Gender Selective Abortion

Background

The most recent invisible phenomenon of modern day world in reproductive health is Gender selective abortion. Abortion is spontaneous, unintended and unfortunate event for some people whereas sometimes abortion is induced due to various reasons, mostly preclude the probable danger to the life of pregnant women. Nevertheless, this advancement of safe abortion in medical field has been also used as the sex selection tool for the birth of desired offspring aborting fetus of undesired sex.

This phenomenon has been observed especially in those countries, where the patriarchy prevails and the birth is restricted by law or societal pressures. Even though profound effect of this phenomenon, the intensity of this problem is difficult to measure. Measuring female to male ratio at the time of birth is one of the indirect methods of the underlying gender selective abortion. Direct measurement of gender selective abortion is particularly challenging because of its ethical, moral, legal and social ground. The secrets are guarded and the population scientists are unable to measure the depth of this problem.

The abortion policy in Nepal allows abortion up to 12 weeks of fetal age with the consent of pregnant woman unlike previous laws and only woman can decide whether to continue or discontinue the pregnancy. Although Nepal has engendered a very liberal abortion policy since 2002, to abort a fetus based on its sex is strictly illegal and considered criminal act in Nepal. So, many abortions might occur undercover. Hence, the indirect measurement of selective abortion such as sex ratio, population sex ratio, desired gender composition could be suitable tools to measure the gravity of sex selective abortion. Many researchers have figured out falling sex ratio at the time of birth as reflection of this phenomenon.

Factors of gender preference and sex selective abortion

Macro level Factors

Here I would like to focus on certain Macro level factors of sex selective abortion.

• Socio-Cultural dimension: Culture is important aspect of our life. We live and learn the culture from the day we are born. Similarly the perception that prefer sons over daughters has been passed down from one generation to another generation as an integral part of culture. Many of our countries in the world, the society is patriarchal and males are head of the households, they are the ones who forms social networking and maintains the boundary, integrity and function of the social net. Males are given higher position in that society and they are required for any ritual procedures during vital events like birth and death. I would like to particularly specify an example in Nepal. Couples are pressurized to have at least one son as they feel that if they are not given funeral pyre by their son, they wouldn't be able to go to heaven after life and daughters are not allowed to involve in such ritual. Though, many daughters have come forward to break this stereotype, It still is ingrained in minds of many people.
  
• Economic Transition:Our traditional society was agrarian where the larger number of offsprings would be desirable assets to the family. Sons were valued the most because of their high physical strength and utility compared to daughters. Yet, they could be help to the household chores and strengthening the family relationships. There was negligent concept of child health and care so the number of offsprings was not an issue of high concerns but with human civilization and modernization, child care and the number of children in the family have been central focus of the family now. Higher number of offsprings have also been stigmatized as a sign of ignorance. High investment in child care, concern about the number of children and fixed attitude towards gender; son as must-have offspring have led the many men and women taking such decisions.
  
• Technological advancement:Technological advancement has also been a contributing factor in sex selective abortion to some extent. Early detection of sex of the fetus with advanced ultrasonography and claimed safe abortion procedures serves to make decision for the trade for women health and the child of desired sex.
• Demographic transition and Policy: As the population growth rate and the fertility rate were high, the government in China came up with the "One child policy". Similarly, the government led family health programs in Nepal came up with the slogans of two children . These official and unofficial government policies have also fueled the limitation of birth and consequently, gender selective abortion in invisible way.

By Pramila Rai

Birth Preparedness and Complication readiness

Case Scenario

“In a rural area of Nepal, a woman is due to childbirth and she lives almost 5-6 hours far from the health care center. She belongs to low middle income socio-economic class. she is not aware of danger signs of pregnancy. Her family members think that childbirth is simply a natural process of giving birth and there is no necessity of special precaution because they gave birth to their children at home without anyone’s attendance from generation to generation. They know there is ambulance service but they don’t know the contact details of the ambulance service. The woman, her husband and other family members are not aware of any danger signs of childbirth. She starts getting contraction and pain but her mother in law is very sure that she delivers baby without any events. Her labor progresses, but instead of head, the cord prolapses. The outcome is yet unknown”

In above scenario, what are the conditions that can lead to adverse events of maternal and child morbidities, deaths?

1.  She is not institutionalized for the childbirth.
2.  They don’t have enough money saved for childbirth
3. They don’t have vehicle even if they want to take her to health care center in case of   emergency. She might reach the health center after golden hours.
4. They even don’t know when should they be contacting health care workers
5. They haven’t identified the people, who can donate blood if needed
6. They will take very long time to identify the complications, arrange money, vehicles and to decide which health center, they will be going.

