred method according to place of residence. Only one-third of the current non- users women intend to use contraception in future in the state – 33 percent in rural areas and 30 percent in urban areas. On the other hand, over 38 percent of current non-user husbands intend to use contraception in future in the state – 40 percent in rural areas and 32 percent in urban areas.

The percentage of non-user who intend to use in future family planning by preferred method of female sterilization was 67 percent in the state – 70 percent in rural areas and 55 percent in urban areas. Similarly, 58 percent of the husband preferred female sterilization in the state

110 Table 6.13 ADVICE ON CONTRACEPTIVE USE Percentage of current non-users* who were advised by the ANM/health worker to use contraception by suggested method according to place of residence and availability of health facility in the village, Himachal Pradesh, 2002-04 Availability of health Residence 1 facility in the village Advise/future intension to use Total Rural Urban No Yes

Percentage of current non-users advised by ANM/health worker to use of contraceptive method 15.6 15.4 16.6 11.7 18.1

Number of non-users 2,437 1,985 452 822 1,163

Percent distribution of women who were advised by method Female sterilization 33.1 33.5 31.2 39.8 30.7 Male sterilization 4.1 4.6 2.3 3.4 5.1 IUD/loop 17.3 14.4 29.5 7.9 17.3 Pill 25.2 27.2 17.0 24.7 28.4 Condom/Nirodh 19.0 19.3 17.9 22.8 17.7 Rhythmic /periodic abstinence 0.0 0.0 0.0 0.0 0.1 Other 0.8 0.4 2.1 1.4 0.0 Missing 0.4 0.5 0.0 0.0 0.7

Total percent 100.0 100.0 100.0 100.0 100.0

Number of non-users 381 306 75 96 210 * Exclude women in menopause or those who have undergone hysterectomy. 1 Includes sub-centre, primary health centre, community health centre or referral hospital, government hospital, and government dispensary within the village.

Table 6.14 FUTURE INTENTION TO USE Percentage of current non-users* who were intended to use contraception in future by preferred method according to place of residence, Himachal Pradesh, 2002-04

Women Husband Future intention to use/method Total Rural Urban Total Rural Urban

Percentage of respondents who intend to use 32.5 33.2 29.6 38.5 40.3 31.7 contraceptive in future

Number of non-users 2,437 1,985 452 1,175 927 248

Percent distribution of non-user who were preferred to use family methods by preferred method

Female sterilization 67.1 69.7 54.7 57.9 59.4 50.7 Male sterilization 7.5 7.6 7.1 15.4 16.3 11.0 IUD/copper-T/loop 2.6 2.5 3.3 0.8 0.7 1.4 Oral pills 7.0 6.7 8.3 2.3 2.8 0.0 Condom/Nirodh 5.7 4.7 10.4 15.0 14.4 18.2 Rhythm/periodic abstinence 1.7 2.0 0.0 0.2 0.2 0.0 Withdrawal 0.9 0.7 1.8 0.2 0.2 0.0 Other 5.7 4.1 13.4 6.7 4.1 18.7 Missing 1.8 2.0 1.0 1.5 1.8 0.0

Total percent 100.0 100.0 100.0 100.0 100.0 100.0

Number of non-users 790 656 134 446 369 77 * Exclude women who are in menopause or those who have undergone hysterectomy.

59 percent in rural areas and 51 percent in urban areas. In other words, more of women than their husband preferred female sterilization. The percentage of women who intends to use

111 contraception in future preferred male sterilization was over seven percent in the state –eight percent in rural areas and seven percent in urban areas. Similarly, percentage of the husbands who intend to use contraception in future preferred male sterilization was 15 percent in the state – 16 percent in rural areas and 11 percent in urban areas. These data have shown that sterilization- both female sterilization and male sterilization are less preferred in urban areas than in rural areas of Himachal Pradesh. In case of temporary methods, only three percent women as against one percent husbands preferred IUD/Loop. Similarly, seven percent of the women as against only two percent of the husbands preferred Oral pills. On the other hand, six percent of the women as against seven percent of the husbands preferred condom/nirodh. These data have shown that spacing methods are more preferred in urban areas than in urban areas.

6.7.2 Future Intention to Use Among Women by Number of Living Children

Currently married women who were not using any contraceptive method at the time of survey were asked about their intentions to use a method in the future. Those women who intended to use contraceptives in the future were further asked about preferred methods. This type of information helps the programme administrators and policy makers to identify the potential groups of future users and to provide the type of contraceptives that are likely to be in demand. Table 6.15 gives percent distribution of currently married women who were currently not using any contraceptive method by intention to use in future according to number of living children and residence in the state. Among the current non-users, 14 percent of the women intended to use contraception within the next twelve months, eight percent women wanted to use it within one to two years, while one- tenth of the women intended to use contraceptives after more than two years. Thirty-five percent of the women are not sure of their intention to use in future, where as 32 percent women had no intention to use it future. The percentage of women who intended to use contraception in the nest 12 months increases from four percent for women having no living children to 25 percent for women having four or more living children. On the other hand, percentage of women who said ‘not yet decided’ steadily declines from 49 percent for women having no surviving children to 14 percent for women having four or more living children. Further, 32 percent of the women having no living children who said ‘does not intend to use contraception in future’ appears to be more for reasons other than family planning. Further, percentage of women who intended to use contraception after two years decreases with increase in the number of living children.

6.8 Reasons for Discontinuation and Non-Use of Contraception

Currently married non-pregnant women who were not using any contraceptive method at the time of survey were categorised as past users and never users according to their contraceptive experience. Women who had discontinued contraceptive use were asked about the main reason for discontinuation. The women who had never used contraceptives were also asked about the main reason for not doing so. Table 6.16 gives percentage distribution of women who were past- users by reason for discontinuation of the contraceptive method by residence in Himachal Pradesh. Wanted child was the main reason reported by 57 percent of the past-users who discontinued use of contraception in the state – 55 percent in rural areas and 65 percent in urban areas. Other reasons reported by the past-users who discontinued use of contraceptive method were ‘method failed/became pregnant’ (five percent), ‘supply not available’ (two percent), ‘weakness/inability to work’ (two percent),‘irregular periods’ (over two percent),’dizziness’

112 Table 6.15 FUTURE USE OF CONTRACEPTION BY NUMBER OF LIVING CHILDREN Percent distribution of currently married women1 who were not currently using any contraceptive method by intention to use in the future, according to number of living children and residence, Himachal Pradesh, 2002-04 Number of living children Total Intention to use in the future 0 1 2 3 4+ Total

Intends to use in next 12 months 3.9 12.8 23.6 18.7 24.9 13.6 One to two years 2.4 11.2 12.9 12.6 8.2 8.7 More than two years 12.2 12.4 8.8 5.4 1.0 10.2 Does not intend to use 32.3 29.8 28.0 39.1 50.7 32.4 Not yet decided 49.1 33.7 26.5 24.2 14.4 35.0 Missing 0.0 0.0 0.1 0.0 0.9 0.1

Total percent 100.0 100.0 100.0 100.0 100.0 100.0

Number of women 773 765 520 221 159 2,437

Rural

Intends to use in next 12 months 4.1 13.9 24.9 16.7 26.1 14.2 One to two years 2.4 10.4 14.5 14.0 8.4 8.9 More than two years 12.3 13.5 8.2 4.5 1.0 10.2 Does not intend to use 32.2 27.0 24.5 39.7 49.6 31.1 Not yet decided 49.0 35.2 27.7 25.0 14.9 35.6 Missing 0.0 0.0 0.1 0.0 0.0 0.0

Total percent 100.0 100.0 100.0 100.0 100.0 100.0

Number of women 637 592 409 196 151 1,985

Urban

Intends to use in next 12 months 3.3 9.2 18.9 (28.6) * 11.0 One to two years 2.2 14.1 7.1 (2.9) * 7.9 More than two years 12.1 8.6 11.1 (11.4) * 10.3 Does not intend to use 32.8 39.5 40.9 (37.1) * 38.1 Not yet decided 49.7 28.6 22.0 (20.0) * 32.3 Missing 0.0 0.0 0.0 (0.0) * 0.3

Total percent 100.0 100.0 100.0 100.0 100.0 100.0

Number of women 136 173 110 25 9 452

( ) Based on less than 50 unweighted cases. * Percentage not shown based on very few cases.1 Exclude women who are in menopause or those who have undergone hysterectomy.

(over one percent),‘method was inconvenient’ (one percent) and other reasons (25 percent). Method failure/become pregnant was reported by six percent past-users in rural areas and less than one percent in urban areas as reason for discontinuing contraception.

6.8.1 Reasons for Not Using Contraceptive Methods

Table 6.17 gives percentage of current non-users who were currently not using contraceptive method by reason according to place of residence. ‘Lack of knowledge about family planning method’ was reported by one percent women as against nine percent husband as reason for not using contraceptive method. More husbands than women were not having knowledge about family planning, particularly in rural areas. Similarly, ‘health does not permit’ was reported by 19 percent women as against over three percent husband as reason for not using contraceptive method.

113 Table 6.16 REASONS FOR DISCONTINUATION OF CONTRACEPTION Percent distribution of women who were past users (current non-users) by reason for discontinuation of the contraceptive method according to place of residence, Himachal Pradesh, 2002-04 Place of residence Reasons Total Rural Urban

Reason for discontinuation Wanted child 57.1 55.0 64.9 Method failed/became pregnant 4.8 6.0 0.4 Supply not available 1.8 2.3 0.0 Difficult to get method 0.2 0.2 0.0 Weakness/inability to work 2.1 2.3 1.5 Body ache/ Backache 0.8 0.8 0.7 Cramps 0.0 0.0 0.0 Weight gain 0.9 0.9 0.7 Dizziness 1.3 0.2 5.1 Nausea/vomiting 0.2 0.2 0.0 Breast tenderness 0.0 0.0 0.0 Irregular periods 2.4 0.8 8.2 Excessive bleeding 0.1 0.0 0.5 Spotting 0.2 0.0 1.1 White discharge 0.6 0.8 0.0 Lack of pleasure 0.3 0.0 1.3 Method was inconvenient 1.0 0.1 4.3 Other 24.6 28.5 10.4 Missing 1.5 1.7 0.9

Total percent 100.0 100.0 100.0

Number of past users 420 331 90

Table 6.17 REASON FOR NOT USING CONTRACEPTIVE METHOD Percentage of current non-users* who were currently not using contraceptive method by reason according to place of residence, Himachal Pradesh, 2002-04 Women Husband* Reason Total Rural Urban Total Rural Urban

Lack of Knowledge about FP method 1.0 1.3 0.0 8.6 10.9 1.4 Against the Religion 0.9 1.1 0.0 1.9 2.3 0.8 Opposed to family planning 5.1 5.7 2.3 2.3 2.7 1.1 Not like existing method 1.0 1.1 0.6 1.7 1.0 3.9

Afraid of sterilization 0.6 0.6 0.9 0.0 0.0 0.0 Can not work after sterilization 0.1 0.1 0.0 0.2 0.2 0.0 Worry about side effects 3.7 3.5 4.3 0.2 0.3 0.0 Costs too much 1.7 1.8 1.0 0.3 0.2 0.9 Health does not permit 18.6 18.3 20.2 3.5 3.6 3.2 Hard/inconvenient to get method 0.1 0.1 0.5 0.1 0.2 0.0 Inconvenient to use method 0.8 0.6 1.6 1.8 2.1 1.0 Difficult to become pregnant 5.3 5.7 3.4 2.4 2.9 1.0 Wife is pregnant1 - - - 0.9 1.2 0.0 Other 60.2 59.3 64.2 18.8 19.0 18.1 Missing 0.9 0.9 1.0 57.2 53.6 68.6

Total percent 100.0 100.0 100.0 100.0 100.0 100.0

Number of women 1,026 843 183 418 317 101

1 Not applicable for women. * Excluding not decided cases on timing of next child.

Other reasons reported by women for not using contraceptives methods were ‘against religion’ (one percent),‘difficult to become pregnant’ (five percent),‘opposed to family planning’ (five percent), ‘not like existing method’ (one percent),‘worry about side effect’ (four percent),’other’ (60

114 percent). Similarly, other reasons reported by husband for not using contraceptives methods were ‘against religion’ (two percent),‘difficult to become pregnant’ (over two percent),‘opposed to family planning’ (over two percent),‘not like existing method’ (two percent),‘inconvenient to use method’ (one percent) and ‘other’ (19 percent).

6.9 Unmet Need for Family Planning Services

Unmet need for family planning is one of the indicators to assess the effectiveness of the family planning programme. Policy makers and family planning programme planners use this to know the demand for family planning services/supplies. Unmet need is defined in this report separately for limiting and spacing. Unmet need for spacing includes the proportion of currently married women who are neither in menopause nor had hysterectomy nor are currently pregnant and who want more children after two years or later and are currently not using any family planning method. The women who are not sure about whether and when to have next child, are also included in unmet need for spacing. The women who are not sure about the timing of the next child are also included in the unmet need for spacing. Unmet need for limiting includes the proportion of currently married women who are neither in menopause nor had hysterectomy nor are currently pregnant and do not want any more children but are currently not using any family planning method. Total unmet need refers to the totality of unmet for limiting and spacing.

Table 6.18 gives percentage of currently married women with unmet need for family planning services by selected background characteristics in the state. The unmet need of women for spacing was the highest (19 percent) for women below 20 years, for limiting it was the highest (10 percent) for women aged 25-29 years. The unmet need for spacing decreases from 19 percent for women below 20 years to less than one percent for women aged 35 years and above. The unmet need for limiting family increases from about one percent for women below 20 years to 10 percent for women aged 25-29 years and thereafter declines to seven percent. Total unmet need for family planning decreases from 20 percent for women below 20 years to over 14 percent for women aged 25-29 years and thereafter declines to eight percent.

The unmet need of women for family planning was over 12 percent in rural areas and 10 percent in urban areas. The unmet need for family planning was higher (13 percent) among women who had studied for 10 years and above than among non-literate women (10 percent), while it was over 11 percent for women who had studied for 0-9 years. The unmet need for family planning was 12 percent for women with medium SLI as against 11 percent for women with high SLI and 13 percent for women with low SLI. Further, unmet need for family planning was 10-12 percent irrespective of religion of the women. Unmet need for family planning was the highest (16 percent) for scheduled tribe women, followed by 12 percent for scheduled caste women and the lowest (nine percent) for other backward class women. The unmet need for family planning was the highest (20 percent) for women with one living child, followed by 12 percent for women with two living children and the lowest (five percent) for women having no living children.

6.9.1 Unmet Need for Family Planning Services by Districts

Table 6.19 gives percentage of currently married women with unmet need for family planning by district. The unmet need for family planning was 12 percent – over three percent for spacing of family and over eight percent for limiting of family. The unmet need for spacing of family was

115 Table 6.18 UNMET NEED FOR FAMILY PLANNING SERVICES Percentage of currently married women with unmet need for family planning services by selected background characteristics, Himachal Pradesh, 2002-04 Unmet need for FP Background Characteristic Spacing1 Limiting2 Total Number of women

Age 15-19 19.2 0.6 19.9 104 20-24 9.6 8.8 18.4 1,506 25-29 4.3 10.2 14.5 2,185 30-34 1.0 7.0 8.1 1,912 35-39 0.5 7.8 8.4 1,698 40-44 0.5 8.5 9.0 1,213

Residence Rural 3.8 8.7 12.4 6,748 Urban 2.1 7.7 9.7 1,870

Education Illiterate 2.9 7.4 10.2 1,874 0-9 @ years 2.4 9.1 11.5 3,326 10 years and above 4.6 8.4 13.0 3,415

Religion Hindu 3.4 8.4 11.9 8,267 Muslim 4.1 7.7 11.7 124 Sikh 0.3 10.2 10.6 156 Buddhist 2.7 8.3 11.1 54

Caste/tribe# Scheduled caste 3.4 8.7 12.1 1,876 Scheduled tribe 3.7 12.2 15.9 348 Other backward class 3.1 6.2 9.3 856 Others 3.4 8.4 11.8 5,524

Number of living children 0 3.6 1.7 5.3 854 1 13.3 6.7 19.9 1,500 2 1.3 10.3 11.7 3,175 3 0.6 8.5 9.1 1,970 4+ 0.6 10.5 11.1 1,119

Standard of living Index Low 4.2 9.0 13.3 1,888 Medium 3.4 8.5 11.9 3,583 High 2.9 8.0 10.9 3,147

All women 3.4 8.4 11.8 8,618

1 Unmet need for spacing includes the proportion of currently married women who are neither in menopause or had hysterectomy nor are currently pregnant and who want more children after two years or later and are currently not using any family planning method. The women who are not sure about whether and when to have next child are also included in unmet need for spacing. 2 Unmet need for limiting includes the proportion of currently married women who are neither in menopause or had hysterectomy nor are currently pregnant and do not want any more children but are currently not using any family planning method. Note: Total unmet need refers to unmet for limiting and spacing. @ Literate women with no years of schooling are also included. # The total figure may not add to N due to do not know and missing cases. Total includes 18 cases for other religion and 3 with missing information on education who were not shown separately. the highest (six percent) in Sirmaur district, followed by five percent in Lahul & Spiti district and the lowest (two percent) in Bilaspur district. The unmet need for spacing of family was higher than that of the state (over three percent) in Chamba, Hamirpur, Kangra, Kinnaur, Lahul & Spiti, Shimla and Solan districts and in the remaining five districts it was lower than that of the state.

116 Similarly, unmet need for limiting family was the highest (17 percent) in Una district, followed by over 10 percent in Hamirpur district and the lowest (over four percent) in Kullu district. The unmet need for limiting family was higher than that of the state (over eight percent) in Bilaspur, Chamba, Hamirpur and Una districts and in the remaining eight districts it was lower than that of the state. Further, unmet need for family planning was the highest (20 percent) in Una district, followed by 14 percent in Hamirpur district and the lowest (seven percent) in Kullu district. The unmet need for family planning was higher than that of the state (12 percent) in Bilaspur, Chamba, Hamirpur, Kinnaur, Sirmaur and Una district and in the remaining six districts it was lower than that of the state.

Table 6.19 UNMET NEED BY DISTRICT Percentage of currently married women with unmet need by district, Himachal Pradesh, 2002-04

Unmet need for Districts Spacing Limiting Total

Bilaspur 2.0 10.1 12.1 Chamba 4.4 9.1 13.5 Hamirpur 3.9 10.5 14.3 Kangra 3.5 7.9 11.4 Kinnaur 4.5 8.3 12.9 Kullu 2.8 4.4 7.2

Lahul & Spiti 4.8 6.9 11.6 Mandi 2.9 7.1 10.0 Shimla 3.5 5.2 8.7 Sirmaur 6.0 6.4 12.4 Solan 2.5 8.3 10.9 Una 3.0 16.9 19.9

Himachal Pradesh 3.4 8.4 11.8

117 Map-6

Current Use of Any Family Planning Method

118 CHAPTER VII

ACCESSIBILITY AND PERCEPTION ABOUT GOVERNMENT HEALTH FACILITIES

The government health facilities at all the levels provide various RCH services. Auxiliary Nurse Midwife (ANM), family planning worker or male health worker play a key role in delivering the services to the community. Health workers are expected to make regular visits to all the households in their assigned area. During these contacts, the health workers are supposed to monitor various aspects of the health of women and children, provide information related to health and family planning, counsel and motivate to adopt appropriate health and family planning practices, and deliver other selected services. These contacts are also important as they enhance the creditability of services and establish necessary rapport with the clients. In order to assess the extent of utilisation of government health facilities by all eligible women and to find out whether ANM/health workers reach the households for providing RCH services, a separate section in the women’s questionnaire was canvassed to all the eligible women. This chapter deals with the accessibility and the opinion of women about the services provided by the government health workers. The quality of services offered by the government health programme as perceived by currently married women is also presented.

