Maternal Health Survey · Maternal Health Survey, Kerala, India ... slightly later date than other questions ... This may have been associated with the dowry system in India which

Principal authorAmy Davies, Birth for Change

Maternal Health Survey

MaternalHealthSurvey,Kerala,IndiaVer:Final

Principalauthor: AmyDavies,BirthforChange

Contributingauthors: PriyankaIdicula,BirthforChangeRobDavies,NIDA

Graphics: CarolUsher,NIDA

AsurveycarriedoutbyBirthforChangeFoundationinpartnershipwiththeNetworkfor

InformationandDigitalAccess(NIDA)andHardieWrenDevelopmentInitiative(HWDI),2017

ThisworkislicensedunderaCreativeCommonsAttribution-ShareAlike4.0InternationalLicense

MaternalHealthSurveyReport-September2017 2

Contents

Introduction................................................................................................................................3

Background.................................................................................................................................3

Objectivesofthesurvey..............................................................................................................4

Methodology...............................................................................................................................5

Results........................................................................................................................................5Familybackground..........................................................................................................................5Education......................................................................................................................................15Menstruation................................................................................................................................18Contraception...............................................................................................................................23Pregnancy.....................................................................................................................................25Nutrition.......................................................................................................................................28Alcoholandsmoking.....................................................................................................................29Incomeandexpenditure...............................................................................................................33

Limitations................................................................................................................................35

Conclusion.................................................................................................................................35

Keyrecommendations...............................................................................................................35

References................................................................................................................................36


IntroductionAsurveywascarriedoutfromApriltoMay2017byBirthforChangeFoundationMidwivesandNursesinpartnership with Network for Information and Digital Access (NIDA) and Hardy Wren DevelopmentInitiative(HWDI),withanaimtogainanunderstandingofthesituationofwomeninaSouthIndianurbanslum.Thefindingsofthesurveyaimtoinformandenhancefocusonimprovingmaternalhealthliteracyindisadvantagedcommunities.Thesurveywillbefollowedby initiationofhealthclassesandaclinicwithasubsequentimpactevaluation.

Following completion of the survey and initial reporting of findings, correlationswere consideredwhichexplored the relationship between the results from important survey topics. The conclusions of thesecorrelationsarenowincorporatedinthetext.

BackgroundMaternalhealthliteracycanbedefinedasthecognitiveandsocialskillsthatdeterminethemotivationandability ofwomen tounderstand and gain access to information, inways thatwill promote andmaintaintheirownhealthandthatoftheirfamilies(Nutbeam1998,2006).Beliefsthatahealthliteratecommunityhas the best chance of understanding, shaping and improving their lives on a day to day basis arewelldocumented(Kickbusch,2001).

The ability of women to gain access to resources and make independent decisions about their health,fertilityandhealthcarehasanimpactonmaternalmortality,whichwasatarateof174deathsper100,000livebirthsinIndiain2015(WHOetal).InplacessuchasIndia,wherewomenandgirlsmaybeconfinedtoalowsocialstatus, theireducationandhealthneedsareoftenneglected.UNICEF(2012)has identifiedtherootcauseofwomen’sdisadvantagedpositioninmanycountriesandcultures,asthelackofattentiontoandaccountabilityforwomen’srightssuchaseducation.

TheurbanpopulationinIndiaisoneofthelargestintheworld,withalargesectionofthepopulationlivinginpoverty inovercrowdedcityslums (Hazarika,2010).Slumsarecharacterisedbydeterioratedorpoorlystructured housing, crowding, poor water supplies and sanitation. Poor drainage with open sewers,uncollectedwasteandlimitedlightingorelectricity.

AccordingtoAgrawal(2007),forwomeninslumsthereispoorerutilisationofthereproductiveandchildhealth serviceswhen theyareprovidedby thegovernment, a lackof general health knowledge, trust inservices, awareness about child spacing and very low use of contraceptives, all of which leads to pooroutcomesandcouldbelargelypreventedbyaccesstoreproductivehealthservicesandeducation.

AprevioussurveyonhealthbehaviourinIndia(NandanandMisra,2006)reportedthatratherthanseekingaphysician,mostwomenwilldiscusstheirhealthproblemswithmothers,sistersorotherwomenintheircommunity,passingonacquiredknowledge fromwoman towoman.Healthbeliefs related topregnancyand childbirth exist in various cultures globally (M’sokaet al,2015). In India, they can vary from state tostateandoftenfromcommunitytocommunity(WorthingtonandGogne,2011).