What could have done to make sure healthy childbirth?

1. Birth Preparedness and complication readiness!!: definitely an answer among many others.

What is Birth Preparedness and complication readiness?

Whenever we study measures that effectively helped to reduce maternal mortalities and neonatal mortalities, we encounter the phrase ‘birth preparedness and complication readiness’. Birth preparedness package is simply a set of planning strategies that better assist the process of giving birth to a child to make child bearing process safe, appropriate, affordable, and accessible. Though birth preparedness is equally important to everyone, this concept is much more relevant and emergent for the developing world, where the childbirth is taken for granted and maternal death and newborn death during the child bearing process are high. It is proactive step to preclude maternal and newborn complications and mortalities. This strategy includes preparation of family, who are expecting child with counseling for preparing anticipated funds for delivery of baby, vehicles for transportation, probable hospital and health care providers, warm clothes for both baby and mother, blood donors in case of need, educational materials regarding danger signs of pregnancy, childbirth and postpartum period. In a birth preparedness package, counselling and educational materials are provided to the couple and family informing all the preparation.

How it impacts?

It helps in tackling three delays, identified to be main causes of maternal and newborn deaths. Birth preparedness obviates delay in seeking, delay in reaching and delay in receiving the care at the time of birth. For example, in the aforementioned case scenario, there is a high possibility that the family members would take a longer time to identify that the prolapse of cord is a danger sign of the childbirth that may cost child’s life and even if they identify the danger signs, they will take longer time to arrange money, vehicle or if they don’t have any transportation facilities, it will take even days to reach health care facility and health care providers. These delays may cause mother’s morbid conditions, death, and fetal death.

A woman or a family is considered to be prepared for birth and tackling tentative complications if they arrange estimated money, identify blood donors, transportation mechanism, know danger signs of pregnancy, childbirth and postpartum, identify health care providers and health care center.

Promoting Birth Preparedness and complication readiness is one of the three major strategies of safe motherhood and newborn health program of Nepal, others being Aama Surakshya Program and expansion of 24-hour emergency obstetric care services at public health facilities. These strategies have been successful in decreasing the maternal mortality rate of Nepal.

Measuring Maternal Health

What is Maternal Health?

Maternal health is health at the time of pregnancy, childbirth or postpartum period. It is pleasant experience to women and families; however, some women die or develop some complications that affect quality of life. Some even develop maternal complications causing chronic morbidities such as obstetric fistula (it is the condition where there is hole between rectum and vagina or between urinary bladder and vagina and the women suffering with it, are ostracized and secluded from family and the society in many cases), dyspareunia (painful sexual intercourse), prolapse (the pelvic organ is prolapsed down from vagina, women having such condition are stigmatized in the society and women consider it as shameful condition and hides it instead of seeking medical help) and they might be stigmatized and ostracized from the society just because she doesn’t get appropriate intervention at the time of childbirth. Some might have normal childbirth and may not need any assistance but no pregnancy can be considered free of risk as complications can arise at any point of time so there should be availability of appropriate, affordable health care service for each pregnant woman.

How can we measure maternal health?

Maternal health can be measured with specific indicators.

We can use the various indicators to understand the status of anything in any group or population. These are also useful in measuring progress towards predefined objectives. Depending upon the type of indicator, Indicator provides information regarding a health outcome or management process. Indicators are the markers to understand our own position on the pathway to our goal. If we want to cover 1000 km, the covered distance at particular time is the indicator to have understanding of our own progress. To assess the status of maternal health we can use impact indicators, Process indicator and outcome indicator. Impact indicators provide information on the end result, but may not provide understanding into how the outcome was achieved. Process and outcome indicators provide insight into the program activities carried out to achieve the objectives.

Maternal health is measured using such multiple indicators. Those indicators can be broadly categorized as Impact indicator, Outcome Indicator and Process indicator. Impact indicator is the indicator, which reflects the final expected change in the status. It expresses how much programmes have brought a change in the health status.

Outcome and process indicators are used to measure access to and use of care, as well as quality of care. Outcome and process indicators are generally easier to measure than impact indicators. However, the scope of outcome and process indicators is limited in that they do not measure the event of primary importance: maternal mortality. Nevertheless, if we don’t have quality data of maternal deaths, and other required information, then these outcome and process indicators can also be utilized to evaluate maternal health status and programmes. The most recent NDHS 2011 too evaluated outcome and process indicators instead of maternal mortality.

