INTRODUCTION:
The term ‘health’ is a positive and dynamic concept. In common parlance, health implies absence of disease.The World Health Organization (WHO)has defined health as: “a state of complete physical, mental and social well-being and not merely the absence of disease or illness or infirmity”.

The Indian Health sector:
Health is a State Subject in India. That is, it is mentioned in the State List of the Seventh Schedule of the Indian Constitution.

The Indian health sector has a mix of both public and private providers of health services. The private sector and the quality of care provided is variable, ranging from informal providers (quacks) to individually run nursing homes to large polyclinics and multiplex hospitals. The regulation for cost and quality of care is largely absent in most f the states. In the case of public sector, the health services are delivered through a network of health facilities including ASHA (a volunteer health worker) at the community level, Health Sub-Center (HSC), Primary Health Centres (PHCs), Community Health Centres (CHCs), District Hospitals, Government Medical College Hospitals and the state and central government assisted Employees’ State Insurance (ESI) hospitals and dispensaries. Outreach and community level services are provided through coordination between ASHA, Anganwadi Workers (AWWs) and the Auxiliary Nurse Midwife (ANM) at the HSC.

Maternal Health Care:
•Maternal health care is a rather wide term. Often, the term is confused with only the period of time, when the women gives birth to the child.
•However maternal health care is a concept that encompasses family planning, preconception, prenatal (antenatal) and postnatal care.

Antenatal Care:
It is the routine health control of presumed healthy pregnant women without symptoms (screeening), in order to diagnose diseases or complicating obstetric conditions without symptoms, and to provide information about lifestyle, pregnancy and delivery.

Postnatal Care:
•A postpartum period or postnatal period is the period beginning immediately after the birth of a child and extending for about six weeks.
•The World Health Organization (WHO) describes the postnatal period as the most critical and  yet the most neglected phase in the lives of mothers and babies; most deaths occur during  the postnatal period.
•It is the time after birth, a time in which the mother's body, including hormone levels and uterus size, returns to a non-pregnant state.

Key findings of the NFHS –4:

Antenatal Care (ANC):
•NFHS-4 findings reveal that there is better care for women during pregnancy and childbirth -contributing to reduction of maternal deaths and improved child survival.
•Almost all mothers have received antenatal care for their most recent pregnancy and increasing numbers of women are receiving the recommended four or more visits by the service providers.
•The number of pregnant women receiving more than 4 ANC visits has also gone up by 38.37% in the last decade, from 37% in NFHS-3 to 51.2% in NFHS-4.
•States which have shown remarkable improvement in providing ANC to pregnant women are Uttar Pradesh, Chhattisgarh, Assam, West Bengal, Odisha, Jharkhand and Rajasthan, although in terms of absolute values, the percentage of women receiving ANC continues to remain low.
•ANC visits have gone down in Uttarakhand, Tamil Nadu, Goa and Kerala over the last decade.

Total Fertility Rate (TFR):
Total Fertility Rate may be defined as average number of children that would be born to a woman if  she experiences the current fertility pattern throughout her reproductive span (15-49 years). The total fertility rate is a more direct measure of the level of fertility than the birth rate, since it refers to births per woman. This indicator shows the potential for population change in a country.
Overall, the Total Fertility Rate (TFR) or the average number of children per woman has also gone  down from 2.7 in  NFHS - 3 to 2.2 in NFHS -4.

Institutional births:
•Institutional delivery means giving birth to a child in a medical institution under the overall  supervision of trained and competent health personnel where there  are more amenities available to handle the situation and save the life of the mother and child.
• More and more women now give birth in health care facilities and rates have more than  doubled in the last decade in some States like Chhattisgarh (by as much as 390%), Jharkhand  (by 238%), Uttar Pradesh (by 229%), Bihar (by 220%), Assam (by 215%), Madhya Pradesh (by 208%) and Rajasthan (by 183%).
• However, in terms of absolute values, institutional births continues to remain extremely low in Nagaland (32.8%), Meghalaya (51.4%), Arunachal Pradesh (52.3%), Jharkhand (61.9%) and Bihar (63.8%), which are the bottom five states with respect to institutional births.

