Reproductive and Child Health Status Differentials in Tamil Nadu

 

Dr. K. Jothy¹* and Ms. S. Kalaiselvi²

 

¹Associate  Professor of  Population  Studies, Annamalai University, Annamalainagar-608002, Tamilnadu, INDIA

²Assistant Professor of Economics (DDE), Annamalai University, Annamalainagar-608002, Tamilnadu, INDIA

 

Health is a significant contributor to human capital formation and the health status of the population is an important indicator of human resource development.  Investment in health has direct returns in terms of longevity and improvement in the physical and mental development of the people.  Hence, health planning becomes an integral part of socio-economic planning and provision of health care facilities is related to preventive, curative and promotive services.

 

In India, there have been few attempts to evaluate the performance of reproductive health service providers through longitudinal studies. A study done by Sinha, Mohanty, Roy, and Koenig (2002) shows that though in 2002 there is low level of home visit by health workers at over all level in the states of Bihar, Maharashtra and Tamil Nadu, however situation has improved if it is compared with year 1998. The study is based upon a follow-up survey. The study concludes that women who receive regular home visits by the health workers are more likely to utilize the reproductive health services. In this manner, the study argues in favor of effectiveness of reproductive health programme efforts made by public service providers. In longitudinal context, a study done by Roy, Ram, Nangia, Saha & Khan (2003) has shown the role of psychological intentions in explaining the contraceptive demand.

 

Tamil Nadu has been upheld as a model for the rest of India for its impressive progress in fertility reduction and its vast investments in the provision of health care in the public sector. At the same time, women’s health status leaves much to be desired. More than half of ever married women in the age group of 15-49 in Tamil Nadu (53%) have anaemia, including 16 percent with moderate to severe anaemia. The prevalence has decreased by only 3 percentage points between NFHS-2 and NFHS-3.

 

The Reproductive and Child Health (RCH) Programme is the flagship programme of Family Welfare, which combines the trinity of objectives, viz., reproductive health, child survival and fertility regulations.  The inputs are linked to the needs of the area as well as capacity for implementation.  The programme (with district as the basis) is mainly offered through Primary Health Infrastructure.  The overall goals of the programme are to reduce maternal and infant mortality and morbidity and assure reproductivity health and choice and thereby contribute to the stabilization of population.

 

 

 

The programme is supported by World Bank, European Commission, UNFPA, UNICEF and other bilateral donors. In Tamil Nadu, the Reproductive and Child Health Project has been under implementation for 5 years commencing from 1998 with a financial outlay of Rs.23.14 crores in Madurai and Theni districts. The Reproductive Child Health services are aimed to promote 89% institutional deliveries in Tamil Nadu, MTP services, maternal death audit, to avoid the delay in seeking care, delay in reaching and delay in providing care, to provide for hiring of anesthetists and obstetricians, 24 hour delivery care services, RTI/STI clinics, training of medical and paramedical functionaries, upgrading the infrastructure, supply of drugs and equipments. The number of deliveries conducted in PHCs has increased from 44298 in 2000-01 to 73854 in 2002-03.  

 

In the state of Tamil Nadu, regions make the difference in the observed significant association between the utilization of maternal health care and independent variables at the state level. Though religion and age of women are significantly associated with maternal health care at the state level, it is not so in each region. The status of district in terms of human development index is positively associated with the utilization of maternal health care in Tamilnadu. There is a wide gap in the utilization of reproductive health care services among the states in India. Certain states like Kerala, Tamilnadu, and Maharashtra are performing well in the utilization of reproductive health care services. Inequalities in reproductive and child health (RCH) exist, in general, in different regions of India. The present study aims to investigate the current status of RCH and examine the factors responsible for it in different parts of India. 

 

State wise differentials in terms of demographic indicators are well established and reflect upon the divide and regional imbalances within India. To highlight it Bose, A (1996) has used the phrase “north-south demographic divide”. Phrase north-south demographic divide highlights the fact that southern states in India have achieved higher literacy level, economic development, lower fertility and mortality level; however northern states are lagging behind. In India, health care divide suggests inequalities in relation to region, income and caste. It is argued 14 that strategies to target such concern should emerge from understanding the particular distinctive ‘logics’ of local systems which is often embedded in socio-political and cultural specificities of the region (Reddy, S, 2008).