7.1 Home Visit by Health Workers

Table 7.1 gives percentage of women who had home visit by a doctor or male health worker in the three months prior to the survey, among women who had home visit, satisfied with time spent by health workers and with services provided by selected background characteristics in the state. Over five percent of the women reported that the health worker visited them at their residence at least once in last three months preceding the survey. Four percent of women in the age group 15-24 years reported at least one home visit compared to five percent women in the age group 25 years and older. The percentage of women who were home visited by the health worker was over five percent in rural areas as against two percent in urban areas. Further, the health worker home visited four percent of non-literate women as against over five percent of women who had studied for 0-9 years, while it was over four percent for women who had studied for 10 years and above. Again, the health worker home visited over five percent of women with medium SLI as against four percent of women with low and high SLI. More Hindu women (five percent) than Muslim women (four percent) reported home visits by the health worker, while it was over three percent for Buddhist women. Ten percent of the other backward class women, followed by other caste women (four percent) and the lowest (over two percent) scheduled tribe women were home visited by the health worker. The health worker home visited four percent of women living in villages having no health facility in the village as against six percent of women living in villages having health facility in the village.

Women who reported home visit during three months preceding the survey were asked who visited their household and whether they were satisfied with the kind of services/ advice received, and the time spent by these health workers. Eighty-two percent of the women received services from ANM/LHV, 9 percent from male health worker and 12 percent from the doctor. Sixty-eight percent women who received services at home were satisfied with the time spent with them and 92 percent women were satisfied with services/advices given to them. Table 7.1 HOME VISIT BY HEALTH WORKER Percentage of women who had home visit by a doctor, ANM/LHV, or male health worker in the 3 months preceding the survey, among women who had home visit, satisfied with time spent by health workers and with services provided by selected background characteristics, Himachal Pradesh, 2002-04 Percentage of women 1 Percentage Home visit by satisfied with with home Number of ANM / Male health Amount Services/ Number of Background characteristic visit women Doctor LHV worker of time advices women

Age 15.24 3.6 1,610 13.9 77.7 8.4 66.9 88.1 57 25-34 5.0 4,097 11.7 82.4 11.7 70.9 92.8 203 35-44 4.6 2,911 11.4 84.4 5.8 63.4 93.4 135

Residence Rural 5.3 6,748 12.0 81.7 9.8 69.0 92.8 357 Urban 2.0 1,870 (7.9) (92.1) (5.3) (50.0) (86.8) 38

Education Non-literate 3.7 1,874 13.8 74.1 14.1 52.7 87.9 69 0-9@ years 5.4 3,326 9.9 83.9 8.4 71.3 95.3 179 10 and above 4.3 3,415 13.7 84.3 8.1 70.1 90.6 146

Religion Hindu 4.7 8,267 12.2 82.4 8.9 68.2 92.2 386 Muslim 4.2 124 * * * * * 5 Sikh 1.4 156 * * * * * 2 Buddhist 3.3 54 * * * * * 2

Caste/tribe# Scheduled caste 3.4 1,876 13.0 79.2 13.8 52.7 87.5 64 Scheduled tribe 2.3 348 * * * * * 8 Other backward class 10.2 856 5.4 94.1 0.8 69.7 95.5 88 Other 4.3 5,524 13.9 79.0 11.1 70.2 92.3 236

Standard of living index Low 4.0 1,888 6.1 75.4 18.9 63.1 84.3 75 Medium 5.5 3,583 10.6 85.4 7.2 69.9 97.0 198 High 3.9 3,147 17.6 81.9 6.5 67.0 89.5 123

Availability of health facility2 in the village No 4.2 2,735 11.9 76.9 16.2 66.1 91.1 116 Yes 6.0 4,013 12.1 84.0 6.7 70.4 93.6 242

Total 4.6 8,618 11.9 82.4 9.2 67.7 92.3 395

Note: Total includes 3 women with missing information on education, 18 cases of other religion were not shown separately. * Percentage not shown: Based on few cases.. 1 Percentage add to more than 100.0 due to multiple responses. @ Literate mother with no years of schooling are included. # Total number may not add to N due to do not know and missing cases. 2 Includes sub-center, primary health center, Community health center or referral hospital, government hospital, and government dispensary within the village. ( ): Based on less than 50 unweighted cases.

The percentage of women home visited by the doctor was 14 percent for non-literate and women who had studied for 10 years and above and 10 percent for women who had studied for 0-9 years. The percentage of women home visited by the doctor was the highest (18 percent) for women with high SLI and the lowest (six percent) for women with low SLI, while it was 11 percent for women with medium SLI. Further, percentage of women who were satisfied with the advice and service rendered by the health workers during home visit was the highest (95 percent) for women who had studied for 0-9 years and the lowest (88 percent) for non-literate women, while it was 91 percent for women who had studied for 10 years and above. Similarly, percentage of women who were satisfied with the advice and service rendered by the health workers during home visit was the highest (97 percent) for women with

120 medium SLI and the lowest (84 percent) for women with low SLI, while it was 89 percent for women with high SLI. More than 91 percent of the women living in village, irrespective of the status of health facility in the village, were satisfied with the advice and services rendered to them during home visit.

7.2 Home Visit by Health Workers by Districts

Table 7.2 gives percentage of women who were home visited by a doctor, ANM/LHV, male health worker during three months preceding the survey and were satisfied with time spent by health worker and with advice and services rendered to them by district. The percentage of women home visited was the highest (12 percent) in Sirmaur district, followed by seven percent in Kangra district and the lowest (two percent) in Solan and Una district. The percentage of women who were home visited by the doctor was higher than that of the state (12 percent) in Bilaspur, Kullu, Mandi and Una districts, while in eight districts it was lower than that of the state. Further, percentage of women who were home visited by the ANM/LHV was the highest (100 percent) in Lahul & Spiti district, followed by 95 percent in Mandi district and the lowest (36 percent) in Kullu district. The percentage of women who were home visited by the ANM/LHV was higher than that of the state (82 percent) in Chamba, Hamirpur, Kangra, Kinnaur, Lahul & Spiti, Mandi, Shimla and Solan districts, while in four districts it was lower than that of the state. The percentage of women who were home visited by the health worker was higher than that of the state (10 percent) in Bilaspur, Chamba, Kullu and Sirmaur districts, while in eight districts it was lower than that of the state.

The extent of women who were satisfied with time spent by the health worker during home visit was the highest (100 percent) in Lahul & Spiti and Shilma districts and the lowest (37 percent) in Sirmaur district. The extent of women who were satisfied with time spent by the health worker was higher than that of the state (68 percent) in Bilaspur, Chamba, Hamirpur, Kinnaur, Lahul & Spiti, Mandi, Shimla, Solan and Una districts, while in three districts it was lower than that of the state. The extent of women who were satisfied with advice/services given by the health worker during home visit was lower than that of the state (93 percent) in Hamirpur, Kinnaur, Kullu and Mandi districts, while in the remaining eight districts it was higher than that of the state. Figure 7.1 gives distribution of districts by home visit by health worker.

Figure 7.1 Distribution of Districts by Home Visit by Health Worker 20 & above 2 districts 16.6%

10-19.9 2 districts Below 10 16.6% 8 districts 67.7%

Himachal Pradesh, DLHS-RCH, 2002-04

121 Table 7.2 HOME VISIT BY HEALTH WORKER BY DISTRICT Percentage of women who had home visit by a doctor, ANM/LHV, or male health worker in the 3 months preceding the survey, among women who had home visit, satisfied with time spent by health workers and with services provided by district, Himachal Pradesh, 2002-04 Percentage of women 1 Percentage with Home visit by satisfied with District home visit Doctor ANM / LHV Male health worker Time spent Service

Bilaspur 4.9 26.8 66.2 16.7 74.7 96.4 Chamba 3.4 (0.0) (88.3) (11.7) (76.1) (95.4) Hamirpur 7.1 6.3 93.1 0.7 93.7 87.5 Kangra 6.6 9.4 90.6 4.1 54.5 95.1 Kinnaur 1.8 (0.0) (88.9) (0.0) (80.0) (78.9) Kullu 2.2 (18.1) (36.2) (45.7) (54.3) (81.1)

Lahul & Spiti 5.1 0.0 100.0 0.0 100.0 100.0 Mandi 3.4 (13.6) (94.6) (3.4) (70.7) (71.3) Shimla 2.4 (6.2) (87.7) (8.7) (100.0) (100.0) Sirmaur 11.9 5.8 72.9 24.2 37.2 95.6 Solan 1.7 (7.4) (92.6) (0.0) (80.1) (100.0) Una 1.7 (51.2) (40.9) (7.9) (80.0) (93.9)

Himachal Pradesh 4.6 11.9 82.4 9.2 67.7 92.3 1 Percentage add to more than 100.0 due to multiple responses. ( ) Based on less number of cases.

7.3 Matters Discussed during Home visits or Visits to Health Facilities

Women who were visited at home by a family planning worker, as well as those who visited government or other health facility during three months preceding the survey were asked about the different topics discussed with the workers during any of these visits. Table 7.3 gives percentage of women who were visited by health worker during three months preceding the survey, and percentage of women who visited health facility and percentage of women who discussed specific topics with the health worker in the state.

The percentage of pregnant women or women with children born during reference period who were home visited by the health worker said that the main topics discussed were ‘family planning’ (23 percent),’supplementary feeding’ (three percent),’immunization’ (38 percent), ‘nutrition’ (one percent),’disease prevention’ (15 percent),’treatment of health problem’ (over three percent),’antenatal care’ (over three percent),’delivery care’ (one percent),’postpartum care’ (three percent),’child care’ (15 percent),’sanitation/cleanliness’ (four percent) and ‘oral rehydration’ (one percent). The percentage of women currently using contraception who were home visited by the health worker said that main topics discussed were ‘family planning’ (31 percent),’immunization’ (22 percent),’ disease prevention’ (29 percent),’treatment of health problem’ (14 percent),’childcare’ (seven percent),’sanitation/cleanliness’ (seven percent) and ‘other’ (33 percent). The percentage of women currently not using contraception who were home visited by the health worker said that main topics discussed were’family planning’ (29 percent),’immunization’ (19 percent),’disease prevention’ (10 percent),’treatment of health problem’ (three percent),’oral rehydration’ (three percent) and other (35 percent). However, women who were home visited by the health worker said that main topics discussed were ‘family planning’ (28 percent),’breastfeeding’ (one percent),’supplementary feeding’ (over one percent), ‘immunization’ (28 percent),’nutrition’ (one percent),’disease prevention’ (22 percent),’treatment of health problem’ (nine percent),’antenatal care’ (two percent),’delivery care’ (one percent),’child- care’ (nine percent),’sanitation/cleanliness’ (five percent),’oral rehydration’ (over one percent) and other (28 percent).

122 Table 7.3 MATTER DISCUSSED DURING CONTACT WITH A HEALTH WORKER Percentage of women who were visited by health worker in the three months preceding the survey, and percentage of women who visited health facility, and the percentage of women1 who discussed specific topics with the health worker, Himachal Pradesh , 2002-04

Pregnant women or Other women Topic discussed women with children Current Current after reference period2 contraceptive users nonusers Total

During home visit Family planning 22.7 31.3 (29.0) 28.4 Breastfeeding 0.0 1.5 (0.0) 0.8 Supplementary feeding 2.7 0.9 (0.0) 1.5 Immunization 37.9 21.8 (19.4) 27.8 Nutrition 1.2 0.7 (0.0) 0.8 Diseases prevention 15.3 28.8 (9.7) 22.2 Treatment of health problem 3.3 14.1 (3.2) 9.2 Antenatal care 3.3 1.1 (0.0) 1.8 Delivery care 0.7 0.9 (0.0) 0.8 Postpartum care 3.1 0.9 (0.0) 1.6 Childcare 14.7 6.9 (0.0) 9.2 Sanitation / cleanliness 3.7 7.1 (0.0) 5.3 Oral rehyderation 0.9 1.8 (3.2) 1.4 Other 17.8 33.4 (35.5) 27.6

Number of women 143 220 31 395

During visit to health facility

Family planning 4.5 1.9 0.0 3.2 Breastfeeding 0.6 0.0 0.0 0.3 Supplementary feeding 1.0 0.0 0.0 0.6 Immunization 25.0 0.6 2.1 14.6 Nutrition 1.2 0.4 1.5 1.0 Diseases prevention 9.8 45.4 39.3 24.7 Treatment of health problem 13.3 45.2 48.0 27.4 Antenatal care 39.3 0.3 0.3 22.4 Delivery care 6.2 0.1 1.4 3.6 Postpartum care 2.8 0.0 0.5 1.6 Childcare 7.5 4.4 5.1 6.2 Sanitation / cleanliness 0.2 0.2 0.0 0.2 Oral rehyderation 0.5 0.4 0.0 0.4 Other 3.0 6.5 9.1 4.7

Number of women 894 559 122 1,577 Note: Percentage add to more than 100.0 due to multiple responses. 1 Women who visited private health facility are not included. 2 Reference period for phase I, January 1st 1999 and for phase II, January 1st .2001 ( ) Based on less than 50 unweighted cases

The percentage of pregnant women or women with children born during the reference period who visited health facility said that main topic discussed were ‘family planning’ (over four percent),’breastfeeding’ (one percent),’supplementary feeding’ (one percent),’ immunization’ (25 percent),’nutrition’ (one percent),’disease prevention’ (10 percent),’treatment of health problems’ (13 percent),’antenatal care’ (39 percent),’delivery care’ (six percent),’postpartum care’ (three percent) and ’childcare’ (seven percent). The percentage of women currently using contraception who visited health facility said that main topics discussed were ‘family planning’ (two percent),’immunization’ (one percent),’disease prevention’ (45 percent),’treatment of health problem’ (45 percent) and ‘childcare’ (over four percent). The percentage of women currently not using contraception who visited health facility said that the main topics discussed were ‘immunization’ (two percent),’nutrition’ (over one percent),’disease prevention’ (39 percent),’treatment of health problem’ (48 percent),’delivery care’ (over one percent) and ‘childcare’ (five percent). However, women who visited health facility said that the main topics

123 discussed were ‘family planning’ (three percent),’supplementary feeding’ (one percent), ‘immunization’ (15 percent),’disease prevention’ (25 percent),’treatment of health problem’ (27 percent),’antenatal care’ (22 percent),’delivery care’ (four percent),’postpartum care’ (two percent) and ‘childcare’ (six percent). It is surprising to find that family planning was not discussed with current non-users.

7.4 Visit to Health Facility

Table 7.4 gives percentage of women who needed to visit health facility and visited, and percent distribution of women visiting health facility by type of health facility and according to place of residence and availability of health facility in the village. The percentage of women who needed to visit health facility and visited it was 24 percent in the state irrespective of residence. The percentage of women who needed to visit health facility and visited was 22 percent for women living in villages having no health facility in the village as against 26 percent women living in villages having health facility in the village. The percentage of women who needed to visit health facility and not visited it was over four percent in the state – five percent in rural areas and three percent in urban areas. The percentage of women who needed to visit health facility and visited the government health facility was 74 percent, 23 percent visited private health facility and over two percent ISM and other health facility. There is rural-urban difference in the use of health facility.

Table 7.4 VISIT TO HEALTH FACILITY Percentage of women who need to visit health facility and visited, and percent distribution of women visited health facility by type of health facility and according to place of residence and availability of health facilities in the village, Himachal Pradesh, 2002-04 Availability of health facility1 in Residence the village Health facility Total Rural Urban No Yes

Percentage of women who needed to 4.4 4.7 3.2 4.1 5.2 visit health facility and not visited

Percentage of women who needed to 24.2 24.3 23.9 22.0 25.9 visit health facility and visited

Number of women 8,618 6,748 1,870 2,735 4,013

Government health facility Hospital / CHC / FRU /RH 56.5 54.1 65.5 55.6 53.2 Dispensary 8.6 9.4 5.6 7.1 10.7 Primary health center 8.3 10.3 0.6 11.4 9.7 Sub-center 0.8 0.9 0.4 1.0 0.9

Private health facility Hospital 20.1 20.4 19.0 19.2 21.1 Dispensary 3.2 2.9 4.3 3.2 2.7

ISM2 hospital/dispensary 1.8 1.0 4.7 0.8 1.1

Other 0.7 0.9 0.0 1.5 0.6

Total percent 100.0 100.0 100.0 100.0 100.0

Number of women 2,083 1,636 447 601 1,035 Note: CHC: Community health center, FRU: First referral unit, RH: Referral Hospital 1 Includes sub-center, primary health center, Community health center or referral hospital, government hospital, and government dispensary within the village 2 Either government or private health facility of Indian System of Medicine

124 7.5 Visit to Health Facility by Districts

Table 7.5 presents the percentage of currently married women who needed to visit health facility and visited the health facility by districts. The percentage of women who needed to visit health facility but not visited it was the highest (13 percent) in Sirmaur district, followed by 12 percent in Kullu district and the lowest (over one percent) in Hamirpur district, while it was over four percent for the state. The percentage of women who needed to visit health facility and visited it was the highest (39 percent) in Sirmaur district, followed by 38 percent in Kangra and Kinnaur districts and the lowest (13 percent) in Una district, while it was 24 percent for the state. The percentage of women who needed to visit health facility and visited government health facility was the highest (95 percent) in Lahul & Spiti district, followed by 90 percent in Hamirpur district and the lowest (71 percent) in Kangra district, while it was 75 percent for the state. The percentage of women who needed to visit health facility and visited private health facility was the highest (29 percent) in Kangra district, followed by 28 percent in Chamba district and the lowest (four percent) in Lahul & Spiti district, while it was 24 percent for the state.