ItisreportedbytheMinistryofHomeAffairs,GovernmentofIndiathat40%ofwomeninIndiahaveneverbeentoschool(2001).However,thecensusof2011claimedthatthestateofKeralahassurpassedthistobecomethemostliteratestateinIndiawithaliteracyrateof93.91%,(maleliteracy96.02%;femaleliteracy93.91%).Thisshowsanimprovementfromthepreviouscensusin2001inwhichliteracyrateswere90.86%in total. Evenwith this increase, the lower rateof female literacyhas thepotential tohavea significantimpactonthehealthofwomen,theirchildrenandonfamilyplanning,familynutritionandonhigherratesofmaternalandinfantmortality(CensusofIndia,2011).


Healthresearchersandhealthcareprofessionalshavelongbeenawareaboutthelinkbetweeninadequateeducationandhealth (Evans, 1994)Reports fromaround theworld formany yearshavehighlighted thepositiveimpactofeducationonhealthandinparticularwomen’shealth,birthoutcomes,andthehealthoftheirchildren(Nussbaum,2000andJohrietal,2015). Poormaternalhealth literacyhasbeenassociatedwithchildnutritionaldeficiencies(Johti,2016)andlowincidenceofbreastfeeding(Ickes,2015).

TheWorldHealthOrganisation (WHO,2015) recommends thatnomore than10 -15%ofwomenaroundtheworldhavecaesareansectionsaroundtheworld,includingIndia,yetinthepastdecadenumbershaverisensothatinKerala41%ofbirthsarebycaesareansection(ICMRschoolofpublichealth,2017).Privatehospitalsarenot required to report their caesarean section ratebut reportshave suggestednumbersof50%andaboveofbirthsbycaesareansectioninsomehospitals(SinghandGupta,2013).

InIndia,childbirthhasbecomeamoney-makingindustrywithreportsofmedicalpractitionersencouragingandscaremongeringhealthylow-riskmotherstohaveinvasiveproceduresandsurgeryratherthanafocusonaccesstodignified,appropriatecare(BirthIndia,2017),withpracticesfallingfarshortofevidence-basedandresultinginpoortreatmentofwomen(Nagpaletal,2015)Thelackofknowledgeorunderstandingthatwomenhavewhenaccessingservicesmeanstheyare‘doneto’withoutanyinsightintowhatisproposed,sinceitisinstalledinthemthat’doctorknowsbest’fromanearlyage.Becauseofthispeopledonottakeresponsibilityfortheirhealthcareandleavedecisionstothedoctor.Educationandhealthliteracyareakeyelementtoimprovingmaternalchoice,experienceandoverallhealthcareoutcomes.

Thishealth literacyresearchwillaimtoexplorefurtheravenuessuchasempowermentprocesses,surveydesign for health literacy, assessment of different population groups and outcome measures of healthpromotioninterventions.

ObjectivesofthesurveyTogainasnapshotofthesituationaffectingmaternalhealthintheslum,regarding:

• Familybackground• Livingstandards• Education• Menstruation• Contraception• Pregnancies,birthsandbreastfeeding• Nutrition• AlcoholandSmoking• Incomeandexpenditure


MethodologyThesurveywasdevelopedbyBirthforChangeFoundationmidwivesinpartnershipwithNIDAandHWDI.Thesurveywascompletedforwomenbetweentheagesof18and60yearsoldwhichwaswithinareproductiveagerangeandthereforemorefocusedonareasofinterest.Arandomsampleofthefirst100womeninthefirst82householdsvisitedbytheresearcherswereincluded.Theresearcher-ledsurveywasconductedfromdoortodoorintwoslumcoloniesnamedUdayaandPNTinthecitycentreofKochi.ThesurveywasdirectedintheKeralanstate languageofMalayalam,withresponsestranslatedbytheresearcherandenteredontothe pre-developed Survey Gismo (www.surveygismo.com) online questionnaire in English. Participantnumberswereallocatedtoprotectconfidentialityandidentifyingdetailswerestoredinasecurecasewiththeresearchmidwifewithinthesecuresettingofthebirthcentre,asforhealthrecords.

ResultsFamilybackgroundEachagegroupwaswellrepresentedwithinthesample(Fig1).Womenreportedthattheyweremarriedin91%oftheresponses(Fig.2).ItisworthbearinginmindthatmarriageandhavingchildrenwithinwedlockistheculturalnorminIndia,thereforeitispossiblethatwomenwouldnothaveansweredotherwise,eveniftheywerenotmarried.Womeninthesamplehadlivedintheslumcolonybetween0and40years,with28%havinglivedthereforover30years(Table1).Themostcommonreasongiven(38%)formovingtotheslumwasformarriageandfamilyreasons.Only2respondentswerebornintheslum(Fig.3).

Fig.1:Agesofsurveyrespondents


Fig.2:Relationshipstatus

Fig.3:Reasonformovingtoslum

Years Numberofresponses

%Responses

%Respondents

<1 2 2.02%

99.00%

1-5 14 14.14%6-10 11 11.11%11-15 12 12.12%16-20 12 12.12%21-25 11 11.11%26-30 9 9.09%31-35 13 13.13%36-40 13 13.13%40+ 2 2.02%

Totalresponses 99 100.00%Didnotanswerquestion 1 1.00%

Total 100 100.00%

Table1:Howlonghaveyoulivedhereinslum?