A study done by Jejeebhoy and Sathar (2001), highlights the importance of political state.  The study shows very clearly that state or region is stronger predictor of women autonomy than religion. Socio-political milieu is emphasized here, which is likely to play an important role in public-private partnerships as well. Needless to say here that there is critical importance of human factor andculture in the entire reproductive health system.  Roy et al in a book on population and development in Bihar (Sinha and Sinha, 1994) clearly highlights the role of health personnel (human factor) and shows the positive relationship between performance indicators and health personnel. In the same book, Mishra (1994) highlights the negative role of caste in reproductive health services utilization. 

 

Like India, Tamilnadu is also a state of many social, ethnic, religious and caste groups which, by and large, residing in villages where poverty, illiteracy, ignorance and superstitions prevail to some extent. Hence, the situation of population, health and health care practices, fertility and infant mortality is therefore, not uniform throughout the state. In this study an attempt has been made to an overall picture of the present scenario of differentials in health care utilization relative to reproductive and child health.

 

DATA AND METHODS:

This study utilized data obtained mainly from two Indian studies – (i) National Family Health Survey – 3 (NFHS- 2005-06) and (ii) District Level Household Survey (DLHS – 2002-04). Family welfare Statistics of India and reports of the Tamilnadu Health and Family Welfare Department, reports of various research institutions, and Census of India, 2011, were also used to obtain some ancillary information relating to the outcomes  of reproductive health for this analysis.

 

Reproductive Health Index was computed which gives an insight of the reproductive health status in different districts of Tamilnadu. The index has been calculated on the basis of five variables, such as total fertility rate, infant mortality rate, birth order, delivery care and female educational attainment in two stages. In the first stage, separate indices were calculated for each of the reproductive health variable. The Reproductive Health Index has been calculated from the indices calculated for the five variables by giving equal weight to each variable. The data source and detailed procedure for computation of RH Index is given in Appendix.

 

Total Fertility Rate:

A profound demographic transformation seems to be taking place in the country and going by the data emerging from the 2011 census, fertility rates are dropping across the States, with at least eight of them showing a fertility rate below the replacement level of 2.1. (Replacement level fertility can be the level of fertility at which a population replaces itself from one generation to the next. In developed countries, replacement level fertility can be taken as 2.1 children per woman).

India's total fertility rate (TFR) - the average number of children expected to be born per woman during her reproductive years -has fallen by19% over the past decade. Among bigger states, the percentage decline in TFR during this period the last decade varied from as high as 28% in Punjab to 5.6%in Kerala. The state's TFR has sharply declined from 3.9 children per couple in 1971 to 1.7 in the last survey, an achievement on par with Kerala and is among the lowest in the country, where the national average is 2.8 against a world average of 2.6. With its total fertility rate (TFR) coming  down to 1.7, the lowest in the country, Tamil Nadu has managed to tighten its bulging belly and may well be on its way to surpassing neighboring Kerala in bringing down the number of births per couple. TFR in Tamilnadu  declining in general, and is more pronounced in many districts in particular. It can be seen from the Table-1, that there exists a wide variation in TFR between different districts of Tamilnadu. The districts of Thoothukudi with a TFR of 2.6, and Nilgiris, with a TFR of 1.5 show the highest and lowest rate respectively. Like Thoothukudi, districts like Dharmapuri (2.4), Perambalur (2.3), Nagapattinam, Vellore, Villupuram and Virudhunagar (2.2) show a level higher than the replacement level. In turn, Erode (1.6), Kancheepuram (1.6) show a comparatively lower TFR. The other districts show a value more or less similar to Tamilnadu`s state average (1.7).

 

Table-1, Selected Reproductive Health Indicators-Tamilnadu Districts.