Table 7.5 VISIT TO HEALTH FACILITY BY DISTRICT Percentage of women who needed to visit health facility, but not visited and percentage of women who visited health facility by type of health facility by district, Himachal Pradesh, 2002-04 Percentage of women Percentage of women Percentage of women who visited to who need to visit health who need to visit health Government Private health facility facility, but not visited facility and visited Districts health facility

Bilaspur 7.7 25.4 86.8 12.7 Chamba 3.6 30.6 71.5 27.9 Hamirpur 1.5 17.2 89.8 9.9 Kangra 1.7 38.0 70.9 28.7 Kinnaur 8.2 38.0 85.6 14.1 Kullu 12.3 14.1 84.9 15.1

Lahul & Spiti 3.4 22.3 95.1 3.6 Mandi 1.9 20.4 78.6 20.7 Shimla 6.5 14.5 77.4 21.6 Sirmaur 12.9 39.5 77.6 19.4 Solan 1.7 17.9 72.4 27.1 Una 3.4 12.9 78.2 20.8

Himachal Pradesh 4.4 24.2 75.0 24.2

7.6 Client’s Perception of Quality of Government Health Services

Utilization of services is an essential indicator reflecting the quality of services. Better quality of services would have a higher utilization rate, which is very important from the policy point of view. Unless clients are satisfied with the services provided by the government, efforts made by the government will be wasted. In order to assess the utilization of government health facilities, a question was asked whether they had visited any health facility for their health problem during past three months to the survey. Those who visited the government health facility were asked their perceptions about quality of services, (personal manner like courtesy, respect, sensitivity, and friendliness of the physician and staff, technical skills and quality like thoroughness, carefulness, and competence and waiting time for receiving the services) and the same is presented in Table 7.6. Women who visited government health facility and rated quality and availability of services as good and excellent were ‘convenience of the health facility

125 location’ (81 percent), ‘length of time spent towards waiting’ (72 percent), ‘personal manner of the physician’ (95 percent), ‘technical skills and quality of the physician’ (95 percent), ‘personal manner of nurse’ (95 percent), ‘technical skills and quality of nurse’ (96 percent), ‘personal manner of other staff’ (96 percent), ‘technical skills and quality of other staff’ (94 percent), ‘explanation of what was done to her’ (96 percent), ‘medical, surgical and diagnostic equipment’ (85 percent) and ‘general comfort’ (94 percent). These data have shown that the respondents, who visited government health facility, were generally satisfied with the services and facilities, including general comfort, available there.

Table 7.6 QUALITY OF GOVERNMENT HEALTH FACILITY Percentage of women who visited government health facility and rated quality and availability of services during most recent visit to a government health facility in the three months proceeding the survey, Himachal Pradesh, 2002-04 Quality indicator Poor Good Excellent The convenience of the health facility location 19.0 65.4 15.2 Length1 of time spend towards waiting 27.2 60.1 12.3 Personal manner2 of the physician5 4.4 88.1 7.2 The technical skills and quality3 of the physician5 4.2 88.3 7.1 Personal manner2 of nurse 4.9 90.0 4.8 The technical skills and quality3 of nurse 3.1 83.9 12.8 Personal manner of other staff5 3.7 83.7 12.4 The technical skills and quality of other4 staff 5.6 89.5 4.7 The explanation of what was done to her 3.3 83.0 13.4 Medical, surgical and diagnostic equipment 14.6 82.0 3.0 General comfort 5.5 92.5 1.6 1 Poor indicate long waiting time, good indicate average waiting time, and excellent indicate short waiting time 2 Courtesy, respect, sensitivity, friendliness 3Thoroughness, carefulness, competence 4 Including paramedical staff 5Includes hospital/community health center/ first referral unit/ referral hospital, dispensary, and primacy health center last visit made by women

7.7 Reason for not visiting Government Health Centre

Women who visited the private health facility were asked about the reason for not visiting the government health facility and the results are presented in Table 7.7. Women who visited private health facility reported reason for not visiting the government health facility as ‘not conveniently located’ (eight percent), ‘time is not suited’ (12 percent), ‘poor quality of services’ (19 percent), ‘heavy rush’ (27 percent), ‘doctors/health workers do not examine properly’ (seven percent) and ‘medicine not/rarely given or of bad quality (nine percent). Further, rural–urban differential in responses are quite serious for reason as ‘not conveniently located’, time is not suited’, ‘heavy rush’ and ‘poor quality of services’. Similarly, differential in responses due to health facility status in the village are quite serious for reason as ‘not conveniently located’, time is not suited’, heavy rush’ and ‘medicines not/rarely given or of bad quality’.

7.8 Family Planning Information and Advice Received

Table 7.8 gives percentage of current non-users who were advised to adopt family planning method by method of family planning by ANM/health worker, according to residence in the state. The current non-users who were advised to adopt family planning method was 16 percent in the state – 15 percent in rural areas and 17 percent in urban areas. The method advised was female sterilization (33 percent), male sterilization (four percent), IUD/Loop (17 percent), Pills(25 percent) and condom (19 percent). Further, rural-urban differential are quite serious in the case of male sterilization, IUD/Loop and Pills.

126 Table 7.7 REASON FOR NOT PREFERRING GOVERNMENT HEALTH FACILITY Percent distribution of women visited private health facility by reason for not visiting government health facility and according to residence and availability of health facilities in the village, Himachal Pradesh, 2002-04 Availability of health Residence facility1 in the village

Reason Total Rural Urban No Yes Not conveniently located 8.2 8.8 6.3 12.4 6.8 Time is not suited 11.7 13.9 4.3 10.8 15.7 Poor quality of services 18.8 17.1 24.0 16.9 17.3 Heavy rush 27.1 21.1 46.8 25.9 18.5 Non/rare-availability of doctors/health workers 2.4 1.6 4.9 0.7 2.1 Doctors/health workers do not examine properly 7.1 8.8 1.6 8.3 9.1 Medicine not/rarely given or of bad quality 9.3 11.2 3.0 8.1 12.9 Doctors/paramedical staff does not behave properly 1.7 2.3 0.0 0.0 3.5 Services are charged 0.5 0.7 0.0 1.3 0.4 Referred by government doctor 0.9 0.9 0.7 2.6 0.0 Other 12.4 13.6 8.4 13.0 13.9

Total percent 100.0 100.0 100.0 100.0 100.0

Number of women 504 386 118 137 249 1 Includes sub-center, primary health center, Community health center or referral hospital, government hospital, and government dispensary within the village

Table 7.8 ADVISE TO ADOPT FAMILY PLANNING METHOD Percentage of current non-users who reported ever advised to adopt family planning method by method of family planning by ANM/health worker, according to residence, Himachal Pradesh, 2002-04 Method Total Rural Urban

Percentage of non-users who were advised to adopt family planning method 15.6 15.4 16.6

Number of women 2,437 1,985 452

Method Female sterilization 33.1 33.5 31.2 Male sterilization 4.1 4.6 2.3 IUD 17.3 14.4 29.5 Pills 25.2 27.2 17.0 Condom 19.0 19.3 17.9 Rhythem/periodic abstinence 0.0 0.0 0.0 Other 0.8 0.4 2.1 Missing 0.4 0.5 0.0

Total percent 100.0 100.0 100.0

Number of women 381 306 75 Note: Total includes 5 cases missing on advice to adopt family planning method.

7.9 Availability of Pills and Condom

Table 7.9 gives percentage of current condom or Pills users who ever had a problem getting a supply of condoms/pills by residence. The percentage of current users of condom who had problem in getting supply of condom was over five percent in the state- six percent in rural areas and five percent in urban areas. Similarly, percentage of current users of Pills who had problem in getting supply of Pills was six percent - six percent in rural areas and five percent in urban areas.

7.10 Quality of Care of Family Planning Services

Several aspects of quality of family planning services were also investigated. Current users of sterilization were asked whether the person or centre where sterilization had been performed, informed them about other alternative methods of family planning; and whether they were

127 Table 7.9 AVAILABILITY OF REGULAR SUPPLY OF CONDOMS/PILLS Percentage of current condom or pill users who ever had a problem getting a supply of condoms/pills by residence, Himachal Pradesh, 2002-04 Percentage who had a Method/residence problem getting supply Number of users Condom

Rural 5.7 222 Urban 4.8 106 Total 5.4 328

Pills

Rural 6.2 663 Urban 4.8 452 Total 5.6 1,115 told by the health workers about possible side effects of the method at the time of acceptance of the method; whether he/she received any follow-up care after accepting the method. Tables 7.10 and 7.11 present the results of this investigation. Twenty-eight percent of the current users of sterilization were sterilized at the government health facility, 40 percent at the family planning or RCH camp/village secession and 40 percent at the private health facility. Thirty-two percent of the current users of sterilization reported that they were informed about modern methods by the health facility where they got sterilized in the state – 32 percent in rural areas and 29 percent in urban areas.

Table 7.10 INFORMATION OF OTHER MODERN METHOD BEFORE STERILIZATION Percentage of current users of sterilization who were informed about other modern method by the source where they get sterilized, according to the source of sterilization and residence, Himachal Pradesh, 2002-04 Source of sterilization Total Rural Urban Number of users

Government health facility 28.0 27.7 29.5 2,719 Family planning or RCH camp/ village session 40.2 41.0 26.1 1,163 Private health facility 40.3 38.4 44.0 64 Other (26.3) (35.7) (0.0) 33

Total 31.8 32.2 29.3 4,000

Note: Total includes 15, and 6 women who said that they sterilized at mobile clinic, and who do not know including missing information of place/source of sterilization, are not shown separately. ( ) Based on les than 50 unweighted cases.

The percentage of current users of sterilization methods who were told about side effects or other problems of sterilization by health worker or ANM/Nurse was over 35 percent in the state – 37 percent in rural areas and 29 percent in urban areas. Similarly, percentage of current users of other modern methods who were told about side effects or other problems of the current methods by health worker or ANM/Nurse was 27 percent in the state – 29 percent in rural areas and 23 percent in urban areas. The percentage of current users of any modern method who were told about side effects or other problems of current methods by health worker or ANM/Nurse was 33 percent in the state – 35 percent in rural areas and 26 percent in urban areas. These data have shown that counselling coverage of contraceptive services was better in rural areas than in urban areas.

Over 21 percent of sterilization users as against only four percent of users of other modern methods received follow-up services after accepting the method. Only one-sixth (over 16 percent) of the current users of any modern method reported follow-up visit by health worker or ANM/Nurse

128 Table 7.11 INFORMATION ON SIDE EFFECT AND FOLLOW-UP FOR CURRENT METHOD Percentage of current users of modern contraceptive methods who were told about side effects or other problems of current method by a health worker or ANM/Nurse at the time of accepting the method and percentage who received follow-up services after accepting the method by current method and residence, Himachal Pradesh l, 2002-04 Information/follow-up Total Rural Urban Told about side effects Sterilization 35.5 36.7 29.1 Other modern method 26.8 29.1 23.2 Any modern method 33.0 35.0 26.1

Received follow-up Sterilization 21.5 22.7 15.3 Other modern method 4.1 3.4 5.3 Any modern method 16.5 18.3 10.2 after accepting the method. The rural-urban differential in the follow-up services is eight percentage points, which is quite high. These data have shown that follow-up services are not quite satisfactory and that scenario is more pathetic in urban areas.

7.11 Quality of Care Indicators for Contraceptive Users by District

Table 7.12 shows inter-district variations in the percentage of users of sterilization who were told about other methods before getting sterilization and about side effects or other problems related to the current method or users of modern contraceptive methods, and the percentage of users who received follow-up services. The percentage of sterilization-users who were told about other method before getting sterilized was the highest (65 percent) in Chamba district, followed by 55 percent in Kangra district and the lowest (seven percent) in Kullu district. The percentage of sterilization-users who were told about other method before getting sterilized was higher than that of the state (32 percent) in Bilaspur, Chamba, Kangra, Kinnaur, Lahul & Spiti, Sirmaur and Una districts, while in five districts it was lower than that of the state.

The percentage of current-users of modern contraceptive method who were told about side effects or other problems associated with sterilization method was the highest (84 percent) in Chamba district, followed by 78 percent in Lahul & Spiti district and the lowest (14 percent) in Solan and Shimla districts. Further, percentage of current-users of modern contraceptive method who were told about side effects or other problems associated with sterilization method was higher than that of the state (35 percent) in Chamba, Kangra, Kinnaur, Lahul & Spiti and Sirmaur districts, while in seven districts it was lower than that of the state. The percentage of current-users of modern contraceptive method who were told about side effects or other problems associated with other modern method was the highest (66 percent) in Lahul & Spiti district, followed by 51 percent in Kinnaur district and the lowest (10 percent) in Hamirpur district. The percentage of current-users of modern contraceptive method who were told about side effects or other problems associated with other modern method was higher than that of the state (27 percent) in Bilaspur, Chamba, Kangra, Kinnaur, Lahul & Spiti, Shimla and Sirmaur districts, while in five districts it was lower than that of the state.

The percentage of current-users of modern contraceptive method who received follow- up visit on getting sterilization method was the highest (58 percent) in Kangra district, followed by 42 Bilaspur district and the lowest (two percent) Kullu district. The percentage of current-

129 Table 7.12 QUALITY OF CARE INDICATORS FOR CONTRACEPTIVE USERS BY DISTRICT Among currently married women who are current users of modern contraceptive methods, quality of care indicators related to the use of their current contraceptive method by district, Himachal Pradesh, 2002-04 Percentage told about side effects or other Percentage who Percentage non- problems with method2 received follow –up2 Percentage informed user told ever had about other methods Other Other advised to adopt before getting modern modern contraceptive 1 District sterilization Sterilization method Sterilization method method Bilaspur 32.0 25.8 36.2 41.8 5.6 20.4 Chamba 65.3 84.1 43.3 11.4 4.5 17.4 Hamirpur 23.2 16.8 9.7 13.3 2.3 8.0 Kangra 55.3 72.3 34.2 58.3 4.8 22.6 Kinnaur 47.0 70.2 51.4 9.3 2.2 32.1 Kullu 7.0 15.8 16.6 2.0 2.1 10.5

Lahul & Spiti 47.5 77.7 66.4 12.0 3.2 17.3 Mandi 16.3 15.0 19.3 3.6 2.9 10.6 Shimla 17.7 14.0 28.9 7.6 5.4 11.7 Sirmaur 53.0 63.0 35.3 24.7 5.4 26.1 Solan 18.1 13.7 10.9 11.4 4.1 6.5 Una 32.7 28.3 15.1 18.5 6.1 9.6

Himachal Pradesh 31.8 35.5 26.8 21.5 4.1 15.6 1 At the time of accepting the current method. 2 By a health worker or ANM/Nurse after accepting the current method. users of modern contraceptive method who received follow-up visit on getting sterilization method was higher than that of the state (21 percent) in Bilaspur, Kangra and Sirnaur districts, while in the remaining nine districts it was lower than that of the state. Similarly, percentage of current-users of modern contraceptive method who received follow-up visit on adopting modern contraceptive method was equal to or higher than that of the state (four percent) in Bilaspur, Chamba, Kangra, Shimla, Sirmaur, Solan and Una districts and in five districts it was lower than that of the state. Again, percentage of non-user who told that they had never been advised to adopt contraceptive method was the highest (32 percent) in Kinnaur district, followed by 26 percent in Sirmaur district and the lowest (six percent) in Solan district. The percentage of non-user who told that they had never been advised to adopt contraceptive method was higher that that of the state (16 percent) in Bilaspur, Chamba, Kangra, Kinnaur, Lahul & Spiti and Sirmaur districts, while in six districts it was lower that that of the state.

7.12 Quality of Care of Maternal Health Care

Information on few other aspects of quality of care in terms of maternal care was also collected. Women with last live/still births during three years preceding the survey were asked whether the Doctor/ANM/health worker advised you to go to health facility for delivery when they were pregnant, and received any follow-up services after delivering the baby within 2 weeks of delivery and at least one visit within six weeks of delivery. Table 7.13 shows that percentage of women who were advised to have delivery at health facility was 48 percent in the state – 44 percent in rural areas and 67 percent in urban areas. The percentage of women who were visited within two weeks of delivery was over seven percent in the state – eight percent in rural areas and five percent in urban areas. Again, percentage of women who were visited once within six weeks of delivery was 14 percent in the state – 14 percent in rural areas and 11 percent in urban areas. These data have shown that domiciliary services are not functioning satisfactorily in the state.

130 Table 7.13 ADVISED TO HAVE DELIVERY AT HEALTH FACILITY AND FOLLOW-UP SERVICES FOR POSTPARTUM CHECK-UP Percentage of women* who were advised to have delivery at health facility by doctor/ health worker and percentage who receive follow-up services within 2 weeks and within 6 weeks of delivery by ANM, according to residence, Himachal Pradesh, 2002-04 Advise/follow-up service Total Rural Urban

Percentage of women who were advised to have delivery at health facility 48.1 43.7 66.6

Percentage of women who were visited within 2 weeks of delivery 7.3 7.9 4.7

Percentage of women who were visited at least once within 6 weeks of delivery 13.6 14.2 10.8

Number of women 2,666 2,150 516 * Women who had live birth/still birth after 1.1.1999/2001

Table 7.14 gives quality of care indicators related to delivery care by district in Himachal Pradesh. The percentage of currently married women aged 15-44 years who had live/still birth three years preceding the survey and were advised to have delivery at health facility by doctor/health worker was the highest (63 percent) in Shimla district, followed by 59 percent in Hamirpur district and the lowest (31 percent) in Chamba district, while it was 48 percent for the state.

The percentage of currently married women aged 15-44 years who had live/still birth three years preceding the survey and were visited within two weeks of delivery by ANM was the highest (17 percent) in Lahul & Spiti district, followed by 15 percent in Kangra district and the lowest (over one percent) in Mandi district, while it was seven percent for the state. The percentage of currently married women aged 15-44 years who had live/still birth three years preceding the survey and were visited at least once within six weeks of delivery by ANM was the highest (100 percent) in Kullu district, followed by 17 percent in Lahul & Spiti district and the lowest (over four percent) in Mandi district, while it was 14 percent for the state.

Table 7.14 QUALITY OF CARE INDICATORS FOR MATERNAL CARE Among currently married women* who are given live/still birth three years preceding the survey, quality of care indicators related to delivery care by district, Himachal Pradesh, 2002-04 Percentage of women Advised to have delivery at health facility by doctor/ Visited within 2 weeks Visited at least one within 6 District health worker of delivery by ANM weeks of delivery by ANM

Bilaspur 55.5 13.8 13.8 Chamba 31.0 6.0 6.0 Hamirpur 59.3 10.9 15.9 Kangra 55.2 15.3 15.3 Kinnaur 39.6 5.5 5.7 Kullu 43.5 2.2 99.7

Lahul & Spiti 40.0 17.1 17.1 Mandi 40.9 1.3 4.3 Shimla 63.2 3.0 5.7 Sirmaur 42.8 8.8 9.2 Solan 48.9 2.0 5.2 Una 39.8 4.4 8.3

Himachal Pradesh 48.1 7.3 13.6

* Women who had live birth/still birth after 1.1.1999/2001

131 CHAPTER – VIII

REPRODUCTIVE HEALTH PROBLEMS AND AWARENESS OF RTIs/STIs AND HIV/AIDS

One of the important components of the Reproductive and Child Health Programme is to have a healthy sexual life without any fear of contracting disease. With this approach the RCH programme places a lot of emphasis on promoting and encouraging healthy sexual behaviour among couples through various Information, Education and Communication (IEC) activities. Health workers are also expected to educate women and men about Reproductive Tract Infections (RTIs) and Sexually Transmitted Infections (STIs) and motivate those people with RTI/STI problems to seek medical help. The DLHS-RCH has made an attempt to collect information on awareness and prevalence of RTI/STI. Beside this, information on knowledge of HIV/AIDS, source of information and way of avoiding AIDS were also collected.