Maternal Death:
Maternal death is defined as death of women while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by pregnancy or its management. The maternal mortality ratio is maternal death per 100,000 live births in one year.
•Globally, about 800 women die every day of preventable causes related to pregnancy and childbirth; 20 per cent of these women arefrom India.
•Annually, it is estimated that 55,000 women die due to preventable pregnancy-related causes in India.
•But there is a ray of hope as the Maternal Mortality Ratio –the number of maternal deaths per 100,000 live births–declined to 130 in 2014-16 from 167 in 2011-13.
•The Southern States are performing better than the rest of the country on MMR, with a decline from 93 to 7, close to the country’s target of 70 by 203, under theSustainable development Goals (SDGs).

Women with Low BMI (Body Mass Index):
Body Mass Index (BMI):
•The body mass index (BMI) is a value derived from the mass (weight) and height of an individual. The BMI is defined as the body mass divided by the square of the body height and  is universally expressed in units of kg/m2, resulting from mass in kilograms and height in metres.
• The BMI is an attempt to quantify the amount of tissue mass (muscle, fat, and bone) in an individual, and then categorize that person as underweight, normal weight, overweight, or obese based on that value. Commonly accepted BMI ranges are underweight: under 18.5 kg/m2, normal weight: 18.5 to 25, overweight: 25 to 30, obese: over 30.

•As per NFHS 3, every third woman in India was undernourished (35.5 % with low Body Mass Index) and every second woman (15-49 years) was anemic (55.3%)
•About 15.8 % were moderately to severely thin, with BMI less than 17. Bihar (45%), Chhattisgarh (43%), Madhya Pradesh (42%) and Odisha (41%) were the states with the highest proportion of undernourished women.
•In chronically undernourished women, pregnancy and lactation have an adverse effect on maternal nutritional status. Low pre pregnancy weight and low pregnancy weight gain are  associated with low birth weight and all its attendant adverse consequences.
•Recent findings from NFHS 4 (2015-16) highlight that nutritional status of women and girls (in the age group 15-49 years) has improved for all States, evident in figure 5.
•Overall, there has been a decrease from 35.5% (NFHS-3) to 22.9% (NFHS-4) in the prevalence of women with low BMI.
•The decrease has been by almost 50% in the states of Tripura, J&K, Haryana, Tamil Nadu and Kerala.

Anemia in Women:
•The figure below presents the status of anemia among women and girls between 15-49 years of age.
•It is seen that overall, the levels of anemia among women and girls has stagnated over the last decade from 55.3% in NFHS-3 to 53% in NFHS-4.
•In terms of percentage points, States which have witnessed maximum decrease in the levels of anemia are-Sikkim (24.6), Assam (23.3), Mizoram (15.6), J&K (11.7), Tripura (10.6) and Chhattisgarh by 24.6 (10.5).
•Alternatively, 8 States/ UTs (Punjab, Himachal Pradesh, Meghalaya, Delhi, Haryana, Uttar Pradesh, Tamil Nadu and Kerala) have seen an increase in the prevalence of anemia.

Under the National Health Mission (NHM), the steps taken to tackle anaemia are:

• Anaemia Mukt Bharat(AMB): It has been launched in the year 2018 as part of Intensified National Iron Plus Initiative (NIPI) Program for accelerating the annual rate of decline of anaemia from one to three percentage points.
• The target groups for AMB are Children 6-59 months, 5-9 years, Adolescent Girls & Boys of 10-19 years, Women of Reproductive Age (15-49 years), Pregnant Women and Lactating Mothers.
• Weekly Iron and Folic Acid Supplementation (WIFS): This Programme is being implemented to meet the challenge of high prevalence and incidence of anaemia amongst adolescent girls and boys.
• The intervention under WIFS includes supervised weekly ingestion of Iron Folic Acid (IFA) tablet.
• To control worm infestation biannual deworming with Albendazole is provided.
• Health management information system & Mother Child tracking system is being implemented for reporting and tracking the cases of anaemic and severely anaemic pregnant women.
• Universal screening of pregnant women for anaemia is a part of ante-natal care and all pregnant women are provided iron and folic acid tablets during their ante-natal visits through the existing network of sub-centres and primary health centres and other health facilities as well as through outreach activities at Village Health & Nutrition Days (VHNDs).
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA): It has been launched to focus on conducting special ANC check up on 9th of every month with the help of Medical officers/ OBGYN to detect and treat cases of anaemia.
• Operationalization of Blood Bank: in District Hospitals and Blood Storage Unit in subdistrict facilities such as Sub-Divisional Hospital/ Community Health Centers is being taken to tackle complications due to severe anaemia.