83%of respondents reportedtheyhadbeenpregnant (Fig.4).39.6%of thesewomenhadsuffered frommiscarriage, pregnancy loss or loss of a child (Table 2). 63% of thosewho had provided commentary inresponse to thequestionaboutpregnancy loss (Fig. 5).Overall, 28.2%of those respondinghad sufferedfromamiscarriage.This isasomewhathigherratethanthatforageneralpopulationofwomenwhich isreportedtooccurinaround15-20%ofpregnancies(Poorolajaletal,2014)However,whencomparedtoastudybyPatkiandChauhan(2015)Indianwomenappearmorelikelythanotherethnicitiestomiscarrywith32%of thepopulation in their study suffering froma spontaneousmiscarriage.Globally,miscarriagehasbeenpresumedtobearound10%(Regan,2000)8%ofthewomensampledwerepregnantatthetimethesurveywascompleted(Fig.6).The22‘unknown’relatestotheadditionofthequestiontothesurveyataslightlylaterdatethanotherquestions.

Fig.4:Pregnancyhistory

Numberofresponses

%Responses

%Respondents

Yes 25 39.68%63.00%

No 38 60.32% Totalresponses 63 100%

Didnotanswerquestion 15 15.00%Unknown 22 22.00%%

Total 100 100.00%

Table2:Haveyoueverhadamiscarriage/pregnancyloss/lossofachild?

Fig.5:Lossofchild/children


Fig.6:Currentlypregnant

Theaveragefamilysizeofrespondentswasbetween1and3children.19respondentshadnochildren,24respondentshad1child,29respondentshad2children,22had3childrenbutonly1familyhad4children.Nofamilieshadmorethan4children(Fig.7).Thesefigurescorrelatewiththenationalaverageof2.45childrenperwoman(2016),comparedwith1960whenthereportedaveragefamilysizeinIndiawas5.9,in1980whenitwas4.8andin2000whenitwas3.3.Familysizeappearstohavedecreasedsignificantlyovertheyearssuggestingthatfamilyplanningismoreprevalent.

Fig.7:Numberofchildren

Thegenderratioofchildrenwasneartoequalwith49.3%ofchildrenbeingfemaleand50.6%beingmale(Fig. 8). Discovery of gender during pregnancy wasmade illegal in India in 1994 due to the increase infemale feticide due to the prevailing preference for male children. Prior to this Indian census datasuggested a positive correlation between abnormal gender ratio and socioeconomic status and literacy.ThismayhavebeenassociatedwiththedowrysysteminIndiawhichiscostlyforthefamilyoffemales.


Fig.8:Genderofchildren

62%ofchildrenintheslumcolonywereborningovernmenthospitalsand33%inprivatehospitals(Fig.9).ThepublichealthsysteminIndiaiscomposedofstateownedhealthcarefacilitieswhicharefundedbythegovernmentofIndia.Feesvarybutaregenerallysubstantiallylessthattheirprivatecounterparts.People below the poverty line are exempt from hospital fees. Below poverty line is an economicbenchmark used by the Indian government to indicate severe economic disadvantage so thatgovernmentassistancecanbeoffered.Thisusuallymeansanincomeoflessthan121.52INRperperson(1.90USD/1.46GBP).StandardsofgovernmenthospitalsvarybutwouldalsobeconsideredsuboptimalinmanyinstancesinIndia,comparedwithprivatehospitals.Resourcesarelimited,asarestaffingnumbersperpatientwhicharereportedtobearatioof1doctorper11528people(Bagcchi,2015).However,ascare isgivenwithoutcharges inmind it isaccepted that, ingeneral,unnecessary interventionsmaybeless common than in a privately financed hospital. The frequency of costly caesarean section rates isreported to be 3 higher in private hospitals across Kerala when compared to government hospitals,according to a National family health survey carried out by the International institute for PopulationSciences,India(2013).ThefeeschargedfornormalchildbirthingovernmenthospitalsinurbanareasofIndia are 2117 Indian rupees (INR) on average (33.18USD/25.42GBP) whereas the average price ofchildbirthinanurbanprivatehospitalis20328INR(USD318.62/244.14GBP).

Only4.41%ofrespondents’babieswerebornathomeintheslumto(Fig.9).Oftheserespondentstheolderwomenofthesample,whowereovertheageof35hadthehomebirths.Duringdatacollection,Women told stories of a dais who had served the slum colony. A dais is a traditional Indian birthattendantwhowouldattendthebirthsofbabiesintheslumforapaymentofapieceofclothingorfood.Thewomenreportednoothertraditionalbirthattendantssinceherdeathinthe1980s,whichmayhavecontributedtotheincreaseinhospitalbirthsamongthispopulation,alongwiththegovernmentpushforbirthinhospitalsinIndia.