8.1 Awareness of RTI/STI

An attempt was made to know whether couples were aware of RTI/STI. Currently married women and their husbands were asked about awareness of RTI/STI, and if they were aware, source of information and mode of transmission of the disease.

Table 8.1 gives percentage of currently married women aged 15-44 years who have heard about RTI/STI, percentage who received information from specific sources by selected background characteristics. Data shows that 37 percent of the women in Himachal Pradesh were aware of RTI/STI irrespective of their residence. Awareness of RTI/STI was 22 percent among women aged 15-19 years, which increases to 37 percent in the age group 20-24 and the highest was 39 percent in the age group 30-34 years. Awareness of RTI/STI was the highest (47 percent) for women who had studied for 10 years and above and the lowest (23 percent) for non-literate women, while it was 36 percent for women who had studied for 0-9 years. Awareness of RTI/STI was 38 percent for Hindu and Muslim women, 26 percent for Sikh women and 15 percent for other women. Further, awareness of RTI/STI was the highest (56 percent) for other backward class women and the lowest (nine percent) for scheduled tribe women, while it was around 36 percent for scheduled caste and other caste women. Awareness of RTI/STI was the highest (44 percent) for women with high SLI and the lowest (25 percent) for women with low SLI, while it was 38 percent for women with medium SLI. The data shows that awareness of RTI/STI increases with increase in education and standard of living index of women. In other words, there exists positive association between awareness of RTI/STI of women and education and standard of living index of women.

Those women who had heard of RTI/STI were further asked about the source of information of RTI/STI, which is presented in Table 8.1. The main sources of knowledge reported by the women were ‘radio’ (14 percent), ‘television’ (53 percent), ‘newspaper/books/magazines’ (31 percent),‘slogan/pamphlets/posters/wall hoardings’ (21 percent),‘doctor’ (20 percent), ‘health worker’ (21 percent),‘school teacher’ (five percent),‘community meeting’ (10 percent), ‘relative/friends’ (71 percent) and ‘other’ (11 percent). These data have shown that TV, newspaper /books/magazines and friends/relatives were the main sources of awareness about RTI/STI among women.

Table 8.1 SOURCE OF KNOWLEDGE ABOUT RTI/STI AMONG WOMEN Percentage of currently married women age 15 - 44 who have heard about RTI/STI, percentage who received information from specific sources by selected background characteristics, Himachal Pradesh, 2002-04. Among those who have heard about RTI/STI, percentage who received information from. Slogan/ Percentage Number of who have Newspaper/ Pamphlets/ women who Background heard about Number of Books/ Posters/ School Community Relative/ have heard Characteristic RTI/STI Women Radio Television Magazines Wall Hoardings Doctor Health worker teacher Meeting Friends Others about RTI/STI Age group (years) 15-19 22.3 104 * * * * * * * * * * 23 20-24 37.4 1,506 8.1 51.9 28.0 20.2 15.1 20.0 6.3 5.3 74.9 9.3 564 25-29 37.0 2,185 17.3 57.8 34.7 22.0 17.6 18.5 6.2 10.5 69.4 7.8 808 30-34 38.7 1,912 14.7 49.9 31.3 19.2 23.1 26.6 4.5 10.7 66.5 13.2 740 35-39 36.1 1,698 12.0 49.5 28.5 21.4 24.5 19.4 2.7 11.7 69.9 12.1 613 40-44 38.1 1,213 18.9 58.4 29.1 21.7 22.5 21.3 5.6 9.3 75.7 14.7 462 Residence Rural 37.7 6,748 14.4 52.4 25.8 19.3 20.1 22.7 5.2 10.2 74.8 12.5 2,541 Urban 35.7 1,870 14.4 57.2 49.5 27.2 21.2 14.9 4.5 7.3 54.9 6.3 668 Education Non-literate 22.6 1,874 8.8 31.4 3.1 4.0 15.8 13.0 2.2 5.7 88.6 21.4 423 0-9@ years 35.7 3,326 13.2 49.7 17.1 16.3 18.3 21.0 2.4 7.8 77.3 11.0 1,187 10 and above 46.8 3,415 16.7 61.9 48.1 28.9 23.0 23.3 7.9 12.0 61.0 8.6 1,599 Religion Hindu 37.6 8,267 14.6 53.4 30.9 21.1 20.2 21.4 5.1 9.8 70.5 11.3 3,110 Muslim 38.1 124 (7.7) (38.5) (17.3) (11.5) (23.1) (11.5) (3.8) (3.8) (84.6) (3.8) 47 Sikh 26.3 156 (4.5) (52.3) (29.5) (11.4) (11.4) (4.5) (2.3) (6.8) (61.4) (11.1) 41 Other 15.3 72 * * * * * * * * * * 11 Caste/tribe# 1,876 15.3 52.2 22.4 23.4 20.5 20.8 4.5 10.0 85.4 14.7 687 Scheduled caste 36.6 Scheduled tribe 9.0 348 (18.3) (59.8) (31.7) (18.3) (20.7) (36.6) (4.9) (11.0) (32.9) (6.1) 31 856 12.0 58.3 17.4 17.8 24.5 23.9 3.2 12.0 84.6 7.2 478 Other backward class 55.8 5,524 14.4 52.3 36.8 20.9 19.3 20.5 5.7 9.0 62.2 11.1 2,008 Other 36.3

Standard of living index

Low 25.3 1,888 7.4 31.0 9.4 9.8 13.1 17.4 0.9 5.9 82.9 16.1 477 Medium 37.8 3,583 13.4 53.4 21.5 17.6 21.1 22.0 4.1 7.9 75.6 12.5 1,354 High 43.8 3,147 17.7 61.1 47.2 28.0 22.1 21.4 7.5 12.6 61.5 8.2 1,379

3,209 Total 37.2 8,618 14.4 53.4 30.7 20.9 20.3 21.1 5.1 9.6 70.7 11.2 Note: 3 Cases missing on women education were not shown separately. @ Literate women with no year of schooling are also included. (): Based on less than 50 unweighted cases. # Total number may not add to N due to do not know and missing cases. * Percentage not shown. Based on few cases.

134 Table 8.2 gives percentage of husbands of currently married women who have heard of RTI/STI, percentage who received information from specific sources by selected background characteristics. The percentage of men who have heard of RTI/STI was 34 percent in the state – 33 percent in rural areas and 38 percent in urban areas. Awareness about RTI/STI among men was the lowest (21 percent) for men aged below 25 years and the highest (40 percent) for men aged 45 years and above. Awareness about RTI/STI among men was the highest (41 percent) for men who had studied for 10 years and above and the lowest (12 percent) for non-literate men, while it was 29 percent for men who had studied for 0-9 years. More of Hindu men than men from other religions were aware of RTI/STI. Awareness about RTI/STI among men was the highest (49 percent) for OBC men, followed by 34 percent for other castes men and the lowest (20 percent) for scheduled tribe men. The awareness of RTI/STI was the highest (45 percent) for men with high SLI and the lowest (18 percent) for men with low SLI, while it was 34 percent for men with medium SLI. The data shows that awareness of RTI/STI increases with increase in education and standard of living index of men. In other words, there exists positive association between awareness of RTI/STI among men and education and standard of living index of men. Figure 8.1 gives awareness about RTI/STI by sex and residence.

Figure 8.1 Awarness of RTI/STI by Sex According to Residence

Total

Women 37

Men 34

Rural

Women 38

Men 33

Urban

Women 36

Men 38

30 31 32 33 34 35 36 37 38 39 Percent Himachal Pradesh, DLHS-RCH, 2002-04

Those men who had heard of RTI/STI were further asked about the source of information of RTI/STI, which is presented in Table 8.2. The main sources of knowledge reported by these men were ‘radio’ (24 percent), ‘television’ (67 percent), ‘newspaper/books/magazines’ (53 percent), ‘slogan/pamphlets/posters/wall hoardings’ (41 percent),‘doctor’ (23 percent),‘health worker’ (14 percent),‘school teacher’ (three percent),‘community meeting’ (21 percent) and ‘relative/friends’ (41 percent). These data show that TV, newspaper/ books/magazines, slogan/pamphlets/wall hoardings and friends/relatives were the main sources of increasing awareness about RTI/STI among men.

8.1.1 Knowledge of Mode of Transmission of RTI/STI

Table 8.3 gives percentage of currently married women aged 14-44 years who have heard

135 Table 8.2 SOURCE OF KNOWLEDGE ABOUT RTI/STI AMONG MEN Percentage of husband of eligible women who have heard about RTI/STI and among men who have heard about RTI/STI, percentage who received information from specific sources by selected background characteristics, Himachal Pradesh, 2002-04. Among those who have heard about RTI/STI, percentage who received information from. Number of Percentage men who who have Newspaper/ Slogan/ have heard heard about Number of Books/ Pamphlets/ Posters/ Health School Community Relative/ about Background characteristic RTI/STI men Radio Television Magazines Wall Hoardings Doctor worker teacher Meeting Friends Others RTI/STI Age group (years) < 25 20.8 148 (30.6) (61.1) (36.1) (30.6) (16.7) (19.4) (0.0) (19.4) (47.2) (2.8) 31 25-34 35.0 1,697 25.2 66.2 52.3 42.7 20.9 14.3 3.6 19.1 39.6 5.0 593 35-44 32.7 1,944 26.0 68.6 52.6 40.6 23.6 15.2 2.1 22.5 42.3 4.7 637 45+ 40.2 760 16.6 67.3 57.8 40.5 25.5 9.2 3.1 21.0 40.3 6.9 306 Residence Rural 33.2 3,489 23.4 66.0 49.0 42.1 21.9 14.2 2.9 22.7 45.1 5.6 1,159 Urban 38.4 1,061 25.7 71.8 64.4 38.7 25.0 11.9 2.6 15.8 28.8 4.1 407 Education Non-literate 12.1 407 (20.5) (41.0) (15.4) (12.8) (20.5) (2.6) (0.0) (28.2) (66.7) (10.3) 49 0-9@ years 29.5 1,671 18.6 61.0 31.3 39.4 22.4 10.5 2.0 21.2 49.5 5.8 493 10 and above 41.5 2,470 26.5 71.6 65.2 43.1 22.5 15.6 3.4 20.7 35.8 4.4 1,024 Religion Hindu 35.0 4,379 24.0 67.6 53.0 41.3 23.0 13.6 2.9 21.1 41.2 5.1 1,534 Muslim (23.2) 48 * * * * * * * * * * 10 Sikh 18.5 74 * * * * * * * * * * 14 Other (9.5) 48 * * * * * * * * * * 9 Caste/tribe# Scheduled caste 32.3 1,006 19.0 66.2 47.8 46.9 30.5 9.7 4.2 27.9 51.8 5.8 325 Scheduled tribe 20.1 219 (22.5) (71.8) (53.5) (32.4) (23.9) (18.3) (0.0) (4.2) (14.1) (4.2) 44 Other backward class 48.7 416 23.2 68.3 48.2 43.6 21.6 14.4 0.8 14.1 46.9 6.3 203 Other 34.3 2,895 26.6 67.9 56.3 39.8 19.6 14.2 3.0 20.8 37.3 4.9 992 Standard of living index Low 17.9 1,017 22.7 54.8 37.1 40.8 22.2 10.0 1.0 23.0 43.2 6.9 182 Medium 33.9 1,803 19.6 61.8 42.0 40.5 22.4 13.5 3.4 20.2 46.8 5.0 611 High 44.7 1,730 27.9 75.1 65.5 41.8 23.1 14.5 2.8 21.0 35.7 4.9 773

Total 34.4 4,550 24.0 67.5 53.0 41.2 22.7 13.6 2.9 20.9 40.9 5.2 1,567

Note: Total includes 2 cases with missing information on education are not shown separately. @ Literate men with no year of schooling are also included. (): Based on less than 50 unweighted cases. * Percentage not shown: Based on few cases. # Total number may not add to N due to do not know and missing cases.

136 Table 8.3 SOURCE OF KNOWLEDGE ABOUT MODE OF TRANSMISSION OF RTI/STI AMONG WOMEN Percentage of currently married women age 15-44 who have heard of RTI/STI, knowledge of mode of transmission by selected background characteristics, Himachal Pradesh, 2002-04 Percentage by knowledge of mode of transmission Number of women Homosexual Heterosexual Lack of personnel who have heard of Background characteristic intercourse intercourse hygiene Other Do not know RTI/STI Age 20-24 2.3 60.7 58.3 25.7 19.6 564 25-29 4.8 63.3 64.6 29.6 14.7 808 30-34 6.9 59.4 57.7 30.5 18.4 740 35-39 7.1 63.6 58.4 31.0 14.7 613 40-44 4.3 60.0 60.7 40.8 15.5 462

Residence Rural 3.8 60.1 62.3 32.3 16.9 2,541 Urban 10.5 66.4 51.6 26.1 15.7 668

Education Non-literate 3.5 54.6 57.6 37.3 19.9 423 0-9@ years 2.7 56.0 59.2 32.1 18.7 1,187 10 years and above 7.4 67.3 61.5 28.5 14.3 1,599

Religion Hindu 5.3 61.7 60.3 30.8 16.7 3,110 Muslim (1.9) (51.9) (55.8) (34.6) (17.3) 47 Sikh (2.3) (43.2) (40.9) (22.7) (29.5) 41

Caste/tribe# Scheduled caste 3.9 60.0 62.1 35.3 16.1 687 Scheduled tribe (4.9) (82.9) (41.5) (35.4) (4.9) 31 Other backward class 0.9 67.3 76.0 37.0 8.7 478 Other 6.7 60.3 55.4 27.7 18.9 2,008

Standard of living index Low 1.7 60.2 64.1 32.0 16.4 477 Medium 3.5 55.4 58.3 31.6 18.2 1,354 High 8.0 67.8 60.5 30.1 15.2 1,379

Total 5.2 61.4 60.1 31.0 16.6 3,209 @ Literate women with no year of schooling are also included. (): Based on less than 50 unweighted cases. Note: Total includes 23 cases of age group 15-19 years and in other religion 11 cases were not shown separately. # Total number may not add to N due to do not know and missing cases. of RTI/STI, knowledge of mode of transmission by selected background characteristics. Only 17 them did not know anything about the mode of its transmission. Women who said do not know about the mode of transmission of RTI/STI was 20 percent for women aged 20-24 years, followed by 18 percent for women aged 30-34 years and around 15 percent for other age groups. The percentage of women who said do not know about the mode of transmission of RTI/STI was the highest (20 percent) for non-literate women and the lowest (14 percent) for women who had studied for 10 years and above, while it was 19 percent for women who had studied for 0-9 years. Seventeen percent of Hindu and Muslim women as against 29 percent of Sikh women said do not know about mode of transmission of RTI/STI. Again, 18 percent of women with medium SLI as against 15 percent of women with high SLI and 16 percent of women with low SLI said do not know about mode of transmission of RTI/STI. Further, percentage of women aware of RTI/STI who had knowledge about its mode of transmission reported it as ‘homosexual intercourse’ (five percent), ‘Heterosexual intercourse’ (61 percent), ‘lack of personnel hygiene’ (60 percent) and other (17 percent). Thus the main sources of transmission of RTI/STI reported were ‘heterosexual intercourse’ and ‘lack of personal hygiene’.

137 Table 8.4 SOURCE OF KNOWLEDGE ABOUT MODE OF TRANSMISSION OF RTI/STI AMONG MEN Percentage of husbands of currently married women who have heard of RTI/STI, knowledge of mode of transmission by selected background characteristics, Himachal Pradesh, 2002-04 Percentage by knowledge of mode of transmission Number of men Lack of who have Homosexual Heterosexual personnel Do not heard of Background characteristic intercourse intercourse hygiene Other know RTI/STI Age <25 (2.8) (77.8) (25.0) (8.3) (16.7) 31 25-34 6.5 79.8 38.8 2.6 15.2 593 35-44 5.5 79.3 41.2 4.6 14.4 637 45+ 5.9 80.0 40.9 5.1 14.6 306

Residence Rural 3.1 79.7 40.3 3.7 15.4 1,159 Urban 13.8 79.2 38.6 5.3 12.9 407

Education Non-literate (0.0) (74.4) (51.3) (5.1) (17.9) 49 0-9@ years 2.0 74.1 33.4 4.2 19.2 493 10 years and above 8.0 82.3 42.2 3.8 12.6 1,024

Religion Hindu 5.9 79.5 40.0 4.1 14.8 1,534

Caste/tribe# Scheduled caste 2.8 79.4 42.1 2.1 15.4 325 Scheduled tribe (2.8) (81.7) (32.4) (5.6) (16.9) 44 Other backward class 3.4 78.0 37.7 1.6 21.2 203 Other 7.4 79.9 40.2 5.1 13.1 992

Standard of living index Low 1.7 72.8 42.4 2.8 20.8 182 Medium 2.5 76.9 36.1 3.0 18.6 611 High 9.6 83.3 42.3 5.2 10.3 773

Total 5.9 79.6 39.9 4.1 14.8 1,567 @ Literate men with no years of schooling are also included. ( ): Based on less than 50 unweighted cases. Note: Total includes 10,14 & 9 cases for Muslim, Sikh & other religion were not shown separately. # Total number may not add to N due to do not know and missing cases.

Table 8.4 gives percentage of husbands of currently married women who have heard of RTI/STI, knowledge of mode of transmission by selected background characteristics. The percentage of men who had knowledge about mode of transmission of RTI/STI reported it as ‘homosexual intercourse’ (six percent), ‘heterosexual intercourse’ (80 percent), ‘lack of personal hygiene’ (40 percent) and ‘other’ (four percent). Further, percentage of men who said do not know about the mode of transmission of RTI/STI was 15 in the state – 15 percent in rural areas and 13 percent in urban areas. The percentage of men who said do not know about the mode of transmission of RTI/STI was the highest (19 percent) for men who had studied for 0-9 years and the lowest (13 percent) for men who had studied for 10 years and above, while it was 18 percent for non-literate men. Similarly, percentage of men who said do not know about the mode of transmission of RTI/STI was the highest (21 percent) for men with low SLI and the lowest (10 percent) for men with high SLI, while it was 19 percent for men with medium SLI. The percentage of men who said do not know about the mode of transmission of RTI/STI was the highest (21 percent) for other backward class men, followed by 17 percent for scheduled tribe men and the lowest (13 percent) for men from other castes.

8.2 Prevalence of RTI/STI

In DLHS-RCH, information was collected on the common symptoms of reproductive tract infections and

138 sexually transmitted infections from women and their husbands, and information on menstruation related problems in the three months immediately preceding the survey.

The prevalence of reproductive tract infections and sexually transmitted tract infections is judged by their symptoms. All the respondents were told about symptoms of RTI/STI, and were asked whether they had any of them. In case of the presence of at least one symptom, they were further asked whether they sought treatment for such problems, and if they had sought treatment, details regarding the source of treatment also recorded. The topic of RTI/STI is quite sensitive. The culture of silence prevents people from discussing such topics in front of others. In spite of intensive training of the investigators, the respondent might have hesitated in reporting the symptoms of RTI/STI. What gets reported in the survey though may not give the exact prevalence, but may have given the lower limit for it?

