Putting women’s health at the centre of nation-building

Scientists, physicians, policymakers, community organizations, and most importantly a strong political will need to work in coordination towards a common mission.

As we celebrate Azadi ka Amrit Mahotsav, it does fill one with pride to see how far India has come in several walks of science. Healthcare is no different. From running the longest and largest vaccination campaigns that eradicated polio and controlled Covid-19 to becoming the pharmaceutical hub for the world, our achievements are globally recognized despite the challenges of our enormous population and limited resources.
Growing up as a woman and being a doctor gives me access to the lives of other women and their stories. I’ve witnessed a young lady who came to us almost dead after her fourth delivery (all of which happened in quick succession) survive. She is not only single-headedly bringing up her four daughters but also accomplished her childhood dream of becoming a nurse by becoming an ASHA worker so that she could protect other young girls from going through what she did. We have seen how a commercial sex worker has shielded her daughter all her life to help her eventually grow up to be teacher but failed to live a day with dignity herself. I have seen a lady pilot who flies people to their dream destinations break down in clinic when she was beaten and “raped again” by her intoxicated husband.
These stories remind one of the stark reality of women’s health issues, how they are often swept under the rug in a patriarchal society and how we are slowly but steadily making progress. More importantly, they also tell us how resilient women are; these stories are living examples of scientific research that has shown that when it comes to longevity, surviving illness and coping with trauma, one gender comes out on top. Even the almighty gave the responsibility of child-bearing to the stronger gender. For one second, just imagine a man going through labour-pains.
But women’s health has been historically ignored for a variety of reasons—gender bias and discrimination, barriers in accessing health care, stigma and taboos around menstruation and pregnancy and a lack of political will to prioritize this community. Until recently, even medical research largely focused on men, with women often excluded from clinical trials. As a result, there had been a dearth of data on women’s health.
In the background of Women’s Day, it is important to talk about our past successes and the roadmap ahead.

OUR SUCCESS STORY
To objectively quantify and compare the healthcare of a population or a country, “health indicators” are used. It is globally accepted that women and child health indicators are the ones that are a true reflection of quality and equity in health services. While a lot of these indicators have changed for the better, we as a nation do lag behind probably by decades to other developed countries. Maternal mortality has declined significantly, from 556 deaths per 100,000 live births in 1990 to 174 deaths per 100,000 live births in 2019 due to improved access to antenatal care, skilled birth attendants and emergency obstetric care. Infant mortality has also decreased from 61 deaths per 1,000 live births in 2000 to 28 deaths per 1,000 live births in 2019. Contraceptive use has increased from 13% in 1970 to 48% in 2017. This has helped reduce the number of unwanted pregnancies, space their pregnancies and reduce the risks of maternal and child mortality. From 1990 to 2019, the life expectancy for women has increased from 62 years to 71.2 years.
Similar success is also seen in otherwise lesser acknowledged areas of healthcare. Universal HIV testing of women during pregnancy and timely treatment have not only reduced mortality but have also brought down the rates of mother to child transmission significantly, thus protecting children of being born with HIV.
The government in India has implemented several initiatives to improve women’s health. To name a few: Pradhan Mantri Matru Vandana Yojana (provides financial assistance to pregnant and lactating women for their first live birth), Janani Suraksha Yojana (provides financial assistance to women from low-income families for institutional delivery and post-delivery care), and Mission Indradhanush (provides universal immunization coverage to all children and pregnant women). In any new system, there are always road-blocks, and we need to move ahead collectively.

OUR ROAD AHEAD
Like any calamity, the Covid-19 crisis also highlighted a lot of already existing crack-lines in our health care system. The widest one was the one of inequity. Like other marginalized sections of society, the inequity impacted women’s health to an unfathomable magnitude, more so in the rural areas and the lower socio-economic strata. Some of the major areas which need our urgent attention and corrective measures are:

1. Sexual and reproductive health: An analysis showed that during the 2020 lockdown, there was a 28% drop in women receiving requisite antenatal check-ups and institutional deliveries, leading to a 33% increase in maternal deaths and 28% increase stillbirths globally. On the other hand, millions of women were forced to either continue with an unwanted pregnancy or undergo unsafe abortion due to disruption of reproductive health services. The effect of this will last at least a generation.
2. Cervical and breast cancer: The most common cancers in women are cervical and breast cancer. Fortunately, both have inexpensive screening tools for early detection while the former also has a preventive vaccine. Until now, the imported vaccines remained elusive for Indian girls due to cost. Serum Institute of India has produced and offered the HPV vaccine at 5% of the global cost, thus allowing the GoI to launch the HPV vaccination program. We now need to tone up cancer-screening that remains abysmally low at less than 5%.
3. Mental health: The differences women and men experience due to socially constructed gender roles infiltrate all areas of life: household roles, responsibility and agency, power and social status. And therefore globally, girls and women are more likely to suffer from anxiety and depression. Indian women have higher rates of suicide than women in most developed countries. Psychiatrists and psychologists have seen a 200-300% rise in women with depression and anxiety since Covid times. Realizing the urgency and importance, the government earmarked special budget for mental health as well as stigma reduction in FY2023. Influencers like Deepika Padukone coming out openly to talk about depression has fuelled a wide range of much needed discussions.
4. School dropouts leading to nutritional deficiency and child marriages: India had made substantial progress in the field of children’s education in the last decade; so much so that the dropout rate for females was lower than males in 2018. Post-Covid, the increased poverty, reverse migration, job losses and digital divide led to dropouts across both genders, with girls at an expectedly higher rates. The disruption in the mid-day meal program has increased the incidence of girls with nutritional deficiency, anaemia and exploitation, like child labour, child marriages, pregnancies and prostitution. Reports of child marriage and sexual abuse during the pandemic had risen by up to 52% in some states in India.
5. Gender based violence: The National Family Health Survey of 2019-2021 showed that an overall 30% of women in India face gender-based violence. 70% of women between 15-49 years are victims of physical and sexual violence adversely affecting their health.
6. Work flexibility to enhance health: The health of the family and community rests on a healthy woman. It has been established repeatedly that work efficiency, honesty and productivity are higher with female employees. It is therefore pertinent to provide them leverage of additional leave benefits and work flexibility that can also cover for difficult menstrual periods or family exigencies. In my lifetime, I would like to see an ethical framework that prioritizes women’s rights and health that rest on autonomy, justice and beneficence. Autonomy is important in ensuring that women are empowered to make decisions about their own bodies, health and lives. Justice ensures that women have access to healthcare services and resources regardless of their socio-economic status, ethnicity, or other factors. Beneficence requires healthcare providers to prioritize the health needs of women and provide them with high-quality, evidence-based care.
   This requires not only the scientists and physicians, but also policymakers, community organizations, and most importantly a strong political will to work in coordination towards a common mission. There is an emergent need for political and other opinion leaders to discuss these issues more openly on public fora to create a wider awareness. We need innovation, appropriate use of social media and strong pro-active policies so that every time we strategize a nation-building exercise, we put women’s and girls’ health right in the centre. Like Nelson Mandela said, “If you want to change the world, help the women.”

Dr Trupti Gilada is a mother of two and a physician in Infectious Diseases at Unison Medicare and Research Centre, Saifee, Masina and Bhatia Hospitals in Mumbai.