District	TFR	IMR	BO(3+)	Type of Delivery care		Female Educational attainment
				Institutional	Home with Trained Personal.	Female Literacy Rate	Middle School Enrolment. ratio
Chennai	1.8	15.2	10.7	100	0.0	87.16	49.65
Coimbatore	1.8	16.7	6.6	96.9	0.0	79.16	47.44
Cuddalore	2.1	21.2	19.1	92.4	1.9	71.20	48.69
Dharmapuri	2.4	20.9	21.2	91.6	1.4	60.03	46.28
Dindigul	2.1	19.6	21.7	92.3	2.3	68.82	47.38
Erode	1.6	16.8	3.9	98.5	0.4	65.07	46.82
Kancheepuram	1.6	18.1	11.0	94.5	1.2	80.17	48.95
Kanyakumari	2.1	07.0	4.3	98.9	1.1	90.45	48.39
Karur	1.8	22.8	22.5	91.9	0.7	67.05	47.82
Krishnagiri	-	23.9	22.4	86.9	3.2	64.86	47.82
Madurai	1.9	25.6	17.4	95.5	0.7	76.74	48.03
Nagapattinam	2.2	23.3	17.2	98.4	0.4	78.00	48.83
Namakkal	2.1	20.5	7.0	94.8	1.4	66.68	46.22
Perambalur	2.3	23.8	20.2	92.3	3.8	64.16	47.54
Pudukkottai	1.7	20.4	20.0	97.9	0.9	69.51	48.45
Ramanathapurm	1.9	21.2	16.0	97.5	0.5	74.93	47.88
Salem	2.1	26.5	14.7	95.7	2.0	65.43	45.52
Sivagangai	2.0	22.8	13.4	93.1	4.2	72.33	47.89
Thanjavur	2.1	18.1	19.8	99.1	0.1	76.61	48.23
The Nilgiris	1.5	16.6	10.9	90.9	0.7	79.44	48.68
Theni	2.0	27.1	23.0	93.3	0.0	69.72	45.81
Thiruvallur	1.8	17.3	10.6	97.4	0.0	78.39	48.58
Thiruvarur	2.0	18.8	17.5	96.5	0.7	77.02	48.41
Thoothukudi	2.6	17.5	16.9	97.8	0.2	81.77	48.58
Tirunelveli	1.9	23.9	21.3	98.4	0.6	76.38	48.28
Tiruvannamalai	1.8	27.5	22.6	76.0	2.9	65.71	48.34
Trichy	1.9	22.9	25.3	94.7	0.6	77.24	49.29
Vellore	2.2	28.2	29.8	93.1	4.0	72.43	48.41
Villupuram	2.2	22.9	25.3	94.3	0.3	63.51	47.96
Virudhunagar	2.2	22.2	19.5	91.7	2.4	73.41	47.70
Tamilnadu	1.7	21.2	17.3	94.0	1.5	73.86	48.01

Infant Mortality:

Infant mortality rate (IMR) is a sensitive indicator of health status in any area is always found to be higher in India than in many other developing countries. Tamil Nadu, which formulated a state population policy in 1993, has set goals of making deliveries 100% per cent institutional, bringing down IMR level to 20 or below and stabilizing rural and urban birth rates at around 15 -- all by the year 2010. The state's current IMR (infant deaths per 1000 live births) is 35 against a national average of 55 and a world average of 49. Though IMR has substantially declined in Tamilnadu in the past years, it is still at higher than 21 per 1ooo live births. Like Fertility, in the case of Infant mortality too, a wide range of variation was perceptible in different districts of Tamilnadu. While districts like Kayakumari (7.0), Chennai (15.2), Nilgiris (16.6), Coimbatore (16.7), and Erode (16.8) achieved a low level, Vellore (28.2), Thiruvannamalai (27.5),Theni (27.1).and Salem (26.5) showed a higher level of IMR. However, the situation is encouraging in some districts like, Thiruvallur(17.3), Thoothukudi (17.5), Kancheepuram (18.1), and Thanjavur (18.1).These districts showed a much lower level of IMR than the State average (21.2).

 

Birth order:

It is a generally accepted fact that IMR increases with birth order. This tendency is particularly marked among mothers under 20 and over 40 years of age. It can be observed from the table-1, that Erode, with a frequency of 3.9 per cent, and Vellore with 29.8 per cent, showed the lowest and highest occurrence of a 3+ birth order in Tamilnadu. Districts like Virudhunagar(25.3), Trichy (25.3), Theni(23.0),Thiruvannamalai (22.6) and Karur (22.5) also showed high occurrence. In Kanyakumari (4.3), Coimbatore (6.6), Namakkal (7.0), Thiruvallur (10.6) and the Nilgiris (10.9), high order birth (3+) occurred with less frequency than Tamilnadu`s average (17.3).

 

Medical attention at Birth:

Safe motherhood is epitomized by safe delivery, which means either institutional delivery or delivery at home assisted by trained personnel. Delivery at home is only considered safe if assisted by trained professional, for example a doctor or ANM, but not by a traditional birth attendant. It is seen from the table-1, that institutional delivery, as well as delivery attended by trained personnel, are both high in all the districts (more than 90.0) of Tamilnadu except Thiruvannamalai (76.0) and Krishnagiri (86.9) districts.