Table 8.5 gives percentage of currently married women aged 15-44 years who reported any symptoms of RTI/STI and specific symptoms during three months prior to survey, according to residence in Himachal Pradesh. The percentage of women who reported any symptom of RTI/STI was 31 percent in the state – 33 percent in rural areas and 24 percent in urban areas. The main problems reported by women were ‘itching over vulva’ (10 percent), ‘pain in lower abdomen not related to menses’ (13 percent), ‘low backache’ (22 percent) and ‘pain during sexual intercourse’ (seven percent). Other symptoms of reproductive health reported by women were ‘involuntary escape of urine while coughing or sneezing’ (less than one percent), ‘frequent/painful passage of urine’ (two percent), ‘fever’ (over one percent), ‘boils/ulcers/warts around vulva’ (two percent), ‘some mass coming out of vagina’ (less than one percent), ‘swelling/lump in breast’ (one percent), ‘bleeding after sexual intercourse’ (less than one percent) and ‘swelling in the groin’ (two percent). Figure 8.2 shows symptom of RTI/STI among women.

Figure 8.2 Symptomps of RTI/STI among Women

Any RTI/STI symptoms 31

Low backache 22 Pain in lower abdomen not related to menses 13 Any involuntary escape of urine while coughing or sneezing 0.4 Frequent / painful passage of urine 2 Itching over vulva 10 Pain during sexual intercourse 7 Fever 2 Boils/ ulcers/ warts around vulva 2 Some mass coming out of vagina 0.2 Swelling / lump in breast 1 Swelling in the groin 2 Bleeding after sexual intercourse 1

0 5 10 15 20 25 30 35 Percent

Table 8.6 gives percentage of husbands of eligible women who reported any symptoms of RTI/STI and specific symptoms during three months prior to survey and sought treatment for RTI/

139 Table 8.5 SYMPTOMS OF RTI/STI AMONG WOMEN Percentage of currently married women age 15-44 who reported any symptoms RTI/STI and specific symptoms during three months prior to survey, according to residence, Himachal Pradesh, 2002-04 Residence Symptoms Total Rural Urban Percentage of women reported any RTI/STI symptoms 31.0 33.0 24.1

Symptoms Itching over vulva 9.6 10.5 6.1 Boils/ ulcers/ warts around vulva 2.0 2.3 1.0 Pain in lower abdomen not related to menses 12.6 13.6 8.8 Low backache 21.8 23.2 16.6 Pain during sexual intercourse 6.6 7.4 3.7 Bleeding after sexual intercourse 0.5 0.6 0.2 Swelling in the groin 1.7 1.8 1.4 Frequent / painful passage of urine 2.2 2.4 1.5 Fever 1.5 1.6 0.9 Some mass coming out of vagina 0.2 0.3 0.1 Any involuntary escape of urine while coughing or sneezing 0.4 0.5 0.1 Swelling / lump in breast 0.6 0.7 0.3

Number of women 8,618 6,748 1,870

STI by source of treatment according to residence in the state. The percentage of men who reported any RTI/STI symptoms was four percent in the state irrespective of residence. The symptoms reported by men were ‘discharge from penis’ (less than one percent), ‘any sore/rash/redness on genital or anal area’ (one percent), ‘difficulty/pain while urinating or very frequent urination’ (over one percent), ‘swelling of testis or in groin area’ (less than one percent) and ‘itching/irritation around genital’ (two percent). Figure 8.3 shows symptoms of RTI/STI among husbands.

Figure 8.3 Symptomps of RTI/STI among Husbands

Any RTI/STI symptoms 4

Itching / irritation around genital 2 Swelling of testis or in groin area 0.3 Difficulty / pain while urinating or very frequent urination 2 Any sore / rash / redness on genitals or anal area 1 Any discharge from penis 1

03691215 Himachal Pradesh, DLHS-RCH, 2002-04 Percent

Among men who reported reproductive health problems, 60 percent of them sought treatment in the state irrespective of residence. Only 55 percent men visited government health facility, including primary health centre (13 percent) and sub-centre (one percent), 12 percent visited a private health facility, 27 percent ISM health facility, 11 percent chemist/medical shop and other health facility. A relatively higher proportion of men utilised the government health facility and private health facility in urban areas, while more of men in rural areas utilized ISM facility, chemist or medical shop and other health facility for treatment. A very large proportion of men sought treatment from a doctor (93 percent), male health worker (one percent), traditional

140 Table 8.6 SYMPTOMS OF RTI/STI AMONG MEN Percentage of husbands of currently married women who reported any symptoms RTI/STI and specific symptoms during three months prior to survey and sought treatment for RTI/STI by source of treatment, according to residence, Himachal Pradesh, 2002-04 Residence Symptoms and treatment Total Rural Urban Percentage of men reported any RTI/STI symptoms 3.8 3.8 4.1

Symptoms Any discharge from penis 0.5 0.6 0.2 Any sore / rash / redness on genitals or anal area 0.9 0.7 1.6 Difficulty / pain while urinating or very frequent urination 1.5 1.8 0.5 Swelling of testis or in groin area 0.3 0.4 0.3 Itching / irritation around genital 1.9 1.8 2.3

Number of men 4,550 3,489 1,061

Percentage of men sought treatment for any RTI/STI1 59.6 59.3 (60.0)

Number of men 174 131 43

Percentage sought treatment at health facility2

Government health facility3 55.5 51.6 (61.1) Primary health centre 13.5 18.0 (0.0) Sub centre 1.1 1.5 (0.0)

Private health facility4 12.0 8.5 (11.1)

ISM5 facility 27.0 33.6 (22.2)

Chemist/ medical shop 8.4 10.3 (5.6) Other 2.3 3.1 (0.0)

Percentage obtained treatment from2

Doctor 92.9 91.8 (88.9) Male health worker 0.7 1.0 (0.0) Traditional healer 1.1 1.4 (0.0) Relative/friends 0.5 0.6 (0.0) ISM practitioner 4.0 5.4 (0.0) Home remedy 10.4 13.0 (5.6) Chemist medical shop 2.0 2.7 (0.0) Other 6.0 7.1 (11.1)

Number of men 104 78 26 1 Based on men with any symptoms of RTI/STI 2 Percentage may add more than 100.0 due to multiple responses 3 Includes Government municipal hospital, dispensary, UHC/ UHP /UWFC, CHC/ rural hospital, Primary health centre, sub- centre. 4 Includes private hospital/ clinic, non-governmental / trust hospital/clinic,. 5 Either government or private hospital/clinic of Indian system of medicine. (): Based on less than 50 unweighted cases.

healer (one percent), ISM practitioner (four percent) and chemist/medical shop (two percent), while 10 percent men tried home remedy.

The DLHS-RCH collected information from currently married women on symptoms of RTI, that is, on abnormal vaginal discharge, texture, colour and odour of discharge during three months preceding the survey. The prevalence of reproductive health problems among currently married women is estimated from women’s experiences. Table 8.7 gives percentage of currently married women aged 15-44 years who reported any vaginal discharge during the reference period, percentage who sought treatment and source of treatment according to residence in the state. The percentage of women who reported any vaginal discharge was 18 percent in the state – 20 percent in rural areas and 10 percent in urban areas.

141 Table 8.7 ABNORMAL VAGINAL DISCHARGE Percentage of currently married women age 15-44 who reported had any abnormal vaginal discharge during three months prior to survey and percentage who sought treatment and source of treatment according to residence, Himachal Pradesh, 2002-04 Residence Symptoms and treatment Total Rural Urban Percentage of women reported abnormal vaginal discharge 17.6 19.6 10.3 Number of women 8,618 6,748 1,870

Percentage of women sought treatment for vaginal discharge1 40.6 39.8 45.5 Number of women 1,514 1,321 193

Percentage sought treatment at health facility 2

Government health facility3 71.1 71.9 66.4 Primary health centre 5.2 6.1 0.0 Sub centre 0.3 0.4 0.0

Private health facility4 27.7 27.5 28.8

ISM5 facility 2.0 1.6 4.2

Home remedy 0.8 0.9 0.0

Other 2.8 2.7 3.5

2 Percent distribution of women who obtained treatment from

Doctor 88.7 88.2 91.8 ANM/nurse/midwife/LHV 8.1 8.9 3.6 Other health professionals6 1.0 1.2 0.3 1.8 1.8 1.8 Other

100.0 100.0 100.0 Total percent

Number of women 614 526 88 1 Based on women who reported having vaginal discharge. 2 Based on women who sought treatment for vaginal discharge. 3 Includes Government municipal hospital, dispensary, UHC/ UHP /UWFC, CHC/ rural hospital, Primary health centre, sub-centre and out reach/ MCP clinic in village. 4 Includes private hospital/ clinic, non-governmental / trust hospital/clinic, chemist/ medical shop. 5 Either government or private hospital/clinic of Indian system of medicine, 6 Includes dai (trained or untrained), relative or friends and chemist/ medical shop.

Among the women who reported symptoms of vaginal discharge, 41 percent sought treatment in the state – 40 percent in rural areas and over 45 percent in urban areas. The percentage of women who sought treatment from government health facility was 71 percent, from private health facility 28 percent and from ISM and other health facility five percent, while one percent women tried home remedy.

The percentage of women who sought treatment from a doctor was 89 percent in the state – 88 percent in rural areas and 92 percent in urban areas. Similarly, percentage of women who sought treatment from ANM/Nurse/LHV was eight percent in the sate – nine percent in rural areas and four percent in urban areas. Only three percent women sought treatment from other health professionals.

8.3 Menstruation Related Problems

Table 8.8 gives percentage of currently married women aged 15-44 years who had any menstruation related problems during three months preceding the survey and percentage who sought treatment by source of treatment and residence in the state The data shows that 18 percent of the women had menstruation related problems in the state – 19 percent in rural areas and 14 percent in urban areas. Women who had menstrual related problems reported symptoms as ‘painful period’ (51 percent), ‘frequent or short period’ (36 percent), ‘delayed period’ (13 percent), ‘prolonged period’ (15 percent) and ‘excessive bleeding’ (24 percent). Other reported symptoms were ‘no period’, ‘continuous bleeding’, ‘ scanty bleeding’, and ‘inter-menstrual bleeding’.

142 Table 8.8 MENSTRUATION RELATED PROBLEMS Percentage of currently married women age 15-44 who had any menstruation related problem during three months prior to survey and percentage who sought treatment and source of treatment according to residence, Himachal Pradesh, 2002-04 Residence Symptoms and treatment Total Rural Urban Percentage of women with any menstruation related problem 17.6 18.6 13.9 Number of women 7,245 5,608 1,637

Symptoms1 No period 4.2 4.5 2.6 Painful period 51.3 54.1 38.5 Frequent or short period 36.1 36.1 36.2 Delayed period 12.8 11.8 17.6 Prolonged bleeding 14.7 15.6 10.4 Excessive bleeding 23.7 23.9 22.5 Continuous bleeding 4.0 3.9 4.3 Scanty bleeding 2.0 2.1 1.7 Inter-menstrual bleeding 5.8 5.7 6.6

Percentage of women sought treatment who had any menstruation related problems 45.0 42.4 56.8 Number of women 1,272 1,043 228

Percentage sought treatment at health facility6

Government health facility2 74.4 75.8 69.5 Primary health centre 3.3 4.0 0.7 Sub centre 0.6 0.8 0.0

Private health facility3 24.1 23.1 27.5

ISM4 facility 4.8 3.4 9.6

Other 2.4 2.5 1.9

Percentage of women obtained treatment from6

Doctor 85.1 84.2 88.2 ANM/nurse/midwife/LHV 8.7 10.1 3.7 Other health professionals5 3.3 3.7 1.9 Other 1.4 1.2 1.8

Number of women 572 442 130 1 Based on women who reported any menstruated related problems. 2 Includes Government municipal hospital, dispensary, UHC/ UHP /UWFC, CHC/ rural hospital, Primary health centre, sub-centre and out reach/ MCP clinic in village. 3 Includes private hospital/ clinic, non-governmental / trust hospital/clinic, chemist/ medical shop. 4 Either government or private hospital/clinic of Indian system of medicine, 6 Includes dai (trained or untrained), relative or friends and chemist/ medical shop. 6 Multiple responses.

Further, percentage of women who had menstrual related problems and sought treatment was 45 percent in the state – 42 percent in rural areas and 57 percent in urban areas. The percentage of women who sought treatment from government health facility was 74 percent in the state – 76 percent in rural areas and 69 percent in urban areas. Similarly, percentage of women who sought treatment from private health facility was 24 percent in the state – 23 percent in rural areas and over 27 percent in urban areas. Seven percent of women sought treatment of menstrual problems from ISM and other health facility. More women in urban areas than in rural areas sought treatment from private health facility and ISM health facility. Most of the women sought treatment from the doctor (85 percent), from ANM/Nurse/LHV (nine percent) and five percent from other health professional and other. More women in rural areas than in urban areas sought treatment from other than a doctor.

8.4 Prevalence of RTIs/STIs by District

Table 8.9 gives percent of currently married women and their husbands who reported reproductive

143 Table 8.9 REPRODUCTIVE HEALTH CARE INDICATORS BY DISTRICT Percentage of currently married women and their husbands who reported reproductive health problems and percentage who sought treatment for the problems by district, Himachal Pradesh, 2002-04 Percentage of women Percentage of men With any Sought treatment With any Reported any abnormal Sought treatment symptoms of for abnormal symptoms of vaginal discharge for RTI/STI District RTI/STI vaginal discharge RTI/STI problems

Bilaspur 34.2 17.5 45.8 2.5 (48.3) Chamba 41.7 26.0 34.0 1.0 (62.3) Hamirpur 22.7 11.1 45.3 1.2 (100.0) Kangra 37.5 23.1 35.0 1.9 (77.4) Kinnaur 45.5 31.9 35.4 1.3 (27.5) Kullu 17.1 10.8 33.4 4.3 (20.6)

Lahul & Spiti 39.4 23.1 36.5 0.4 (50.4) Mandi 20.4 13.5 45.6 2.7 (54.4) Shimla 23.8 13.0 40.1 3.4 (25.8) Sirmaur 50.9 30.9 49.3 8.1 44.4 Solan 36.9 13.4 49.0 9.1 85.5 Una 22.2 9.9 47.8 5.3 (69.0)

Himachal Pradesh 31.0 17.6 40.6 3.8 59.6

(): Based on less number of cases.

health problems and who sought treatment for the problems by district. The percentage of women with any symptoms of RTI/STI was the highest (51 percent) in Sirmaur district, followed by 45 percent in Kinnaur district and the lowest (17 percent) in Kullu district, while it was 31 percent for the state. Further, percentage of women who reported any abnormal vaginal discharge was the highest (32 percent) in Kinnaur district, followed by 31 percent in Sirmaur district and the lowest (10 percent) in Una district, while it was 18 percent for the state. The percentage of women who sought treatment for abnormal vaginal discharge was the highest (49 percent) in Sirmaur and Solan districts, followed by 48 percent in Una district and the lowest (33 percent) in Kullu district, while it was 41 percent for the state.

In comparison to women, fewer men from all districts of Humachal Pradesh reported symptoms of RTI/STI. The percentage of men with any symptom of RTI/STI was the highest (nine percent) in Solan district, followed by eight percent in Sirmaur district and the lowest (less than one percent) in Lahul & Spit district, while it was four percent for the state. The percentage of men who sought treatment for RTI/STI problems was the highest (100 percent) in Hamirpur district, followed by 85 percent in Solan district and the lowest (21 percent) in Kullu district, while it was 60 percent for the state.

8.5 HIV/AIDS

Acquired Immune Deficiency Syndrome (AIDS) is an illness caused by the Human Immune Virus (HIV), which weakens the immune system and leads to death through secondary infection such as tuberculosis or pneumonia. The virus is generally transmitted through sexual contact, through the placenta of HIV-infected women to their children, or through contact with contaminated needle (injections) or blood. Prevalence of HIV and AIDS has been on the rise for more than a decade in India and has reached alarming proportions in recent years. To prevent HIV transmission, the government has been making various efforts.

144 DLHS-RCH has collected information on the general state of awareness of HIV/AIDS, its transmission, its prevention and common misconceptions about HIV/AIDS. All the currently married women in the age group 15-44, and their husbands were first asked if they had ever heard of an illness called HIV/AIDS. Respondents who had heard of HIV/AIDS were further asked about their source of information, mode of transmission, and correct knowledge of HIV/AIDS transfusion.

8.5.1 Knowledge of HIV/AIDS

Table 8.10 gives percentage of currently married women aged 15-44 years who had heard about HIV/AIDS, percentage who received who received information from specific sources by selected background characteristics in the state. Seventy nine percent of the currently married women have heard of HIV/AIDS in the state, which is higher than RCH Round–I. In Round-I only 60 percent of currently married women were aware of HIV/AIDS.

Knowledge of HIV/AIDS among women was 79 percent in the state – 76 percent in rural areas and 91 percent in urban areas. Further, knowledge of HIV/AIDS was the highest (81 percent) for women aged 20-34 years and the lowest (64 percent) for women aged 15-19 years, while it was 75 percent for women aged 35 years and more. The knowledge about HIV/AIDS was the highest (96 percent) for women who had studied for 10 years and above and the lowest (46 percent) for non-literate women, while it was 81 percent for women who had studied for 0-9 years. Again, knowledge about HIV/AIDS was the highest (82 percent) for Sikh women, followed by 79 percent for Hindu women and the lowest (64 percent) for Muslim women. Around 82 percent of the OBC women and also women from other castes were having knowledge about HIV/AIDS, 74 percent for scheduled caste women and 59 percent among scheduled tribe women. The knowledge about HIV/AIDS was the highest (93 percent) for women with high SLI and the lowest (53 percent) for women with low SLI, while it was 80 percent for women with medium SLI. Main sources of knowledge were ‘radio’ (23 percent),‘television’ (84 percent),‘newspaper/books/magazines’ (32 percent), ‘slogan/pamphlets/wall hoardings’ (36 percent),‘doctor’ (15 percent),‘health worker’ (20 percent) and ‘relatives/friends’ (40 percent). Other sources of knowledge were ‘school teacher’ (five percent) and ‘community meeting’ (eight percent).

Table 8.11 shows the percentage of husbands of currently married women who were have heard about HIV/AIDS, percentage who received information from specific sources by selected background characteristics in the state. The percentage of men who had heard about HIV/AIDS was much higher than that of women. Ninety percent of men had heard of HIV/AIDS as against 79 percent of women. Figure 8.4 shows awareness of HIV/AIDS by sex according to residence.