Fig.9:Birthplaceofchild/children

In 68.2% of cases, respondents reported having a normal birth. 31.79% were caesarean (Table 3).ComparedwiththeWHOrecommendationof10-15%caesareansectionratethisisaraisedincidence.Nowomenreportedhavingaventouseorforcepsinstrumentaldelivery.InstrumentaldeliveryratesintheU.Kaccountforaround13%ofbirths,thisfigurevariesaroundEuropebetween0.5%and16.4%(Macfarlane,2016)A recordof the rateof instrumentaldeliveries in India isnotavailable.According toWHOandUNagencies assisted vaginal delivery (instrumental delivery) is one of the six critical functions of basicemergency care, it is therefore unlikely that none of these women would have undergone this birthintervention.HospitalsinCochinareequippedtocarryoutthisintervention,withobstetricianshavinghadthetrainingtoperformitifnecessary.Theabsenceofthisinformationfromtherespondentscouldbeduetoa lackofunderstandinggiventowomenaboutbirth in India intheantenatalperiod:antenatalclassesareveryrareandthismaymeanawomanwouldclassavaginalbirthasanormalbirthwhethertherewasuse of instruments or not. A reported lack of consent for procedures and minimal information aboutproceduresgiventowomenaftertheeventshouldalsobeconsidered.Familiesarenotallowedtoattendbirths or come into the birthing room, on the whole. Therefore, women often report having limitedknowledgeofwhathappenedtothemduringtheirbirthingprocess.

Numberofresponses

%Responses

%Respondents

Normalbirth 103 68.21%

93.75%Instrumental-ventouse/forceps 0 0.00%Caesareansection 48 31.79%

Totalbirths 151 100% Totalresponses

question75

Didnotanswerquestion 5 6.25%

Total 80 100.00%

Table3:Howwaseachchildborn?

42%ofrespondentsgavebirthbetweentheagesof21and25(Fig.10).Theyoungestageofbirthwas14yearsoldandtheoldest37yearsold.ThisisslightlyolderthantheaverageageofwomeninIndiawhichis19.90 (UnitedNations,2013). Thegeneral trendacross theworld is thatmothers inmore socially liberalcountrieshavetheirchildrenlaterwhilethoseinpoorercountrieshavechildrenatayoungerage.


Correlationsofdatasuggestthatthepercentageofwomenhavingvaginalbirthsinrecentyearsisdecreasinginyoungerwomenofchildbearingageandthatcaesareansectionratesarerising.Womenbetweentheagesof26-35yearsoldinthissamplehadthemostcaesareansections.48.8%ofthewomeninthisagerangehadacaesareansection. Just15.5%of thewomen in theagerange46-60reportedhavingacaesareansection(84.4%vaginalbirthrate).Thereisacleargrowthinthenumberofcaesareansectionsfromtheoldertotheand younger women. Reasons for this are not clear but are in line with increasing rates of medicalinterventioninchildbirthworldwide(Betran,2016andTheRoyalCollegeofMidwives,2016).

Fig.10:Ageatchildbirth

Oftherespondents,womenwhocouldneitherreadorwriteweremorelikelytogivebirthingovernmenthospitals, with 80% choosing government hospitals and 20% choosing a private hospital. Of those whocouldreadandwrite,55%chosegovernmenthospitalsand45%choseprivatehospitalcare(Fig.11).Thisdifferenceinuseofthetwotypesofcarebetweenilliterateandliteratewomenmaybeduetoaccesstoinformation reinforcing the belief that private hospital care will be an improvement on governmenthospitalcare.

Of the illiterate respondents, 82.76% reportedhavinga vaginalbirth. Literatewomen reporteda vaginalbirth in 56% of cases. 96% of women who had no education had a vaginal birth and 61% of educatedwomen, 38% of educated women had a caesarean section but only 3.5% of uneducated women did,suggesting that literacy and access current information and educationmay influencemode of birth andleadtoloweroutcomesof‘normal’vaginalbirth.


Inaddition,thecorrelationoftypeofbirthandwhereeachchildwasbornshowsastarkcontrastbetweenprivateandgovernmenthospitaloutcomes.Oftherespondentswhochoseagovernmenthospitalfortheirbirth, 80.6% had a vaginal birth, compared to 17% at a private hospital, while. 68% of women had acaesarean section at private hospitals compared to 31.7% at government hospitals. It is possible toconcludethatmoreilliteratewomenareattendinggovernmenthospitals,whichisinturnthecauseofthehighernumberofvaginalbirthamongstthem.