 

Female Literacy:

Literacy is universally recognized as a social development indicator and is considered as a powerful instrument of social change. It is argued that literacy among women has far reaching consequences on their health seeking behavior. Low level of literacy is a serious cause of concern among women and serious development lag. A high rate of female literacy is recorded for the districts of Kanyakumari (90.45), Chennai (87.16), Thoothukudi (81.77) and Kancheepuram (80.17). However, the rate is strikingly low in Dharmapuri (60.03), Villupuram (63.51), Perambalur (64.16), and Krishnagiri (64.86).The middle school enrollment ratio for girls is ranges between 45.2 per cent (Salem) and 49.65 per cent (Chennai). It shows more or less a consistent pattern in all the districts in Tamilnadu. The overall middle school enrollment ratio for girls in Tamilnadu (48.01%) is far from satisfactory as its rate is ahead just 1.2 percentage points of National average (46.83%).

 

 

Differentials in Female literacy:

Index of Reproductive Health:

The Reproductive Health Index is a composite index constructed by taking into account five variables representing different aspects of reproductive health outcomes. These are,(i) Total Fertility Rate,(ii) Infant Mortality Rate,(iii) Proportion of higher order births(3+),(iv) Type of delivery- this has two components, proportion of institutional delivery and proportion of home delivery assisted by trained personnel and (v) Female Educational attainment-this also has two components-Female adult literacy rate and middle school enrollment ratio among girls. Based on these five summary indices, a joint score obtained by averaging these indices, called Reproductive Health Index, was computed. The Table-2 shows the differences in the indices of the five reproductive health indicators and the computed Reproductive Health Index among various districts in

 

Tamilnadu. The Reproductive Health Index for Tamilnadu is 77.25.It is evident that among the states of Tamilnadu, 20 districts have an index value less than the index value of the State. This suggests that there are factors affecting reproductive health outcomes and the situation is grim in these districts.

 

 

RHI differentials in Tamil Nadu:

 

Table-2, Selective Reproductive Health Indices-Tamilnadu Districts:

District	Index of TFR	Index of IMR	Index of BO(3+)	Index of Medical attention at birth	Index of Female Educational attainment	Index of Reproductive Health
Chennai	95.45	93.85	83.71	75.00	74.66	84.53
Coimbatore	95.45	92.56	95.42	72.68	68.59	84.94
Cuddalore	88.64	88.72	59.71	69.77	63.69	74.11
Dharmapuri	81.82	88.97	53.71	69.05	55.44	69.79
Dindigul	88.64	90.08	52.28	69.80	61.67	72.49
Erode	100.0	92.48	103.14	73.97	58.99	85.72
Kancheepuram	100.0	91.37	82.85	71.18	69.76	83.03
Kanyakumari	88.64	100.85	102.00	74.45	76.43	88.47
Karur	95.45	87.36	50.00	69.10	60.64	72.51
Krishnagiri	NA	86.41	50.28	65.97	59.18	65.46
Madurai	93.18	84.96	64.57	71.80	67.17	76.34
Nagapattinam	86.36	86.92	65.14	73.90	68.28	76.12
Namakkal	88.64	89.31	94.28	71.45	59.86	80.70
Perambalur	84.09	86.49	56.57	78.17	58.62	72.78
Pudukkottai	97.73	89.40	57.14	73.65	62.49	76.08
Ramanathapuram	93.18	88.72	68.57	73.25	65.91	77.92
Salem	88.64	84.19	72.28	72.28	58.79	75.23
Sivagangai	90.90	87.35	76.00	70.87	64.18	77.86
Thanjavur	88.64	91.37	57.71	74.35	67.15	75.84
The Nilgiris	102.27	92.65	83.14	68.35	69.18	83.12
Theni	90.90	83.67	48.57	69.97	61.75	70.97
Thiruvallur	95.45	92.05	84.00	73.05	68.45	82.60
Thiruvarur	90.90	90.76	64.28	72.55	67.48	77.19
Thoothukudi	77.27	91.88	66.00	73.40	70.71	75.85
Tirunelveli	93.18	86.41	53.42	73.95	67.01	74.79
Tiruvannamalai	95.45	83.33	49.71	57.72	59.92	69.23
Trichy	93.18	87.26	42.00	71.17	67.92	72.31
Vellore	86.36	82.73	29.14	70.82	64.42	66.69
Villupuram	86.36	87.26	42.00	70.80	58.32	68.95
Virudhunagar	86.36	87.86	58.57	69.37	64.84	73.40
Tamilnadu	97.72	88.71	63.71	70.88	65.24	77.25