Knowledge about HIV/AIDS among men was 90 percent in the state – 88 percent in rural areas and 96 percent in urban areas. The knowledge of HIV/AIDS among men varies from 87 percent in the age group less than 25 years to 93 percent in the age group 25-34 years. The knowledge about HIV/AIDS among men was the highest (97 percent) for men who had studied for 10 years and above and the lowest (59 percent) for non-literate men, while it was 87 percent for men who had studied for 0-9 years. Similarly, knowledge about HIV/AIDS among men was the highest (98 percent) for men with high SLI and the lowest (74 percent) for men with low SLI, while it was 92 percent for men with medium SLI. Main sources of knowledge were ‘radio’ (43 percent),’television’ (84 percent),’newspaper/books/magazines (63 percent),’slogan/pamphlets/

145 Table 8.10 SOURCE OF KNOWLEDGE ABOUT HIV/AIDS AMONG WOMEN Percentage of currently married women age 15 - 44 who have heard about HIV/AIDS and among women who have heard about HIV/AIDS, percentage who received information from specific sources by selected background characteristics, Himachal Pradesh, 2002-04. Among those who have heard about HIV/AIDS, percentage who received information from. Number Slogan/ of women Percentage Pamphlets/ who have who have Number Newspaper Posters/ Relative heard heard about of Televi / Books/ Wall Health School Community / about Background characteristic HIV/AIDS Women Radio sion Magazines Hoardings Doctor worker teacher Meeting Friends Others HIV/AIDS

Age group (years) 15-19 63.6 104 20.6 73.7 18.0 30.5 0.4 7.0 6.6 0.6 27.4 10.3 66 20-24 81.6 1,506 18.5 84.7 32.3 33.3 14.1 19.2 5.1 5.4 37.8 2.2 1,229 25-29 81.1 2,185 26.4 84.9 36.0 41.3 15.9 18.4 5.5 7.6 39.9 3.4 1,772 30-34 81.3 1,912 24.3 83.2 32.3 35.2 16.3 21.9 4.9 8.6 38.8 4.1 1,554 35-39 75.3 1,698 23.4 82.7 28.6 33.6 16.5 20.3 3.8 9.3 42.3 4.4 1,278 40-44 75.1 1,213 24.1 82.6 30.0 34.0 12.8 21.1 4.1 8.3 44.6 4.1 910 Residence Rural 75.6 6,748 21.6 79.6 24.0 30.4 15.2 22.4 4.7 7.7 43.3 3.7 5,104 Urban 91.2 1,870 29.4 95.9 56.5 52.5 15.4 12.6 5.0 8.2 31.1 3.7 1,706 Education Non-literate 45.6 1,874 14.8 61.2 2.1 6.7 7.9 17.0 1.5 5.4 55.4 3.6 855 0-9@ years 80.6 3,326 19.0 78.2 14.5 25.8 13.2 20.9 2.9 5.7 40.7 3.9 2,681 10 and above 95.8 3,415 29.6 94.0 54.4 51.8 18.8 20.0 7.2 10.2 35.9 3.6 3,271 Religion Hindu 79.2 8,267 23.8 83.6 31.9 35.9 15.3 20.4 4.9 7.9 40.4 3.8 6,549 Muslim 63.6 124 9.0 81.0 30.5 36.8 14.7 8.1 2.2 2.3 52.8 0.9 79 Sikh 82.2 156 18.1 94.1 44.1 33.8 7.3 6.9 3.2 2.2 25.0 0.4 128 Other 75.4 72 21.4 75.7 39.4 35.5 26.4 19.3 5.0 11.8 42.2 1.1 54 Caste/tribe# Scheduled caste 74.1 1,876 19.2 80.4 22.1 30.7 14.7 18.6 4.2 7.2 45.4 4.6 1,390 Scheduled tribe 59.2 348 27.1 81.7 26.2 30.0 15.3 12.2 4.7 5.1 30.7 3.2 206 Other backward class 81.9 856 17.6 78.4 22.0 39.0 17.0 21.0 3.3 7.0 58.4 2.2 701 Other 81.5 5,524 25.6 85.6 37.1 37.3 15.1 20.6 5.2 8.2 36.2 3.7 4,504 Standard of living index Low 53.3 1,888 18.1 55.6 9.6 19.8 12.2 20.6 1.6 6.3 48.7 5.0 1,005 Medium 80.0 3,583 20.2 82.3 19.1 26.6 13.7 20.7 4.0 6.2 42.4 3.0 2,867 High 93.3 3,147 28.7 94.6 52.6 50.6 17.7 19.0 6.7 9.9 35.2 4.0 2,938

Total 79.0 8,618 23.5 83.7 32.1 35.9 15.2 20.0 4.8 7.8 40.2 3.7 6,810 Note: Total includes 3 cases missing information on education are not shown separately. @ Literate women with no year of schooling are also included. # Total number may not add to N due to do not know and missing cases.

146

Table 8.11 SOURCE OF KNOWLEDGE ABOUT HIV/AIDS AMONG MEN Percentage of husband of currently married women who have heard about HIV/AIDS, percentage who received information from specific sources by selected background characteristics, Himachal Pradesh, 2002-04. Among those who have heard about HIV/AIDS, percentage who received information from. Number of Slogan/ men who Percentage who Newspaper/ Pamphlets/ have heard have heard Number of Books/ Posters/ Wall Health School Community Relative/ about Background Characteristic about HIV/AIDS men Radio Television Magazines Hoardings Doctor worker teacher Meeting Friends Others HIV/AIDS Age group (years) < 25 87.1 148 51.3 85.6 44.4 56.3 13.6 9.4 4.9 26.2 31.8 3.0 129 25-34 92.7 1,697 44.2 84.2 53.4 54.4 17.9 17.0 3.6 21.8 32.7 3.3 1,573 35-44 89.1 1,944 42.5 84.6 53.7 52.5 22.0 19.9 3.5 22.5 32.1 3.4 1,733 45+ 88.1 760 41.1 82.3 54.5 52.4 22.7 17.3 3.2 20.5 33.5 2.5 670 Residence Rural 88.5 3,489 43.8 81.1 47.8 50.6 18.5 18.2 3.2 23.2 34.4 3.0 3,089 Urban 95.8 1,061 41.3 93.3 70.6 61.4 25.8 17.5 4.7 18.6 27.0 3.9 1,017 Education Non-literate 59.5 407 39.4 71.0 11.0 19.0 10.0 9.2 0.4 18.6 44.3 1.6 242 0-9@ years 87.3 1,671 34.9 73.9 33.6 44.1 15.3 15.1 1.1 22.0 35.8 2.4 1,459 10 and above 97.4 2,470 48.6 91.6 69.7 62.4 24.3 20.7 5.3 22.4 29.4 3.9 2,405 Religion Hindu 90.3 4,379 43.8 84.1 53.4 53.7 20.5 18.2 3.6 22.2 32.8 3.1 3,954 Muslim (78.3) 48 (35.2) (70.4) (35.2) (46.3) (16.7) (16.7) (3.7) (20.4) (40.7) (1.9) 40 Christian 93.4 74 16.9 85.6 61.1 34.2 12.0 11.4 0.5 9.6 16.6 9.5 69 Other (91.8) 48 (45.4) (88.5) (55.1) (51.6) (24.7) (10.1) (8.4) (17.4) (39.0) (7.7) 43 Caste/tribe# Scheduled caste 89.5 1,006 38.3 82.1 43.7 49.5 19.0 17.2 3.3 22.4 39.5 1.8 900 Scheduled tribe 81.8 219 45.0 88.2 59.7 55.3 19.2 18.8 2.5 16.6 28.0 3.4 179 Other backward class 88.7 416 40.0 88.8 49.1 48.5 22.1 17.3 2.6 23.5 34.2 6.3 369 Other 91.3 2,895 45.4 83.7 57.1 55.3 20.6 18.5 3.8 22.2 30.4 3.3 2,644 Standard of living index Low 73.6 1,017 44.9 62.4 29.3 42.6 14.7 13.8 1.1 22.7 36.8 1.2 748 Medium 92.4 1,803 39.0 84.3 43.7 49.1 17.5 18.3 2.9 20.1 32.8 2.9 1,666 High 97.8 1,730 46.6 93.5 73.6 62.1 25.5 19.6 5.2 23.7 30.4 4.4 1,692

Total 90.2 4,550 43.2 84.1 53.4 53.3 20.3 18.0 3.5 22.0 32.6 3.2 4,106

Note-1: Table includes 2 cases missing information are not shown separately. @ Literate men with no year of schooling are also included. ( ): Based on less than 50 unweighted cases. # Note-2: Total number may not add to N due to do not know and missing cases.

147 Figure 8.4 Awarness of HIV/AIDS by Sex According to Residence

Total

Women 79

Men 90

Rural

Women 76

Men 89

Urban

Women 91

Men 96

0 20 40 60 80 100 120 Percent Himachal Pradesh, DLHS-RCH, 2002-04

wall hoardings’ (53 percent), ‘doctor’ (20 percent), ‘health worker’ (18 percent) and ‘relatives/friends’ (33 percent), ‘community meeting’ (22 percent).

8.5.2 Knowledge of Mode of Transmission about HIV/AIDS

Women who were aware of HIV/AIDS were asked about the mode of its transmission, which is presented in Table 8.12. The percentage of women who were aware of HIV/AIDS but did not know about its mode of transmission was eight percent in the state – eight percent in rural areas and five percent in urban areas. Again, percentage of women who were aware of HIV/AIDS but did not know about its mode of transmission was 19 percent for women aged 15-19 years, seven percent in the age group 20-34 years and over eight percent in the age group 35 years and more. The percentage of women who were aware of HIV/AIDS but did not know about its mode of transmission was the highest (14 percent) for non-literate women and the lowest (three percent) for women who had studied for 10 years and above, while it was 11 percent for women who had studied for 0-9 years. The percentage of women who did not know about mode of transmission of HIV/AIDS was 10 percent for Muslim women as against eight percent for Hindu women and less than one percent for Sikh women. The percentage of women who did not know about mode of transmission of HIV/AIDS was 10 percent for scheduled caste women, followed by other caste women (seven percent) and around five percent for scheduled tribe and other backward class women. The percentage of women who did not know about mode of transmission of HIV/AIDS was the highest (12 percent) for women with low SLI and the lowest (over four percent) for women with high SLI, while it was over nine percent for women with medium SLI.

Among women who reported different ways of transmission of HIV/AIDS, 90 percent of them mentioned ‘heterosexual intercourse’ as a mode of transmission. All of the socio-economic groups reported that ‘heterosexual intercourse’ was the main mode of transmission of HIV/AIDS. Other modes of transmission reported by women were ‘needles/blade/skin puncture’ (50 percent), ‘transfusion of infected blood’ (35 percent) and ‘mother to child’ (21 percent). Only over seven

148

Table 8.12 SOURCE OF KNOWLEDGE ABOUT MODE OF TRANSMISSION OF HIV/AIDS AMONG WOMEN Percentage currently married women age 15-44 who have heard of HIV/AIDS , knowledge of mode of transmission by selected background characteristics, Himachal Pradesh, 2002-04 Percentage by knowledge of mode of transmission Number Mother Transfusion Do of women Homo Hetero Needles/ who have to of infected not sexual sexual blade/ skin heard of Background characteristic intercourse intercourse puncture child blood Other know HIV/AIDS Age 15-19 1.9 79.5 24.8 5.3 20.0 0.0 18.8 66 20-24 4.8 91.9 49.7 17.3 33.3 0.6 6.8 1,229 25-29 7.5 91.0 52.4 24.1 37.4 1.5 7.0 1,772 30-34 8.8 90.5 49.1 20.7 34.6 1.8 7.2 1,554 35-39 8.5 88.6 49.7 20.9 36.4 2.1 8.8 1,278 40-44 7.7 89.5 46.9 20.9 32.1 2.4 8.3 910 Residence Rural 5.7 89.5 44.8 17.4 29.8 1.5 8.4 5,104 Urban 12.7 92.7 64.1 31.3 50.3 2.0 5.3 1,706 Education Non-literate 3.4 83.6 24.3 8.1 15.0 2.4 14.4 855 0-9@ years 4.3 87.1 37.5 13.6 22.4 1.6 10.9 2,681 10 years and above 11.1 94.7 66.2 30.2 50.4 1.4 3.2 3,271 Religion Hindu 7.7 90.2 49.8 21.1 35.2 1.7 7.8 6,549 Muslim 2.5 89.4 42.1 23.8 26.6 0.0 10.4 79 Sikh 3.6 96.4 49.8 9.5 26.9 1.2 0.4 128 other 1.5 96.2 41.6 18.3 36.7 0.0 3.1 54 Caste/tribe# Scheduled caste 5.2 88.9 44.7 18.9 30.6 1.3 10.0 1,390 Scheduled tribe 8.3 90.1 45.5 20.3 36.0 1.9 5.2 206 Other backward class 3.3 93.3 46.6 24.4 34.0 2.9 5.6 701 Other 8.8 90.3 51.8 21.0 36.4 1.5 7.4 4,504 Standard of living index Low 3.5 86.7 29.0 9.9 16.5 1.6 11.6 1,005 Medium 5.3 88.3 42.7 16.2 28.9 1.4 9.5 2,867 High 10.9 93.5 63.5 29.2 47.2 1.9 4.5 2,938

Total 7.5 90.3 49.7 20.9 34.9 1.6 7.6 6,810 Note: Total includes 2 cases missing information on education, are not shown separately. # Total number may not add to N due to do not know and missing cases. @ Literate women with no year of schooling are also included.

percent of the women mentioned that ‘homosexual intercourse’ was also a mode of transmission, while two percent women stated that there were also other ways of transmission of HIV/AIDS.

Table 8.13 presents the knowledge about mode of transmission of HIV/AIDS among men. The percentage of men who had heard about HIV/AIDS but did not know its mode of transmission was seven percent in the state – eight percent in rural areas and over two percent in urban areas. The percentage of men not knowing the mode of transmission of HIV/AIDS was the highest (19 percent) for non-literate men and the lowest (over two percent) for men who had studied for 10 years and above, while it was 12 percent for men who had studied for 0-9 years. The percentage of men not knowing the mode of transmission of HIV/AIDS was over eight percent for all the age groups except age 25-34 years where it was five percent. Further, the percentage of men not knowing the mode of transmission of HIV/AIDS was the highest (12 percent) for men with low SLI and the lowest (over two percent) for men with high SLI, while it was nine percent for men with medium SLI.

149 Table 8.13 SOURCE OF KNOWLEDGE ABOUT MODE OF TRANSMISSION OF HIV/AIDS AMONG MEN Percentage of husbands of currently married women who have heard of HIV/AIDS , knowledge of mode of transmission by selected background characteristics, Himachal Pradesh, 2002-04 Percentage by knowledge of mode of transmission Needles/ Transfusion Number of men Homosexual Heterosexual blade/ skin Mother to of infected Do not who have heard Background characteristic intercourse intercourse puncture child blood Other know of HIV/AIDS Age <25 19.6 77.9 50.9 8.5 27.9 1.0 8.5 129 25-34 14.7 92.0 56.2 14.8 41.5 2.0 4.9 1,573 35-44 12.4 88.1 54.9 16.4 42.1 2.0 8.2 1733 45+ 12.4 88.7 53.6 19.8 42.8 1.0 8.3 670

Residence Rural 10.8 88.3 50.8 12.6 36.1 1.5 8.4 3,089 Urban 22.0 92.5 67.9 26.8 58.0 2.6 2.5 1017

Education Non-literate 4.6 77.4 17.7 3.7 13.8 0.1 18.9 242 0-9@ years 8.3 83.8 36.7 5.4 22.6 0.8 12.4 1,459 10 years and above 17.6 93.9 69.9 23.9 55.7 2.5 2.5 2405

Religion Hindu 13.8 89.4 55.1 16.3 41.6 1.8 6.9 3,954 Muslim (7.4) (87.0) (51.9) (14.8) (37.0) (3.7) (11.1) 40 Sikh 6.1 86.4 45.2 10.0 29.6 2.8 10.5 69 Other (1.4) (92.3) (57.5) (6.6) (41.1) (0.3) (7.0) 43

Caste/tribe# Scheduled caste 8.7 88.7 49.4 13.0 37.5 1.4 8.4 900 Scheduled tribe 15.5 91.8 57.7 10.8 40.4 2.2 4.3 179 Other backward class 6.2 91.1 49.6 9.8 33.7 0.8 8.3 369 Other 16.1 89.1 57.5 18.2 43.9 1.7 6.5 2,644

Standard of living index Low 9.5 82.8 29.8 5.3 18.6 0.5 12.4 748 Medium 10.2 88.0 50.0 10.3 34.1 0.7 9.0 1,666 High 18.6 93.6 71.2 26.6 58.9 3.5 2.5 1,692

Total 13.5 89.3 55.0 16.1 41.5 1.8 7.0 4,106 @ Literate men with no year of schooling are also included. (): Based on less than 50 unweighted cases. # Total number may not add to N due to do not know and missing cases.

The percentage of men who had heard about HIV/AIDS and reported different ways of its transmission, 90 percent of them mentioned ‘heterosexual intercourse’ as a mode of transmission. All of the socio-economic groups reported that ‘heterosexual intercourse’ was the main mode of transmission of HIV/AIDS. Other modes of transmission reported by men were ‘needles/blade/skin puncture’ (55 percent), ‘transfusion of infected blood’ (41 percent) and ‘mother to child’ (16 percent). Only 13 percent of the men mentioned that ‘homosexual intercourse’ could also be a mode of transmission. Two percent men stated that there were other ways of transmission of HIV/AIDS.