However, althoughbirthing inagovernmenthospital appears tomeanmorevaginalbirths thisdoesnotnecessarily suggest that theoverall birth experience forwomenwasbetter, sincenormal birthpracticesandhumanrightsinchildbirthinIndiaarewidelyheldtobeseverelylacking(BirthIndia,2017).Qualityofcareinbothprivateandgovernmenthospitalsisanissueforfurtherexploration.

Fig.11:Hospitalbirthsandliteracy

Oftheeducatedwomeninthesample,41%choseaprivatehospitalfortheirbirth,comparedtojust4%intheuneducatedwomen(Table4).Thiscouldbeassumedtobeduetoeducatedwomenhavingbetterjobsandthereforemoremoneytopayforprivatecare.However,ourfindingsfromasmallsamplesuggestthatamother’sincomedoesnotimpacttheirdecisiononplaceofbirth,withwomenfromallrangesofincomechoosingbothprivateandgovernmenthospitalcare(Table5).Ourfindingssuggestthatwomenaresavingmoneytopayforprivatehealthcareandconsequentlyexperiencinghighratesofcaesareansection.

In2017,apetitionaskingtheWomenandChildDevelopmentministrytoissueanadvisorytotheMedicalCouncil of India was commenced, making it mandatory for hospitals to declare their caesarean sectionstatisticratestothepublicsothatwomenhaveachoiceandtosafeguardthehealthandrightsofwomenandchildren(Ghosh,2017).

Table4:Hospitalbirthsandeducation

Haveyoueverhadanyeducation?

Yes % No % Numberofresponses

%Responses

%Respondents

Gov.hospital 63 58.88% 21 95.45% 84 65.12%

86.25%Privatehospital 33 41.12% 1 4.55% 45 34.88% 107 100.00% 22 100.00% 129 100.00% Totalresponses 69 Didnotanswerquestion 11 13.75%

Total 80 100.00%


Table5:Birthplaceofchildrenandamountofjointincome87.33%ofrespondents’breastfedtheirbabies,with78%ofwomencontinuingtobreastfeedtheirchilduptosomepointbetween1and5yearsofage(Fig.12).FiguresfromtheWHOGlobalDataBankonInfantFeedingandYoungChildfeeding(2005-2006)suggestthat97.4%ofwomenbreastfeedtheirbabyatsomepointinKerala.However,themediantimeforwhichamotherbreastfeedsexclusivelyis3months.Althoughtherateofbreastfeedingislowerinthefindingsofoursurvey(Table6),theaveragelengthoftimewomenbreastfeedforissignificantlyhigher.Thismaysuggestthatrelativepovertyandnecessityhaveapositiveoutcomeonlengthofbreastfeedingtime.Womengaveanormalrangeofreasonsforstoppingbreastfeedingincludingweaning,breastfeedingissuesandmedicalissues(Table7).

Fig.12:Methodoffeedingbabies

Gov.hospital

%

Privateho

spital

%

Home

%Number

ofresponses

%Responses

%Respondents

<100 0 0.00% 0 0.00% 0 0.00% 0 0.00%

77.42%

100-499 0 0.00% 0 0.00% 0 0.00% 0 0.00%500-999 0 0.00% 0 0.00% 0 0.00% 0 0.00%1,000-1,999 3 12.50% 0 0.00% 0 0.00% 3 7.50%2,000-2,999 1 4.17% 2 13.33% 0 0.00% 3 7.50%3,000-3,999 4 16.67% 0 0.00% 1 100.00% 5 12.50%4,000-4,999 6 25.00% 5 33.33% 0 0.00% 11 27.50%5,000-9,999 4 16.67% 5 33.33% 0 0.00% 9 22.50%10,000-11,999 5 20.83% 0 0.00% 0 0.00% 5 12.50%12,000-14,999 1 4.17% 2 13.33% 0 0.00% 3 7.50%15,000-20,000 0 0.00% 1 6.67% 0 0.00% 1 2.50%>20,000 0 0.00% 0 0.00% 0 0.00% 0 0.00% 24 100.00% 15 100.00% 1 100.00% 100.00% Totalbirths 40 Totalresponses 24 Didnotanswerquestion

7 22.58%

Total 31 100.00%


Numberofresponses

%Responses

%Respondents

Upto1month

1 0.67%

98.67%

Upto6months 11 7.33%Upto1year 21 14.00%1to2years 61 40.67%2to5years 54 36.00%>5years 2 1.33% Totalfeedingmethods 150 100% Totalresponses 74


Total 75 100.00%

Table6:Ifyoubreastfed,howlongfor?