 

 

 

Certain districts, such as Krishnagiri (65.46), Vellore (66.69), had the lowest index value whilst, Kanyakumari (88.47) the adjacent district of the state of Kerala had the highest index value. States like, Erode (85.72), Coimbatore (84.94), Chennai (84.53), The Nilgiris (83.12), Kancheepuram (83.03), Thiruvallur (82.60) and Namakkal (80.70) showed a higher Reproductive Health Index values. Side by side lower levels of this index were recorded in the districts like Vellore (66.69),Villupuram (68.95),   Thiruvannamalai (69.23)and Dharmapuri (69.79). The remaining states like Thoothukudi (75.85), Thanjavur (75.84), Pudukkottai (76.04), Nagapattinam (76.12), Madurai (76.34), Thiruvarur(77.19), Sivagangai (77.86),and Ramanathapuram (77.92), showed an index more or less similar to the state`s average. However, the five summary indices do not strictly follow the trend reflected by Reproductive Health Index.

 

DISCUSSION:

On the basis of the Reproductive Health Index, Tamilnadu districts can be divided in to three categories. These are:

 

High Performing districts

Kanyakumari, Erode, Coimbatore, Chennai, The Nilgiris, Kancheepuram, Thiruvallur, and Namakkal.(RHI-80+)

 

Medium Performing districts: 

Ramanathapuram, Sivagangai, Thiruvarur, Thoothukudi, Madurai, Nagapattinam, Thanjavur, Salem and Pudukottai.

(RHI-75-80)

 

Low Performing districts:

Tirunelveli, Cuddalore, Perambalur, Karur, Dindigul, Virudhunagar, Trichy, Dharmapuri, Villupuram, Vellore,

Thiruvannamalai, Krishnagiri and Theni.

(RHI-below75)

 

In terms of reproductive and child health, a wide range of variation exists in Tamilnadu and in its different districts. The study reveals that among the districts of Tamilnadu, 20 districts have an index value lesser than the index value of the State.  Kanyakumari, Erode, Coimbatore, Chennai, The Nilgiris, Kancheepuram, Thiruvallur,  and Namakkal are the eight districts score Reproductive Health Index more than 80, termed as high performing districts. Ramanathapuram, Sivagangai, Thiruvarur, Thoothukudi, Madurai, Nagapattinam, Thanjavur, Salem and Pudukottai are the nine districts show moderate performance in terms of reproductive health indicators score between 75 and 80. The remaining thirteen districts such as Tirunelveli, Cuddalore, Perambalur, Karur, Dindugul, Virudhunagar, Trichy, Dharmapuri, Villupuram, Vellore, Thiruvannamalai,  Krishnagiri, and Theni are identified as low performing districts as they score only less than 75. While analyzing the performances of various reproductive health indicators of all the districts in Tamilnadu, the performance level relating to Female Educational attainment of the low performing districts are lower than the state`s average. In particular, Dharmapuri, Perambalur, Villupuram, Krishnagiri, Thiruvannamalai and Karur are the districts show a poor performance relating to Female Educational attainment. Though, the female literacy level in all the districts of Tamilnadu shows more or less a consistent pattern in all the districts in Tamilnadu, the overall middle school enrollment ratio for girls in Tamilnadu (48.01%) is far from satisfactory as its rate is ahead just 1.2 percentage points of National average (46.83%). The above discussion clearly indicate that a large scale inter district variations exist among various districts of Tamilnadu. Though Tamil Nadu was one among the most developed states in the country, the report, prepared in December 2007, stated that the differences were a “matter of serious concern.” The difference in the HDI between the top-ranking district and the lowest-ranking district was substantial (State Planning Commission, 2007).

 

Talking of the disparity, the state human development report, which referred to the first Tamil Nadu State Human Development Report (2003), indicate that Chennai maintained the first place in the HDI rank with the value of 0.842. As in the case of the SHDR, Dharmapuri was the last (30th) in rank with 0.656. Krishnagiri and Villupuram held the 29th and 28th ranks respectively. As for the Gender Development Index (GDI), the five top districts were Chennai, Tuticorin, Kancheepuram, Coimbatore and Tiruvallur while the bottom five districts were Dharmapuri, Villupuram, Krishnagiri, Tiruvannamalai and Perambalur. [GDI is an index which adjusts or discounts gender inequality and shows the level of attainment in human development when there is no gender disparity].