8.5.3 How to avoid HIV/AIDS

All the respondents were asked about how to prevent HIV/AIDS. Table 8.14 gives currently married women aged 15-44 years who have heard about HIV/AIDS, percentage of women who reported HIV/AIDS can be avoided in specific ways by selected background characteristics in the Himachal Pradesh. Among women who reported about awareness of HIV/AIDS but did not know how to avoid it was 10 percent in the state – 12 percent in rural areas and over six percent in urban areas. The percentage of women who did not know how to avoid HIV/AIDS was 23 percent

150 Table 8.14 KNOWLEDGE ABOUT AVOIDANCE OF HIV/AIDS AMONG WOMEN Among currently married women age 15-44 who have heard about HIV/AIDS, the percentage of women reported HIV/AIDS can be avoided in specific ways by selected background characteristics, Himachal Pradesh, 2002-04 Percentage reported HIV/AIDS can be avoided by: Sex Using condoms Checking Sterilizing Avoiding Do not know With correctly during blood prior needles and pregnancy To Background Only each sexual to syringes when having avoid Number Characteristic one partner intercourse transfusion for injection HIV/AIDS Other HIV/AIDS of women Age 15-19 74.0 27.8 21.1 22.4 4.6 0.0 23.4 66 20-24 86.7 45.7 33.6 45.7 16.3 0.4 9.7 1,229 25-29 88.3 46.7 39.8 49.3 22.2 1.7 9.0 1,772 30-34 85.9 41.8 35.3 44.5 17.2 2.0 10.3 1,554 35-39 84.7 41.3 36.6 45.5 18.7 2.0 11.6 1,278 40-44 87.5 35.1 32.8 43.4 17.5 1.4 10.7 910 Residence Rural 85.5 38.5 30.7 41.0 15.8 1.3 11.6 5,104 Urban 89.9 55.1 51.5 60.2 26.7 2.1 6.5 1,706

Education Non-literate 80.8 18.7 15.7 21.3 6.6 1.9 17.5 855 0-9@ years 82.4 30.9 22.5 33.3 12.0 1.0 14.7 2,681 10 years and above 91.5 58.6 52.2 62.4 27.0 1.9 4.7 3,271

Religion Hindu 86.7 42.6 36.1 46.0 18.7 1.6 10.3 6,549 Muslim 88.0 37.6 31.8 36.9 23.5 0.5 10.3 79 Sikh 79.6 44.4 25.8 43.4 6.6 0.0 8.0 128 other 82.4 52.7 40.0 38.6 17.0 0.2 10.6 54

Caste/tribe# Scheduled caste 85.1 39.8 29.9 41.1 16.3 0.8 12.7 1,390 Scheduled tribe 82.5 38.2 33.5 34.6 13.6 1.0 10.6 206 Other backward class 91.4 37.8 36.0 44.5 22.4 2.3 6.9 701 Other 86.4 44.5 37.9 47.9 18.8 1.6 10.1 4,504

Standard of living index Low 82.7 28.0 18.0 25.4 8.5 0.7 14.8 1,005 Medium 83.8 35.9 28.8 38.8 14.7 1.1 13.0 2,867 High 90.6 54.3 49.0 59.6 25.7 2.2 6.1 2,938

Total 86.6 42.7 35.9 45.8 18.5 1.5 10.3 6,810

Note: Total includes 2 cases missing information on education, are not shown separately. @ Literate women with no year of schooling are also included. # Total number may not add to N due to do not know and missing cases.

for women aged 15-19 years and 9 to12 percent for women of other age groups. The percentage of women who did not know how to avoid HIV/AIDS was the highest (17 percent) for non- literate women and the lowest (five percent) for women who had studied for 10 years and above, while it was 15 percent for women who had studied for 0-9 years. The percentage of women who did not know how to avoid HIV/AIDS was eight percent for Sikh women and over 10 percent for all other religious groups. Further, percentage of women who did not know how to avoid HIV/AIDS was the highest (13 percent) for scheduled caste women, followed by 11 percent for scheduled tribe women and the lowest (seven percent) for OBC women, while it was 10 percent for other caste women. The percentage of women who did not know how to avoid HIV/AIDS was the highest (15 percent) for women with low SLI and the lowest (six percent) for women with high SLI, while it was 13 percent for women with medium SLI.

Among women who mentioned ways to avoid HIV/AIDS, 87 percent of women said that “sex with only one partner” is the way to avoid it. Other ways to prevent HIV/AIDS mentioned

151 by women were ‘using condoms correctly during each sexual intercourse’, (43 percent), ‘sterilizing needles and syringes for injection’ (46 percent each), ‘checking blood prior to transfusion’ (36 percent), and ‘avoiding pregnancy when having HIV/AIDS’ (18 percent). However, all of the specific ways to avoid HIV/AIDS reported by women are proportionally higher in urban areas than in rural areas.

Table 8.15 gives percentage of husbands of eligible women who have heard about HIV/AIDS, who reported HIV/AIDS could be avoided in specific ways by selected background characteristics in the state. Among men who were aware of HIV/AIDS but did not know how to avoid it was nine percent in the state – over 10 percent in rural areas and over three percent in urban areas. The percentage of men who did not know how to avoid HIV/AIDS was around 10 percent in the age group 35 years and above and seven percent in the age group 25-34 years. The percentage of men who did not know how to avoid was the highest (22 percent) for non-literate men and the lowest (four percent) for men who had studied for 10 years and above, while it was over 14 percent for men who had studied for 0-9 years. The percentage of men who did not know

Table 8.15 KNOWLEDGE ABOUT AVOIDANCE OF HIV/AIDS AMONG MEN Among husbands of currently married women who have heard about HIV/AIDS, the percentage of men reported HIV/AIDS can be avoided in specific ways by selected background characteristics, Himachal Pradesh, 2002-04 Percentage reported HIV/AIDS can be avoided by: Using condoms Sterilizing Avoiding Do not Sex with correctly during Checking needles and pregnancy know to only one each sexual blood prior to syringes for when having avoid Number Background characteristic partner intercourse transfusion injection HIV/AIDS Other HIV/AIDS of men Age <25 83.8 61.6 25.8 31.8 9.4 0.0 8.5 129 25-34 89.6 69.0 40.1 47.3 12.1 1.5 6.6 1,573 35-44 87.0 64.4 38.5 45.9 13.6 1.4 10.3 1,733 45+ 89.0 59.8 40.3 46.0 15.9 0.3 9.7 670

Residence Rural 86.4 61.7 34.0 40.7 10.6 1.1 10.5 3,089 Urban 93.7 76.4 54.3 62.2 21.4 1.4 3.4 1,017

Education Non-literate 72.9 37.0 10.6 12.8 3.6 0.2 22.1 242 0-9@ years 82.9 51.4 22.3 27.5 4.5 1.4 14.5 1,459 10 years and above 93.0 76.6 52.1 60.6 19.6 1.2 3.9 2,405

Religion Hindu 88.3 65.6 39.2 46.2 13.5 1.2 8.6 3,954 Muslim (88.9) (55.6) (35.2) (42.6) (11.1) (1.9) (13.0) 40 Sikh 82.7 48.0 25.1 29.4 3.0 0.5 14.1 69 Other (92.0) (80.8) (42.5) (38.3) (7.3) (0.3) (7.3) 43

Caste/tribe# Scheduled caste 87.2 60.3 36.2 40.1 11.6 0.8 10.5 900 Scheduled tribe 92.6 78.0 37.2 43.9 10.4 0.2 5.9 179 Other backward class 87.6 64.8 28.6 40.2 7.8 1.1 10.3 369 Other 88.6 66.5 41.7 49.2 14.9 1.4 7.8 2,644

Standard of living index Low 81.2 46.7 19.1 20.5 4.9 1.2 14.8 748 Medium 87.0 61.6 31.2 40.5 8.7 0.6 10.5 1,666 High 92.5 77.3 55.6 62.7 21.5 1.8 4.2 1,692

Total 88.2 65.3 39.0 46.0 13.3 1.2 8.7 4,106 @ Literate men with no year of schooling are also included. (): Based on less than 50 unweighted cases. # Total number may not add to N due to do not know and missing cases.

152 how to avoid was the highest (15 percent) for men with low SLI and the lowest (four percent) for men high SLI, while it was over 10 percent for men with medium SLI.

Among men who mentioned ways to avoid HIV/AIDS, 88 percent of the men said that “sex with only one partner” is the way to avoid it. Other ways to prevent HIV/AIDS mentioned by men were ‘using condoms correctly during each sexual intercourse’, (65 percent), ‘sterilizing needles and syringes for injection’ (46 percent each), ‘checking blood prior to transfusion’ (39 percent), and ‘avoiding pregnancy when having HIV/AIDS’ (13 percent). However, all of the specific ways to avoid HIV/AIDS reported by men are higher in urban areas than in rural areas.

8.5.4 Misconception about HIV/AIDS

People generally have misconceptions about the ways of transmission of HIV/AIDS, such as ‘shaking hands with a person having AIDS’, hugging and kissing with them, sharing their clothes or sharing eating utensils, stepping on urine/stool, through insect bites, for example, being bitten by mosquitoes, fleas and bedbugs. All these questions were asked to the respondents who had heard of HIV/AIDS.

Table 8.16 shows the percentage of women having misconceptions about transmission of HIV/AIDS by selected background characteristics in the sate. The main misconceptions reported by women were ‘shaking hands’ (nine percent),‘hugging’ (10 percent),‘kissing’ (14 percent), ’sharing

Table 8.16 MISCONCEPTION ABOUT TRANSMISSION OF HIV/AIDS AMONG WOMEN Among currently married women age 15-44 who have heard about HIV/AIDS, the percentage of women having misconception about the transmission of HIV/AIDS by selected background characteristics, Himachal Pradesh, 2002-04 Percentage having misconception about the transmission of HIV/AIDS Sharing Stepping Mosquito, flea, Background Shaking Sharing eating on or bedbugs Number of characteristic hands Hugging Kissing clothes utensils Urine / stool biting women Residence Rural 9.9 10.6 14.9 15.5 15.4 13.8 22.6 5,104 Urban 6.8 6.8 10.6 9.9 10.4 9.0 16.6 1,706

Education Non-literate 14.6 16.1 22.1 24.7 22.9 21.9 26.7 855 0-9@ years 10.3 11.0 15.2 15.9 16.2 14.1 23.4 2,681 10 years and above 6.7 6.9 10.5 9.9 10.2 8.9 17.8 3,271

Religion Hindu 9.3 9.8 13.7 14.2 14.1 12.6 21.2 6,549 Muslim 3.5 3.5 7.7 11.8 14.4 13.3 20.9 79 Sikh 6.2 5.5 21.6 10.5 17.1 10.7 16.2 128 other 8.2 9.4 19.1 16.6 13.6 12.4 21.3 54

Caste/tribe# Scheduled caste 9.9 10.6 14.7 16.2 16.2 14.1 23.7 1,390 Scheduled tribe 6.7 7.6 15.3 16.3 13.8 11.7 20.5 206 Other backward class 10.4 11.6 14.8 16.7 18.2 14.2 20.6 701 Other 8.7 9.2 13.3 12.9 12.9 11.9 20.5 4,504 Standard of living index Low 10.8 13.1 19.3 22.2 20.4 18.7 28.2 1,005 Medium 10.5 10.7 15.1 15.2 15.7 13.2 21.5 2,867 High 7.2 7.5 10.7 10.3 10.5 9.9 18.4 2,938

Total 9.1 9.7 13.8 14.1 14.2 12.6 21.1 6,810 Note: Total includes 2 cases missing information on education, are not shown separately. # Total number may not add to N due to do not know and missing cases. @ Literate women with no year of schooling are also included.

153 clothes’ (14 percent), ‘sharing eating utensils’ (14 percent), ‘stepping on urine/stool’ (13 percent) and Mosquito, flea or bedbugs biting’ (21 percent). The percentage of women having misconceptions was higher in rural areas than in urban areas for all of reported misconception.

Table 8.17 gives percentage of men having misconceptions about the transmission of HIV/AIDS by selected background characteristics. The main misconceptions reported by men were ‘shaking hands’ (seven percent), ‘hugging’ (10 percent), ‘kissing’ (19 percent), ‘(sharing clothes)’ (16 percent), ‘sharing eating utensils’ (17 percent), ‘stepping on urine/stool’ (10 percent) and Mosquito, flea or bedbugs biting’ (24 percent). The percentage of men who reported that HIV/AIDS could be transmitted through biting of mosquitoes or flees or bedbugs was higher among rural men (25 percent) than among urban men (22 percent). Level of misconception about transmission of HIV/AIDS was lowest among men who have studied for 10 years and above and those men with high SLI and higher among non-literate men and those with low SLI.

Table 8.17 MISCONCEPTION ABOUT TRANSMISSION OF HIV/AIDS AMONG MEN Among husbands currently married women who have heard about HIV/AIDS, the percentage of men having misconception about the transmission of HIV/AIDS by selected background characteristics, Himachal Pradesh, 2002-04 Percentage having misconception about the transmission of HIV/AIDS Sharing Mosquito, flea, Shaking Sharing eating Stepping on or bedbugs Number Background characteristic hands Hugging Kissing clothes utensils Urine / stool biting of men Residence Rural 7.2 10.5 20.0 17.6 19.0 11.6 24.9 3,089 Urban 7.2 6.9 14.4 9.4 11.4 7.3 22.0 1,017

Education Non-literate 9.0 9.2 25.4 16.7 18.3 14.9 30.1 242 0-9@ years 9.0 14.2 23.1 22.4 24.3 15.8 29.2 1,459 10 years and above 5.9 6.9 15.2 11.3 12.6 6.9 20.5 2,405

Religion Hindu 7.1 9.6 18.8 15.7 17.4 10.7 24.6 3,954 Muslim (9.3) (7.4) (22.2) (9.3) (9.3) (7.4) (18.5) 40 Sikh 13.3 14.9 14.9 19.3 12.3 4.8 11.4 69 Other (1.7) (2.1) (3.8) (3.8) (3.8) (2.4) (12.5) 43

Caste/tribe# Scheduled caste 8.3 10.5 18.1 16.7 19.3 12.2 25.1 900 Scheduled tribe 4.7 9.1 14.7 13.6 11.7 7.8 21.1 179 Other backward class 8.9 9.3 17.1 11.3 12.4 9.4 21.9 369 Other 6.8 9.4 19.3 16.0 17.5 10.3 24.5 2,644

Standard of living index Low 9.9 13.0 24.7 21.8 23.7 13.6 27.8 748 Medium 8.3 11.8 20.1 18.2 20.1 13.6 26.2 1,666 High 4.9 5.9 14.4 10.2 11.3 6.1 20.6 1,692

Total 7.2 9.6 18.6 15.6 17.1 10.5 24.2 4,106 @ Literate men with no year of schooling are also included. (): Based on less than 50 unweighted cases. # Total number may not add to N due to do not know and missing cases.

The percentage of men having misconceptions about the transmission of HIV/AIDS was the highest (25 percent) for Hindu men, followed by 18 percent for Muslim men and the lowest (11 percent) for Sikhs. The percentage of men having misconceptions about the transmission of HIV/AIDS was the highest (25 percent) for scheduled caste men, followed by over 24 percent for men from other castes and the lowest (21 percent) for scheduled tribe men.

154 8.5.5 Knowledge of Curability of HIV/AIDS

Table 8.18 gives percentage distribution of currently married women and their husbands who have heard about HIV/AIDS by knowledge of curability of HIV/AIDS, according to selected background characteristics in the state. The percentage of respondents who said HIV/AIDS is curable was 22 percent for women and 14 percent for men. Similarly, percentage of respondents who said HIV/AIDS is not curable was 53 percent for women and 71 percent for men. Further, percentage of respondents who said HIV/AIDS ‘do not know’ about its curability was 24 percent for women and 15 percent for men. The percentage of rural respondents who said ‘do not know’ about curability of HIV/AIDS was 27 percent for women and 16 percent for men. Similarly, percentage of urban respondents who said ‘do not know’ about curability of HIV/AIDS was 27 percent for women and 11 percent for men. Again, percentage of women who said HIV/AIDS is curable was the highest (24 percent) for women who had studied for 10 years and above and the lowest (18 percent) for non-literate women, while it was over 21 percent for women who had studied for 0-9 years. The percentage of women who said HIV/AIDS is curable was 24 percent for women with high SLI and 21 percent for women with low and medium SLI. The percentage of women who said HIV/AIDS is curable was 29 percent for OBC women, followed by 22 percent for scheduled caste and other castes women and lowest (15 percent) for scheduled tribe women.

Table 8.18 KNOWLEDGE OF CURABILITY ABOUT HIV/AIDS Among currently married women and their husband, who have heard about HIV/AIDS, Percent distribution of respondents by knowledge of curability about HIV/AIDS, according to some selected background characteristics, Himachal Pradesh, 2002-04 Percent distribution of women Percent distribution of men Number Do not Number of Do not of Background characteristic Yes No know women Yes No know men Residence Rural 20.8 52.3 26.9 5,104 13.6 70.1 16.3 3,089 Urban 26.9 55.7 17.4 1,706 16.5 72.3 11.1 1,017

Education Non-literate 18.4 39.3 42.3 855 11.7 46.7 41.7 242 0-9@ years 21.5 46.9 31.6 2,681 13.9 63.6 22.3 1,459 10 years and above 24.1 61.8 14.1 3,271 14.8 77.3 7.9 2,405

Religion Hindu 22.2 53.0 24.8 6,549 14.3 70.8 14.9 3,954 Muslim 30.2 46.6 23.2 79 (14.8) (63.0) (22.2) 40 Sikh 25.4 59.1 15.5 128 26.1 57.8 16.1 69 Other 23.0 61.6 15.3 54 (3.1) (74.2) (22.6) 43

Caste/tribe# Scheduled caste 21.9 50.6 27.4 1,390 14.2 65.8 19.9 900 Scheduled tribe 14.7 62.1 23.2 206 8.5 71.6 19.9 179 Other backward class 28.7 44.9 26.5 701 14.7 69.0 16.4 369 Other 21.8 54.8 23.4 4,504 14.8 72.3 12.8 2,644

Standard of living index Low 21.6 40.7 37.6 1,005 15.6 55.3 28.9 748 Medium 20.7 51.3 28.0 2,867 13.7 70.6 15.6 1,666 High 24.3 59.2 16.6 2,938 14.3 77.5 8.2 1,692

Total 22.4 53.1 24.5 6,810 14.3 70.6 15.0 4,106 Note: Total includes 2 case missing information on education of women # Total number may not add to N due to do not know and missing cases. ( ): Based on less than 50 unweighted cases. @ Literate persons with no year of schooling are also included.

8.6 Awareness of RTI/STI and HIV/AIDS by Districts

Table 8.19 gives percentage distribution of currently married women and their husbands aware

155 of RTI/STI and HIV/AIDS by districts. The percentage of women aware of RTI/STI was the highest (90 percent) in Kangra district, followed by 71 percent in Sirmaur district and the lowest (four percent) in Lahul & Spiti district, while it was 37 percent for the state. On the other hand, percentage of men aware of RTI/STI was the highest (71 percent) in Kangra district, followed by 58 percent in Sirmaur district and the lowest (three percent) in Lahul & Spiti, while it was 34 percent for the state.

The percentage of women aware of HIV/AIDS was the highest (94 percent) in Kangra district, followed by 91 percent in Hamirpur district and the lowest (57 percent) in Kullu district, while it was 79 percent for the state. Further, level of awareness of HIV/AIDS was higher than that of the state (79 percent) in Hamirpur, Kangra, Sirmaur, Solan and Una districts, while in the remaining seven districts it was lower that that of the state. The percentage of men aware of HIV/AIDS was the highest (98 percent) in Hamirpur district, followed by 97 percent in Kangra district and the lowest (71 percent) in Kullu district, while it was 90 percent for the state. Further, level of awareness of HIV/AIDS was equal to or higher than that of the state (90 percent) in Bilaspur, Hamirpur, Kangra, Kinnaur, Lahul & Spiti, Shimla, Sirmaur, Solan and Una districts, while in the remaining three districts it was lower than that of the state. These data have shown that level of awareness of HIV/AIDS was higher among men than among women in all the districts of Himachal Pradesh.