Reason Numberofresponses

%Responses

%Respondents

Age

2 6.45%

30.88%

Childstoppedontheirown 3 9.68%Cracks 3 9.68%Didn’tknowmuchaboutit 2 6.45%Insufficientsupplies 4 12.90%Mastitis 1 3.23%Motherhadchickenpox 1 3.23%Anotherpregnancy 8 25.81%Startedsolids 3 9.68%Startedwork 1 3.23%Surgery 1 3.23%Wantedtostop 2 6.45%

Totalreasons 31 100% Totalresponsesquestion 21


Total 68 100.00%

Table7:Whatmadeyoustopbreastfeeding?

There was a marked difference in correlations of age and menstruation education between older andyounger women. 4.76% of Women over the age of 46 had received some education about theirmenstruationwhichrepresentedtheagerangeinthissampleleasteducatedaboutmenstruation(4.76%ofrespondents).Whereas,53%ofwomenintheageranges21-25and26-35hadsomeeducationaboutthistopicand72.7%ofrespondentsbetweentheagesof18and20,suggestingthatdiscussionofmenstruationmaybeincreasingovertheyears.


Education63%of thewomen responded that they could read andwrite, 9% could read only, 28%of respondentscould neither read orwrite (Fig. 13). Compared to census on Keralan state literacy (2011) this fallswellbelow the 93% of women reported to be literate. 84% of respondents reported to have had someeducation(Fig.14),ofthese77%attendedgovernmentschooland18%privateschool,4%attendedbothatsome time (Fig. 15). Education in India is provided by both the public sector (government) and privatesector. The ratio of use of public to private schools in India is 7:5. Government schools provide freeeducation to children between the ages of 6 and 14. However the education provided in governmentschools is often seenas second rate compared to thatof theprivate schools. It is broadly recognised inIndia that education will lead to a better quality of life (Sreenivasulu, 2013). Therefore, parents fromvaryingsocio-economicbackgroundsoftenspendalargemajorityoftheirincometosendtheirchildrentoprivateschools.Feescanvarybetween1000INR(15.68USD/12.01GBP)to10,000INR(156.80USD/120.18GBP) per month. Reasons for stopping school attendance amongst our survey respondents includedmarriage and failing grades. However, the greatest number of respondents had to leave due to familyfinancial difficulties, having to start work, ill health of a family member and increased householdresponsibilities (Table8).26.8%ofwomenstoppedgoingtoschoolbytheageof15 (Fig.16)with16.6%havingpassedtenthgrade(Fig.17).

Of those responding,nowomen reportedhavingnoeducationunder theageof25,all except1womanbelowtheageof35hadsomeeducationandanincreasewasseenintheamountofwomenwhohadnoeducationwasseen inwomenabovetheageof36,suggestingthat ithasbecomeincreasingly likelythatwomenwillhavesomeeducation.17.86%ofwomenreportedthattheywereilliteratedespitehavinghadsomeeducation.81.25%of respondentswere illiteratehavinghadnoeducationbut12.5%were literatehavinghadnoeducation.6.25%couldreadonlyandnotwrite.Agecorrelationsshowthatgirlswhowenttoschooluntiltheageof14were100%literate.Thosewholeftschoolat7yearsorlesshad12.5%literacy.Thus,apatterndoesemergefromthissmallsample.

Fig.2:Literacy


Fig.14:Education

Fig.15:Whereeducated

Reason Numberofresponses

%Responses

%Respondents

Continuingeducation 9 10.71%

67.00%

Notsenttoschool 2 2.38%Notinterestedinstudying 9 10.71%FailedGrade/Degree 7 8.33%Parents(s)Alcoholic 3 3.57%Deathofparent(s) 3 3.57%Illhealthofparents 4 4.76%PersonalIllness 2 2.38%Financialdifficulties 22 26.19%Householdresponsibilities 7 8.33%Marriage 3 3.57%Pregnancy 1 1.19%StartedWork 3 3.57%Other 9 10.71%

Totalreasons 84 100% Totalresponses

question67


Total 100 100.00%

Table8:Whydidyoustopgoingtoschool?


Fig.16:School-leavingage

Fig.17:Lastgradeachieved


Menstruation80.6% of respondents started menstruating between the ages of 12 and 14 years old (Fig. 18), whichcorresponds to mean Indian age of 13.7 years old (Pathak et al, 2014). 63% of respondents had neverreceivedanyeducationaboutmenstruation(Fig.19).Ofthe37%whohadreceivededucation,commentsranged from 5 respondents not remembering what they were taught and 11 reporting receivinginformation about general personal hygiene during their period. Only 1 woman reported receivinginformationaboutphysicalchangesduringherperiod.Therewereminimalreportsofreceivingeducationregardingmenstruationand theeffectsof iton thebody, fertilityor reproductivehealth. For thosewhohad somemenstruation education, respondents reported being taughtmainly by doctorswho attendedtheirschoolorschoolteachers.

