Since India’s crimes data recording system is not built to capture subtleties, we do not know what proportion of pregnancies in India start off without the consent of the woman, even though the veil of marriage may cover it legally and culturally. While physical and mental violence can be ascertained by a sensitive clinician, the intergenerational impact of a regretful and anxiety-loaded pregnancy is inadequately quantified by current clinical or epidemiological tools. Measuring and tracking matters of import is critical to individual, community as well as national well-being.
Parameters that are valuable
If we equally value all Indians, we should not stick to decennial census operations alone and count ourselves the way we do — on lines that tell us how we can be sorted and addressed in the political economy; rather, we should do so to understand what our cumulative human capital and potential look like. What is valuable is measured frequently, at different life stages, and at disaggregated levels: birthweights; the heights and weights of our children when they enter school; school completion rates; perhaps the age, height and weight of a first-time pregnant woman; and most definitely, the number of women in the formal workforce who are on a par with men in terms of earning.
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Underage marriage of girls must become history. Ensuring secondary school completion of every child, especially girls in rural areas, has far-reaching impact, and needs to be pursued single-mindedly. Provisioning separate, functional toilets and sanitary pads for girls, and teaching boys biology and gender differences (of their own and female) are key enablers to ensuring gender parity in school completion rates. Teaching school-leaving girls and boys the notion of consent, and also the basics of contraception, will ensure that the start of every pregnancy will be a desired and happy one.
Births in the country
Not every pregnancy ends up in a live birth — evocatively captured by the six-word allegedly Hemingway novel: “For sale: baby shoes, never worn”. A desired pregnancy is to be supported by a fully functional health-care system, able to anticipate complications before time and facilitating a safe delivery. Current stillbirth numbers in India are hard to pin down, but after accounting for background losses and abortions, there still remains a distressingly large number of still births, sometimes mis-recorded as early neonatal deaths.
Despite the trend towards nuclear families, pregnancies in India still are familial events — outcomes are eagerly anticipated by more than just the parents, and stillbirths are a rude end to many fond wishes. A young, short and under-schooled woman is more likely to have a bad pregnancy outcome, or, a smaller than expected baby.
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A birth weight is much more than a number — it is a complex outcome, telling of how well the woman and her family eats, her status among them, and also of any particular condition that the individual mother or newborn child has. Tracking average birthweights by district and subdistrict on a regular basis is a fair proxy for food security, the status of women and the delivery of primary health care. For a nation with plans to assign digital health IDs to everyone, this is not a tall ask — what is additionally required is the making of this moving average data live and visible to the people and their government. It should also put to rest all debate about whether some Indians are born more equal than others.
Height-weight proportions
A good start is a great advantage, but easily squandered if subsequent growth and development are blighted by the lack of adequate nutrition, first exclusively from the mother’s breast, then through locally available weaning and complementary foods; and repeated bouts of vaccine preventable or easily treatable illnesses. Parental hopes of a child growing up, going to school and becoming successful hit a major hurdle if the height-weight proportions at age five are not normal. Ensuring this marker is recorded for every child who enters school will also allow for a correlation with birthweights at the district level — giving a better understanding of multi-dimensional property.
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If India is to be truly taking advantage of its large birth cohort in the form of a demographic dividend, then the correlate of birthweight and five-year height-weight needs to be reviewed at the highest political levels regularly. It reflects the physical and cognitive nurture of human capital that the country can bank on for its future. Every child born in India is to be considered a ratna – a jewel and handled as such; some of them will go on to get the formal Bharat Ratna tag eventually.
Improved learning
Schooling is a socio-economic and gender parity springboard if school completion rates show no gender, rural-urban or parental income divides. Consequently, India may not only bring down its maternal mortality ratios but also improve neonatal and under five mortality rates, through delayed marriages and exercising of reproductive choices by its empowered young women.
Grading cognitively ill-equipped or ill-taught children on standardised tests is as much a waste of effort as letting large numbers of young people graduate through courses which are hopelessly out of sync with the expectations of the job interview board. The recently unveiled new education policy seeks to remedy this. It will be a while before we can measure any of the talked about, and hopefully intended, outputs or impact of this policy.
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Unimaginative teaching of anaemic children is a double whammy, partially addressed through protein rich mid-day meals. Deworming, school toilets, sanitary pads and bicycles for girls are progressive policy steps in the right direction; adding remedial training and affirmative feedback for teachers will be transformative. With better cognitive capacities and supportive environment, the stress of learning reduces, and outcomes improve.
Improved learning should translate into better completion rates at post-secondary and baccalaureate levels but need not necessarily correspond to universal, meaningful employment. It is for the government and the corporate world to make opportunities and workplaces happen, irrespective of their gender. Right economic stimuli, anticipating potential workplace disruptions, supporting reskilling and retraining, and decriminalising entrepreneurial failure will go a long way in eliminating work and livelihood-related anxieties making their way back home as domestic violence. As a society, we need to understand and make leeway for failure, and not stigmatise it, whether at school in early childhood, during miscarriages of pregnancies, or when career and business decisions go awry. Stigma erodes self-worth and kills silently.
Data | The link between breastfeeding and under-five mortality rate
Timely data helps
Together, these measurements will tell us far more about where we are, and where we as a nation will go. The tools to get these measurements exist; we just have to see them in real time to be able to take corrective actions where needed. Public health is about people, their continued well-being, and not just about controlling disease outbreaks. Data helps; timely, disaggregated, multidimensional data helps immensely in ensuring collective well being, physical, mental and social. People are India’s greatest possession and will remain so for the conceivable future, provided they are in a state of well-being. An ill-educated, anxious population is a tinderbox, capable of self-harm as well as being kindling for malice-driven mobilisation. Addressing this requires a whole of life and whole of society approach, and measuring the outcomes that matter, regularly. Hopefully the 2017 edition of the national health policy and the new education policy unveiled last month will be the twin rails that India rides towards a true demographic dividend.
Dr. Bobby John is an advocate for global health and the Editor of the Journal of Development Policy and Practice