Indicators	Example
Impact indicator	Maternal mortality rate/ratios, Life time risk of maternal death
Outcome Indicator and Process indicator	Proportion of Deliveries by skilled personnel, proportion of birth by site, Met need for essential obstetrics Referral rate

Why do we need the Indicator?

1. To find out whether the implemented programmed are effective or not

2. To find out progress

3. To decide resource allocation

4. To explore the barriers and challenges in achieving the goal or objectives

Impact indicator is commonly used for evaluation of maternal health status and to assess the effectiveness of the maternal health programmes.

1. Maternal mortality ratio (MMR): is the total number of maternal deaths per 100,000 live births. The MMR is calculated as follows:

WHO recommends including maternal deaths that occur within 42 days of the end of pregnancy. The numerator includes deaths due to direct obstetric complications of pregnancy, labor, and the puerperium and deaths from a previously existing condition that develops during or is aggravated by the pregnancy (Indirect obstetric deaths). Deaths, resulted from accidental or incidental causes, such as an automobile accident, are generally not included in the numerator.  This indicator is used to measure obstetric risk once a woman becomes pregnant and useful to gauge the progress in maternity services.

The maternal mortality ratio measures risk of maternal death once a woman becomes pregnant. This is especially useful to measure progress in maternity services.

2. Maternal Mortality rate: The maternal mortality rate is the maternal deaths per 1,000 women of reproductive age. The maternal mortality rate measures the risk of dying and also includes the likelihood of both becoming pregnant and dying the pregnancy or the puerperium. 

 

3. Lifetime risk of maternal death

This enumerates a woman’s probability of dying from maternal causes over her reproductive life span, usually given as 30-35 years. This measure is determined by the probability of becoming pregnant and the risk of death once pregnant.This is the life time risk of a girl reaching to the age of 15 years. If some region have higher fertility rate, then the lifetime risk also increases as the woman is exposed to risk multiple times in her reproductive age and if the fertility is less the lifetime risk of maternal death is less.

4. Case Fatality rate

The case fatality rate is the proportion of death of women with obstetric complications in a specific facility providing emergency obstetric care. The CFR is calculated as follows:

For example, if the department of obstetrics and gynecology receives 100 cases of hemorrhage, 50 cases of prolonged or obstructed labor, 100 cases of postpartum sepsis, 100 cases of complications of abortion, 50 cases of preeclampsia/eclampsia, 100 cases of ectopic pregnancy and 100 cases of ruptured uterus in one month. Two hundred women die of such complications during this duration of one month.

The CFR would be

200                

______ = 0.33

600

The case fatality rate is an indicator of the likelihood that a woman with an obstetric complication will survive after admission to the medical facility. CFR can be calculated for specific complications as well as in whole.

This measure will be affected by the quality and promptness of medical care provided, and the condition of the woman upon admission to the facility.

5. Proportionate maternal mortality

Proportionate mortality is a useful measure of the percentage of deaths among women of reproductive age that are due to pregnancy.

6. Cause specific proportionate maternal mortality rate: we can also enumerate cause specific proportionate maternal mortality rate.

7. Proportion of maternal morbidity: It can be estimated to measure effectiveness and efficiency of maternal health care program as well as burden of diseases. Maternal morbidity refers to any physical, mental illness caused by pregnancy or childbirth. Prevalence or incidence of maternal complications and sequelae: we can also estimate the prevalence or incidence of maternal complications to get scenario of maternal health and quality, efficiency of maternal health care services.

• Acute maternal morbidity
• Postpartum maternal morbidity and disabilities
• Chronic morbidity

Process and outcome indicators

These indicators give clear picture of maternal health service. We can also have understanding about how much we are investing on maternal health programme and how many are getting the appropriate services. Number of trained skilled birth attendants, number of birthing centers per population, Proportion of Deliveries by skilled personnel, proportion of birth by site, Met need for essential obstetrics, Referral rate are such indicators.

Some terminologies

Maternal Health Status in Nepal

Nepal has achieved significant progress in Maternal health demonstrated by decreasing maternal mortality ratio in Nepal. Maternal mortality ratio is the impact indicator of the maternal health programmes. It was possible due to prioritization of safe motherhood and newborn healthprogram of Nepal along with other multiple socioeconomic and political advances.

To analyze the progress of the maternal health in Nepal, Lets look into the maternal health indicators.

(Impact indicator: It includes maternal mortality ratio, maternal mortality rate, lifetime risk of maternal death etc.)