Fig.18:Agestartedmenstruating

Fig.19:Educationaboutmenstruation

57.14%ofrespondentshadnotbeentaughtanythingabouttheirmenstruationbytheirmothers(Fig.20).26oftherespondents’mothershadtaughtthemaboutpersonalhygiene,1wasembarrassedtotalkaboutmenstruationwhenasked,1wasadvisedtobecarefulwithmen(Fig.21).44.9%ofmothersreportedthattheyhadtaughttheirdaughtersaboutmenstruation(Fig.22).Again,themajorityofthiswasreportedtobeaboutgeneralhygiene(Fig.23).AccordingtoGargandAnand(2015)thementionofmenstruationinIndiaisperceivedasataboo.Duetothesocialandculturalinfluencesattachedtothis,itappearstohavehadanimpactontheadvancementofknowledgeonthesubject.


Fig.20:Taughtaboutmenstruationbymother

Fig.21:Informationaboutmenstruationprovidedbymother

Fig.22:Tolddaughter(s)aboutmenstruation


Fig.23:Informationprovidedtodaughter(s)aboutmenstruation

Correlationdatasuggeststhatliteracydidnotincreasethenumberofmotherswhotaughttheirdaughtersaboutmenstruation(Table9).39%ofliteratemothershadtaughttheirdaughterbut59%hadnot,whereas48%of illiteratemothers had taught their daughters something aboutmenstruation. This could indicatethatliteratemothersarerelyingonschoolstoteachtheirdaughters.Interestingly,womenwholeftschoolatanearlierageof7yearsoldorbelowappeartohavebeenmore likelytoteachtheirdaughtersaboutmenstruationthanthosewhostayedatschoolforlonger(Fig.24).Thenumbersofthosewhohadandhadnot taught their daughter about menstruation and left school at age of 15 were equal. The very smallsamplenumbersgeneratedbythiscorrelationrequirevalidationthroughalargersample.

Table9:Literacyandhasinformeddaughter(s)aboutmenstruation

Hastolddaughter(s)aboutmenstruation

Yes % No % Numberofresponses

%Responses

%Respondents

Readandwrite 16 39.02% 19 59.38% 35 39.02%

86.25%Readonly 5 12.20% 2 6.25% 7 9.59%Neither 20 48.78% 11 34.38% 31 42.47% Totalresponses 73 Didnotanswer

question2 13.75%

Total 75 100.00%


Fig.24:Schoolleavingageandhasinformeddaughter(s)aboutmenstruation

58.5%ofrespondentsuseddisposablepadstomanagetheirmenstruation,23.40%usedcloth(which isusually unwanted fabric that iswashed after use and reused), a traditional practice in India. In recentyears,anemphasishasbeenplacedon theneed towashanddry the reused fabric in thesunandnotinsidethehome,sothatbacteriaarekilledefficientlyandtherefore less infectionsarecaused.Womenhavepreviouslytendedtodrytheirclothinsidetoavoidembarrassmentbeingcausedbypeopleseeingthecloth.

11.7% of respondents used a mixture of disposable pad and cloth. No respondents reported usingtampons,which corresponds to general use in India,with tampons being the least popularmethodofperiodmanagementaccordingtoanIndianFemininehygienemarketoverview(2016).Womenovertheageof35appearedtouseclothmore,whileyoungerwomenuseddisposablepads(Table10).Ahighernumberofwomenbelow26yearsold,reportedsoleuseofdisposablepads.Adeclineofusageofclothwasshowninwomenbetweentheagesof26-35and36-40yearsold,suggestingthatdisposablepadshavebecomemorepopularover the last20years.Amixtureofclothanddisposablepadswasused in81.82% of women who did have education about their menstruation. No women who reportedmenstruation education used cloth only and all women who did use cloth had no education aboutmenstruation. 38.1% of women who had been taught about menstruation by their mothers used amixtureofclothanddisposablepads.

Numberofresponses

%Responses

%Respondents

Disposablepads 53 56.38%

94.00%

Reusablepads 0 0.00%Cloth 22 23.40%ClothandDisposablepads 13 13.83%Tampon 0 0.00%Other 1 1.06%Notapplicable 5 5.32%

Totalresponsesquestion

94 100.00%Didnotanswerquestion 6 6.00%

Total 100 100.00%

Table10:Howdoyoumanageyourperiod?


Women were taught a variety of traditions and beliefs surrounding menstruation, including hygiene,taking regular oil baths, not touching religious items or attending religious places, staying in anotherroomawayfromothersandchangesindiet(Fig.25).Ofthetraditionsandbeliefstheyhadbeentaught,whenasked if they felt the informationtheyhadreceivedwas true,partly true,untrueor if theywerenotsure,morerespondentsbelievedthattheinformationwastruewhencomparedtoanyoftheothercategories(Fig.25).InsomepartsofAsiaisolationtoanouthouseduringmenstruationisstillatradition:thispracticeisthoughttobemoreprevalentinNorthIndia.