Table 8.19 AWARENESS OF RTI/STI AND HIV/AIDS BY DISTRICT Percentage of currently married women and their husbands aware of RTI/STI and HIV/AIDS by district, Himachal Pradesh, 2002-04 District Percentage of women Percentage of men Aware of RTI/STI Aware of HIV/AIDS Aware of RTI/STI Aware of HIV/AIDS

Bilaspur 24.3 76.7 18.7 95.3 Chamba 34.7 62.7 18.9 86.5 Hamirpur 24.9 90.9 31.0 97.7 Kangra 90.5 94.5 71.0 97.1 Kinnaur 8.1 74.2 13.9 92.1 Kullu 11.2 55.9 12.5 70.7

Lahul & Spiti 3.6 69.9 3.3 91.7 Mandi 19.1 71.7 25.9 83.5 Shimla 21.2 76.3 27.3 90.2 Sirmaur 71.3 84.3 58.4 93.0 Solan 12.3 80.9 20.4 93.5 Una 12.1 79.7 30.5 91.6

Himachal Pradesh 37.2 79.0 34.4 90.2

156 Appendix – A

Sampling Error Estimation

The accuracy of programme indicators such as contraceptive prevalence rate, unmet need and institutional delivery, antenatal coverage etc. estimated from DLHS-RCH can be assessed in terms of stability of the estimated indicators as measured by the standard errors. Standard errors reflect only the appropriateness and suitability of sampling design adopted for RCH survey. However, the accuracy of estimated programme indicator are also affected to a great extent by non-sampling errors arising from lack of proper operationalisation and non- response cases, and is inherent in large scale surveys. The estimation producers of District Level Reproductive & Child Health survey takes into consideration design appropriateness and non-response rates. DLHS-RCH estimator of a programme indicators is design as

y ∑∑∑whji hji y r = hji = ………………………………………. (1 ) ∑∑∑whji xhji hji x

where the cell (h, j, i) stands for ith observational unit in jth primary sampling unit (PSU) in hth stratum, basically rural-urban areas of a district are taken as strata. Whij is the sampling weight of (h, j, i)th cell inflated by response rates. The variables y and x denote the main and the auxiliary characteristics required for computation of proportion or ratios.

The equation for estimation of variance of programme indicator ( r ) is obtained after Taylor series linearisation as

1 var ( r ) = [ var ( y ) + r2 var ( x ) - 2 r cov (y, x )] ……………… …………….(2 ) x 2

2 ⎛ ⎞ ⎜ w y ⎟ n ⎜∑∑ hji hji ⎟ var ( y ) = ∑ h [ ∑∑(w y ) 2 – ⎝ ji ⎠ ] .………….( 3 ) n −1 hji hij h h ji nh

(∑∑ whji yhji )(∑∑ whji xhji ) nh 2 ji ji cov ( y , x ) = [ whji yhji xhji − ] ……….( 4 ) ∑ n −1 ∑∑ h h ji nh and nh is the number of sampled PSUs representing rural or urban areas of a district/state.

List of Selected Programme Variables for Sampling Errors, RCH 2002-04

Variable Estimate Base Population

CPR (Any Method) Proportion Currently married women age 15-44 years

Unmet Need Proportion Currently married women age 15-44 years

Any ANC Proportion Last live/still births in the past three years

ANC3+ Proportion Last live/still births in the past three years

Institutional Delivery Proportion Last live/still births in the past three years

Safe Delivery Proportion Last live/still births in the past three years

BCG Proportion Children age 12-23 months

Measles Proportion Children age 12-23 months

BO3+ Proportion Currently married women age 15-44 years with births in past three years

158

Sampling errors, Himachal Pradesh, 2002-04 Number of cases 95% Conf. Interval Estimate Sampling Design Relative R-1.96 R+1.96 Variables (R) error (SE) Unweighted Weighted Effect Error (%) SE SE Contraceptive Prevalence Rate (Currently Married Women age 15-44) Total 0.701 0.007 8,618 8,618 1.850 1.0 0.688 0.714 Rural 0.690 0.008 6,748 6,748 1.837 1.1 0.675 0.705 Urban 0.742 0.014 1,870 1,870 1.891 1.9 0.715 0.769 Unmet Need (Currently Married Women age 15-44) Total 0.118 0.005 8,618 8,618 1.827 4.0 0.109 0.128 Rural 0.124 0.005 6,748 6,748 1.808 4.3 0.114 0.135 Urban 0.097 0.009 1,870 1,870 1.909 9.7 0.079 0.116 Received Any Antenatal Check up (last live/still birth of past 3 years) Total 0.910 0.007 2,688 2,666 1.723 0.8 0.895 0.924 Rural 0.897 0.008 2,195 2,150 1.653 0.9 0.880 0.913 Urban 0.962 0.013 493 516 2.539 1.4 0.936 0.989 Received 3+ Antenatal Check up (last live/still birth of past 3 years) Total 0.680 0.012 2,688 2,666 1.773 1.8 0.657 0.704 Rural 0.638 0.014 2,195 2,150 1.775 2.2 0.611 0.666 Urban 0.854 0.020 493 516 1.698 2.4 0.815 0.894 Institutional Delivery (last live/still birth of past 3 years) Total 0.451 0.013 2,688 2,665 1.924 3.0 0.425 0.477 Rural 0.381 0.015 2,195 2,150 1.911 3.8 0.353 0.410 Urban 0.741 0.025 493 515 1.735 3.4 0.692 0.791 Safe Delivery (last live/still birth of past 3 years) Total 0.514 0.013 2,688 2,666 1.887 2.6 0.488 0.540 Rural 0.449 0.015 2,195 2,150 1.879 3.3 0.420 0.478 Urban 0.786 0.024 493 516 1.720 3.0 0.740 0.833 Received BCG Vaccination (last and last but one living children, age 12-23 months) Total 0.961 0.007 929 932 1.278 0.7 0.947 0.975 Rural 0.961 0.008 769 769 1.237 0.8 0.945 0.976 Urban 0.963 0.018 160 163 1.481 1.9 0.927 0.999 Received Measles (last and last but one living children, age 12-23 months) Total 0.886 0.012 929 932 1.422 1.4 0.862 0.911 Rural 0.879 0.014 769 769 1.460 1.6 0.851 0.907 Urban 0.919 0.023 160 163 1.165 2.5 0.872 0.965 Birth order 3+ (birth in last three years) Total 0.244 0.011 2,899 2,881 1.737 4.3 0.223 0.265 Rural 0.260 0.012 2,410 2,358 1.736 4.6 0.237 0.283 Urban 0.172 0.021 489 523 1.686 12.4 0.130 0.214

159

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Contraceptive Prevalence Rate (Currently Married Women age 15-44) Bilaspur 0.689 0.017 834 833 2.5 0.655 0.722 Chamba 0.662 0.018 726 726 2.7 0.626 0.697 Hamirpur 0.662 0.019 764 765 2.9 0.626 0.699 Kangra 0.705 0.018 749 749 2.6 0.670 0.739 Kinnaur 0.688 0.019 674 674 2.8 0.651 0.724 Kullu 0.753 0.019 690 691 2.5 0.716 0.790

Lahul & Spiti 0.653 0.020 606 607 3.1 0.613 0.693 Mandi 0.727 0.018 716 716 2.5 0.693 0.762 Shimla 0.792 0.017 700 700 2.1 0.759 0.826 Sirmaur 0.709 0.021 830 830 3.0 0.668 0.750 Solan 0.692 0.020 683 680 2.9 0.654 0.731 Una 0.583 0.020 646 645 3.4 0.543 0.623

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Unmet Need (Currently Married Women age 15-44) Bilaspur 0.121 0.012 834 832 9.9 0.097 0.145 Chamba 0.135 0.013 726 726 9.6 0.110 0.161 Hamirpur 0.143 0.014 764 765 9.8 0.117 0.170 Kangra 0.114 0.012 749 749 10.5 0.090 0.138 Kinnaur 0.129 0.014 674 674 10.9 0.102 0.155 Kullu 0.072 0.011 690 691 15.3 0.050 0.094

Lahul & Spiti 0.116 0.014 606 608 12.1 0.090 0.143 Mandi 0.100 0.012 716 716 12.0 0.077 0.123 Shimla 0.087 0.011 700 700 12.6 0.065 0.109 Sirmaur 0.124 0.017 830 830 13.7 0.090 0.157 Solan 0.109 0.013 683 680 11.9 0.083 0.135 Una 0.199 0.016 646 645 8.0 0.167 0.231

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Received Any Antenatal Check up (last live/still birth of past 3 years) Bilaspur 0.922 0.020 193 201 2.2 0.883 0.960 Chamba 0.863 0.021 261 265 2.4 0.822 0.904 Hamirpur 0.971 0.012 220 218 1.2 0.948 0.994 Kangra 0.972 0.011 231 236 1.1 0.950 0.993 Kinnaur 0.949 0.014 252 249 1.5 0.923 0.976 Kullu 0.811 0.038 163 165 4.7 0.736 0.885 Lahul & Spiti 0.914 0.019 230 240 2.1 0.876 0.951 Mandi 0.871 0.025 211 213 2.9 0.822 0.921 Shimla 0.859 0.026 215 199 3.0 0.808 0.910 Sirmaur 0.927 0.021 284 303 2.3 0.886 0.967 Solan 0.956 0.014 215 212 1.5 0.929 0.982 Una 0.910 0.021 213 211 2.3 0.869 0.950

160

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Received 3+ Antenatal Check up (last live/still birth of past 3 years) Bilaspur 0.701 0.035 193 201 5.0 0.634 0.769 Chamba 0.530 0.032 261 265 6.0 0.468 0.593 Hamirpur 0.809 0.031 220 218 3.8 0.749 0.869 Kangra 0.760 0.028 231 236 3.7 0.704 0.816 Kinnaur 0.648 0.031 252 250 4.8 0.587 0.709 Kullu 0.662 0.043 163 165 6.5 0.577 0.747

Lahul & Spiti 0.634 0.033 230 240 5.2 0.570 0.699 Mandi 0.617 0.036 211 211 5.8 0.547 0.688 Shimla 0.716 0.034 215 198 4.7 0.650 0.782 Sirmaur 0.570 0.039 284 303 6.8 0.493 0.646 Solan 0.730 0.033 215 212 4.5 0.666 0.795 Una 0.677 0.034 213 211 5.0 0.611 0.743

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Institutional Delivery (last live/still birth of past 3 years) Bilaspur 0.620 0.037 193 201 6.0 0.547 0.693 Chamba 0.250 0.028 261 265 11.2 0.196 0.305 Hamirpur 0.480 0.037 220 219 7.7 0.407 0.552 Kangra 0.550 0.034 231 235 6.2 0.482 0.617 Kinnaur 0.335 0.032 252 249 9.6 0.273 0.397 Kullu 0.480 0.046 163 166 9.6 0.391 0.569

Lahul & Spiti 0.354 0.033 230 240 9.3 0.290 0.419 Mandi 0.314 0.033 211 212 10.5 0.249 0.378 Shimla 0.625 0.037 215 199 5.9 0.552 0.697 Sirmaur 0.310 0.038 284 303 12.3 0.236 0.384 Solan 0.538 0.037 215 213 6.9 0.466 0.610 Una 0.402 0.035 213 211 8.7 0.333 0.472

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Safe Delivery (last live/still birth of past 3 years) Bilaspur 0.649 0.037 199 199 5.7 0.577 0.721 Chamba 0.285 0.029 265 265 10.2 0.228 0.342 Hamirpur 0.615 0.037 218 218 6.0 0.543 0.687 Kangra 0.655 0.033 235 235 5.0 0.591 0.720 Kinnaur 0.384 0.033 248 248 8.6 0.320 0.447 Kullu 0.508 0.046 165 165 9.1 0.419 0.598

Lahul & Spiti 0.480 0.034 239 239 7.1 0.413 0.548 Mandi 0.349 0.034 212 212 9.7 0.282 0.416 Shimla 0.652 0.036 198 198 5.5 0.581 0.723 Sirmaur 0.344 0.038 303 303 11.0 0.269 0.418 Solan 0.593 0.036 212 212 6.1 0.523 0.663 Una 0.522 0.036 212 212 6.9 0.452 0.593

161

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Received BCG Vaccination (last and last but one living children, age 12-23 months) Bilaspur 1.000 0.000 76 80 1.0 1.000 0.0 Chamba 0.849 0.043 69 68 0.8 0.934 5.1 Hamirpur 0.966 0.019 58 57 0.9 1.004 2.0 Kangra 0.990 0.010 80 80 1.0 1.009 1.0 Kinnaur 0.977 0.018 78 79 0.9 1.012 1.8 Kullu 0.940 0.039 61 65 0.9 1.016 4.1

Lahul & Spiti 0.963 0.025 72 72 0.9 1.013 2.6 Mandi 0.961 0.024 69 66 0.9 1.008 2.5 Shimla 0.986 0.014 74 69 1.0 1.013 1.4 Sirmaur 0.907 0.026 92 96 0.9 0.958 2.9 Solan 0.948 0.029 73 71 0.9 1.006 3.1 Una 0.988 0.012 70 71 1.0 1.012 1.2

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Received Measles (last and last but one living children, age 12-23 months) Bilaspur 0.777 0.047 76 80 0.7 0.868 6.0 Chamba 0.765 0.050 69 68 0.7 0.864 6.6 Hamirpur 0.955 0.022 58 57 0.9 0.999 2.3 Kangra 0.943 0.025 80 80 0.9 0.992 2.7 Kinnaur 0.860 0.039 78 79 0.8 0.936 4.5 Kullu 0.853 0.056 61 65 0.7 0.964 6.6

Lahul & Spiti 0.922 0.032 72 72 0.9 0.984 3.5 Mandi 0.884 0.038 69 66 0.8 0.959 4.3 Shimla 0.897 0.037 74 69 0.8 0.970 4.1 Sirmaur 0.797 0.045 92 96 0.7 0.885 5.6 Solan 0.861 0.042 73 71 0.8 0.944 4.9 Una 0.931 0.034 70 71 0.9 0.998 3.7

Sampling errors, Himachal Pradesh, 2002-04 Estimate Sampling Number of cases Relative 95% Conf. Interval District (R) error (SE) Unweighted Weighted Error (%) R-1.96 SE R+1.96 SE Birth order 3+ (birth in last three years) Bilaspur 0.254 0.033 212 221 13.0 0.190 0.317 Chamba 0.422 0.031 285 290 7.3 0.362 0.482 Hamirpur 0.249 0.034 222 218 13.7 0.183 0.316 Kangra 0.191 0.026 252 254 13.6 0.139 0.242 Kinnaur 0.308 0.029 276 274 9.4 0.251 0.365 Kullu 0.226 0.039 167 167 17.3 0.150 0.301

Lahul & Spiti 0.319 0.033 224 232 10.3 0.255 0.382 Mandi 0.203 0.028 240 245 13.8 0.149 0.258 Shimla 0.178 0.029 230 212 16.3 0.122 0.235 Sirmaur 0.410 0.035 353 367 8.5 0.342 0.479 Solan 0.185 0.028 228 222 15.1 0.131 0.240 Una 0.264 0.032 210 214 12.1 0.202 0.327

162 APPENDIX B

DLHS-RCH STAFF, HIMACHAL PRADESH

Society for Applied Research in Humanities, New Delhi

Project Director Dr. O.P.Vig

Project Coordinators Mr. Bharat Katariya Mr. Narpal Singh Field Mangers Mr. Satish Kumar Mr. K.P. Singh Field Officers Mr. Rajesh Kumar Mr. Arun Kumar Team Supervisors Mr. K.P.Singh Mr. Prem Pal Singh Mr. Shantanu Kumar Mr. Rajeev Nag Field Editors Miss. Sulaskhana Miss. Pushpa Mr. Tejbir Miss Anita Health Investigators Mr. Ved Parkash Mr. Vinay Kumar Jha Mr. Pradeep Mr. Randhir Panday Mr. Anil Kaushik Mr. Anjani Kumar Jha Mr. Sarvesh Mr. Manoj Kumar Interviewers Mr. Haridutt Sukla Miss. Shilpa Sharma Mr. Prem Pal Singh Miss. Anju Mr. Sanjeev Miss. Archana Mr. Ankur Bhatiya Miss. Parveen Mr. Kuldeep Mr. Sushil Gupta Mr. Ashwani Household listing Supervisors Mr. Chander Prakash Mr. Vijender Singh Household Listers and Mappers Mr. Tara Chand Mr. Rajnish Kananjia Mr. Rajesh Mr. Arvind Kumar Office Editors Miss. Sunaina Miss. Geeta Singh Data Entry Operators Mr. Vinod Miss. Sangeetha Antony Miss. Hema Bhangari Miss. Santosh Rawat Mr. Gulam Yezdani Miss. Alka Yadav

163 International Institute for Population Sciences, Mumbai

Project Coordinators Dr. F. Ram Dr. B. Paswan Dr. L. Ladu Singh

Senior Research Officers Mr. Rajiv Ranjan Mr. K. C. Lakhara Mr. Nizamuddin Khan

Research Officers Mr. M. Nagavara Prasad Mr. Suhas Narkhede Mr. Akash N. Wankhede Mr. Pramod Kumar Gupta Mr. Uttam J Sonkamble Mr. Bipul Hazarika Mr. Ashok Kumar Dr. Manoj Alagarajan Ms. Jigna Thacker Dr. Kalyan Saha Ms. Baishali Goswami Dr. N Anbazhaham Ms. Sancheeta Ghosh Dr. Saithya Susaman Ms. Kirti Mishra Mr. Manoj Kumar Ms. Sucharita Pujari Mr. Dibya L Mohanta Ms. Preeti Chauhan Mr. Mohan Tiwari Mrs. Santhi N.S. Mr. Battala Madhusudana Ms. Sanjeeta Gupta Mr. Bardanwala S.I. Ms. Reshmi R.S. Mr. Jiten Kumar Singh Ms. Rinki Saha Mr. Manoranjan Barik Mr. Arnendu Kumar Jha Mr. Laxmi Prasad Sonwani Mr. Atanu Ghosh Mr. Nimakwala M. I. Mr. Manas Pradhan

Accounts and Administrative staff Mr. Sunil Adavede (Sr. Accountant) Mrs. Seema V. Zagade (Office Assistant) Mrs. Deepa J. Nair (Office Assistant) Mr. Jeba Kumar (Data Entry Operator) Ms. Pratima P. Zore (Data Entry Operator) Mr. Chandra D. Singh (Office Boy) Ms. Preeti S. Kharat (Data Entry Operator) Mr. Ravindra P. Gawade (Office Boy) Ms. Sayali Shivalkar (Data Entry Operator) Mr. Sanjay P. Kadam (Office Boy)

164 LIST OF CONTRIBUTERS

Dr. O.P. Vig , Project Director, DLHS-RCH Himachal Pradesh and General Secretary, Society for Applied Research in Humanities, New Delhi.

Mr. Ummed Singh, Research Associate, Society for Applied Research in Humanities, New Delhi.

Mr. Ghanshyam Upadhyay, Research Associate, Society for Applied Research in Humanities, New Delhi.

Mr. B.K. Yadav, Research Associate, Society for Applied Research in Humanities, New Delhi.

Mr. Ajay Tiwari, Research Associate, Society for Applied Research in Humanities, New Delhi.

Mr. Ravikesh, Research Associate, Society for Applied Research in Humanities, New Delhi.

Dr. F. Ram, Professor & Head, Department of Fertility Studies, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai-400088.

Dr. B. Paswan, Reader, Department of Population Policy and Programme, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai-400088.

Dr. L. Ladu Singh, Professor & Head, Department of Mathematical Demography and Statistics, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai-400088.

Mr. K. C. Lakhara, Senior Research Officer, DLHS-RCH, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai-400088.

Mr. Akash Wankhede, Research Officer, DLHS-RCH, International Institute for Population Sciences, Govandi Station Road, Deonar, Mumbai-400088.

165 Appendix – C

NOTES