 

CONCLUSION AND POLICY SUGGESTIONS:

The above documentary evidences also show that there were large scale inequalities among the districts of Tamilnadu in achieving the components of Human development Index. The above identified low performing districts with respect to the components of Reproductive health Index were also show a poor performance in all the parameters of HDI. The study reveals that among the districts of Tamilnadu, 20 districts have an index value lesser than the index value of the State.  Kanyakumari, Erode, Coimbatore, Chennai, The Nilgiris, Kancheepuram, Thiruvallur,  and Namakkal are the eight districts score Reproductive Health Index more than 80, termed as high performing districts. Ramanathapuram, Sivagangai, Thiruvarur, Thoothukudi, Madurai, Nagapattinam, Thanjavur, Salem and Pudukottai are the nine districts show moderate performance in terms of reproductive health indicators score between 75 and 80. The remaining thirteen districts such as Tirunelveli, Cuddalore, Perambalur, Karur, Dindugul, Virudhunagar, Trichy, Dharmapuri, Villupuram, Vellore, Thiruvannamalai, Krishnagiri, and Theni are identified as low performing districts as they score only less than 75. While analyzing the performances of various reproductive health indicators of all the districts in Tamilnadu, the performance level relating to Female Educational attainment of the low performing districts are lower than the state`s average. In particular, Dharmapuri, Perambalur, Villupuram, Krishnagiri, Thiruvannamalai and Karur are the districts show a poor performance relating to Female Educational attainment. Though, the female literacy level in all the districts of Tamilnadu shows more or less a consistent pattern in all the districts in Tamilnadu, the overall middle school enrollment ratio for girls in Tamilnadu (48.01%) is far from satisfactory as its rate is ahead just 1.2 percentage points of National average (46.83%). The above discussion clearly indicate that a large scale inter district variations exist among various districts of Tamilnadu.

 

Women`s autonomy in health care decision making is extremely important for better maternal and child health outcomes, and as an indicator of women empowerment. In this connection, it can be mentioned here may lie the key to improving the overall health and reproductive health status of women and effective measures should be taken to improve the women`s level of educational attainment and increase their active participation in economic activities for better employment especially in the poor performing districts. This will also help women to have more autonomy in decision making and to overcome the high rate of infant mortality and other parameters of poor health status. Thus, an attempt has to be made to reorient the programmes towards active female empowerment and change the attitude of the service providers at gross root level and also to strengthen the services at the outreach level.

 

REFERENCES:

1        Gupta M, Thakur JS, Kumar R. Reproductive and Child health Inequalities in Chandigarh Union Territory of India, Journal of Urban Health, 2008; 85(2):291-9

2.       International Institute for Population Sciences (IIPS), 2010, District Level Household and Facility Survey (DLHS-3), 2007- 08: India. Tamilnadu: Mumbai: IIPS.

3.       Basu, S. K. 1992. Health and culture among the under-privileged groups in India, Health for the Millions. Feb- Apr; 18 1-(2), 23-4.

4.       Jothy K, S.Kalaiselvi, Utilization of Reproductive Health Care Services in BIMARU states in India, International Journal of Current Research, Vol.3, Issue-10, Sep.2011.

5.       International Institute for Population Sciences (IIPS). 2004. India Summary Report Reproductive and Child Health, 2002-04. Mumbai:  IIPS.

6        .Census of India, 2011, Provisional Population Totals, Directorate of Census of operations, Tamilnadu,

7        International Institute for Population Sciences (IIPS), National Family Health Survey, Tamilnadu (2005-06),

 

Appendix-1

Index of TFR=6-TFR/6-1.6X100

Index of IMR=125-IMR/125-8X100

Index of Birth Order=40-% of birth order 3+/40-5X100

Index of Delivery Care= (3X% of institutional delivery) + (% of delivery

Attended by trained persons)/4

Index of Educational Attainment= (2x Female Adult literacy rate)

+ (middle School enrolment ratio)/4

(Source: Nikhilesh Parchure and others, Differentials in Reproductive and Child Health Status in India, Italian Journal of Public Health, vol.8, No.4.)