Trends of Maternal mortality ratio and major development in the field of maternal health in Nepal

The decrement in MMR from 790 to 580 from 1990 to 1995 could be result of National Health Policy 1991 that had prioritized on preventive health services including Family planning, safe motherhood.

OUTCOME AND PROCESS INDICATOR

Nepal demographic and health survey 2011, instead of impact indicator, measured outcome and process indicator, which is relatively easy to enumerate than maternal mortality rate and ratios. Outcome and Process indicators are also important to evaluate the maternal health programmes as these will directly impact the progress in maternal health.

Indicator	Current data	Source
Antenatal care (% Of women attended at least four times during pregnancy by any provider)	50.1	NDHS, 2011
Skilled attendance at birth (% of births attended by skill health staff)	36	NDHS, 2011
Anti-Retroviral for women (HIV- positive pregnant women to reduce mother to child transmission)	20.1	NDHS, 2011
Postnatal care for mothers (% of mother who received care within two days)	45	NDHS, 2011

Maternal Health Services in Nepal: All the maternal health Policies, strategies and programmes are directed to make family planning service, antenatal care, delivery care, Postnatal care efficient so that mothers receive required services, get proper diagnosis and proper intervention when necessary. Activities in safe motherhood programme of Nepal focuses on making those essential care available, accessible to every woman and family. 

1. Antenatal Care

Antenatal care services include:

• At least four antenatal check‐ups: first at 4th month, second at 6th month, third at 8^th month and fourth at 9th month of pregnancy;
• Monitor blood pressure, weight and fetal heart rate;
• Provide information, education and communication (IEC) and behavior change communication (BCC) for danger signs and care during pregnancy and timely referral to the appropriate health facilities;
• Birth preparedness and complication readiness (BPCR) for both normal and obstetric emergencies (delivery by skilled birth attendants, money, transportation and blood);
• Early detection and management of complications;
• Provision of tetanus toxoid (TT) immunization, iron and deworming tablets to all pregnant women and malaria prophylaxis where necessary

Nepal had a target to achieve 80 percent of women completing at least four antenatal care visits during their last pregnancy by 2015.

2. Delivery care

Delivery care services include:

• Skilled birth attendants at deliveries (either home‐based or facility‐based); however, our programmes has focused on facility based deliveries
• Early detection of complicated cases and management or referral after providing obstetric first aid by health worker to appropriate health facility where 24 hours emergency obstetric services are available;
• Obstetric first aid at home and/or HP/SHP if complications occur, using Emergency Obstetric Care Kit (EmOC kit);
• Identification and management of complications during delivery and referral to appropriate health facility as and when needed;
• Registration of births and maternal and neonatal deaths.
• Nepal has committed in achieving 60 percent deliveries by SBA BY 2015 (2071/72). Institutional delivery as percentage of expected pregnancies has been increasing trend from 44 to 50 percent from 2068/69 to 2070/71 to achieve targeted 60% institutional delivery by 2015 (NHSP II, 2010-2015).

3. Postnatal care

Postnatal care services include:

• Three postnatal visits: First visit within 24 hours of delivery, second visit on the third day and third visit on seventh day after delivery;
• Identification and management of mother's and newborn in complications of postnatal period and referral to appropriate health facility as and when needed;
• Promotion of exclusive breastfeeding;
• Personal hygiene and nutrition education, post‐natal vitamin A and iron supplementation for the mother;
• Immunization of newborns; and
• Post‐natal family planning counseling and services

4. Emergency Obstetric Care:

The SMNH long term plan (2006‐2017) has envisaged that by 2017, CEONC services will be available in 60 districts, 80 percent of PHCCs will provide BENOC services and 70 percent of HPs will provide delivery services. All women who needed obstetric complication should receive EmOC services and there should be universal coverage of EmOC.

C/S as a proportion of all live births has been found increasing as compared to last two consecutive years. In FY 2070/71, C/S as a proportion of all live births has increased by 2 percent reaching 8 percent of all live births. At population level 5‐15% of C/S as a proportion of all live births is accepted as minimum and maximum standard by the WHO.

Still, there are many challenges affecting accessibility, availability, affordability and sustainability of maternal health programmes as some of the programmes are driven by external fund. However, the government should be alert enough for its sustainability or alternatives. Our progress is satisfactory, but still number of women die with preventable causes so universal coverage of maternal health services and prioritization of safe motherhood in the health sector should be continued.

Sources:

1. DOHS. Annual Report 2070/2071

2. Nepal’s Quest for health. Plan, Policies and their implications.

3. WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division Maternal Mortality Estimation Inter-Agency Group. Maternal Mortality in 1990-2015:Nepal.