Fig.25:Traditionsandbeliefsaboutmenstruation


ContraceptionOftherespondents82.2%ofwomenwereawareofsomeformofcontraceptionthatwasavailabletothem(Fig.26).However,63%ofrespondentsreportedusingnocontraception,notincludingthoseresponding,‘notapplicable’ (womenwhowere no longer fertile) (Fig. 27). Therefore 84% of respondents to whom it wasapplicableusednocontraception.Anexplanationforthiscouldbethewidespreaduseoftuballigation,whichisanirreversiblesurgicalprocedurewhereawoman’sfallopiantubesareblocked,tiedorcuttomaketheminfertile(Table11).TuballigationhasbecomeacommonoccurrenceinIndia,withmorethan4millionoftheoperations being performed between 2013-2014. However, questions regarding informed consent for theprocedurehavearisenfollowingtheinitiationofagovernmentrunmasssterilisationcampin2012aspartofaprogrammetocontrol India’spopulation, inwhichanumberofwomendiedandmorebecameseriouslyunwell(Pulla,2014).Itisevidentthatfamilysizehasdecreasedovertheyears,butevensoreporteduseofcontraceptioninwomenofchildbearingageappearstobeinminimaluse.Furtherinvestigationintowomen’sfeelingsandunderstandingofcontraceptionmayshedsomemorelightonthecause(s)ofthis.

Fig.26:Contraceptiveawareness

Fig.27:Contraceptiveuse


Numberofresponses

%Responses

%Respondents

Yes 10 10.00%

100.00%No 63 63.00%Notapplicable 27 27.00%



Total 100 100.00%

Table11:Haveyoueverusedadifferenttypeofcontraception?

Minimal contraceptionwasused inall age rangesbut thosewho left schoolat theageof15weremoreawareoftheiroptions.ThosewhocouldreadandwriteweremoreawareofCopperT,contraceptivepillsandcondoms.Of the respondentswhowere illiterate, condomsandCopperTwereheard themost,butlesscommonlythanthosewhowere literate. Overall, thosewhowere literateandeducatedknewmoreabouttheavailablecontraceptionthanthosewhowerenot.(Fig.28andFig.29).

Fig.28:Literacyandcontraceptiveawareness

Fig.29:Educationandcontraceptiveawareness


PregnancyWomen were asked whether they were aware of pregnancy symptoms to gain an insight into theirunderstandingoftheirbodiesduringpregnancy.Oftherespondents,96.43%ofwomenrealisedtheywerepregnant because of one ormore pregnancy symptoms, indicating a good level of awareness (Fig. 30).Pregnancy symptoms reportedbywomenwereanormal rangeof symptoms fromnauseaandvomiting,tiredness,foodaversionsandmissedperiods(Fig.31).1womanreportedthatherneighbourwasthefirstto tell her shewas pregnant. 91.95% of women knew theywere pregnantwithin the first 12weeks ofpregnancy(firsttrimester)whichiswhenwomenmostcommonlyrealisetheyarepregnant(Fig32).

Fig.30:Awarenessofpregnancy

Fig.31:Symptomsofpregnancy


Fig.32:Whenawarepregnancy

39%ofwomenreportedchangingtheirdietand/orlifestylewhentheyknewtheywerepregnant(Fig33).17.1% of these respondents reported increasing their fruit and vegetable intake, 28.5% reported takingmorerestorcompletebedrestforthepregnancy,25.7%reportedlossofappetiteoreatingless,14.2%ofrespondentstookapregnancyvitaminsupplement,8.5%reportedeatingmore.Only2.8%reportedstayingactive and exercising. Health advice for pregnancy varies from country to country. However, overall ahealthybalanceddiet,maintainingactivityandtakingpregnancyvitaminsupplementsareseenaspositivepregnancyactivities.Thereisnoevidencetosuggestthatbedrestinahealthypregnancyhasbenefitsbutevidencedoessuggestthatitdoesnothelppreventortreatmostpregnancycomplications(Maloni2011,Bigelow et al 2011) Even so, the historical practice of bed rest is commonly adopted by women inpregnancyinIndia.Therangeoflifestyleordietchangesmadebytherespondentssuggeststhatthereisnouniformadviceoraccesstoinformationregardingpregnancyinthiscommunity.

Fig.33:Changestodiet/lifestyleduringpregnancy


47.9%ofrespondentswhocouldreadandwritereportedchangingtheirlifestyleinpregnancy,whilst82%ofwomenwhowere illiteratemade no health changeswhen pregnant.Womenwho had no educationwere less likely to change their lifestyle in their pregnancy. However slightly fewer women who wereliterate also reportedmaking changes to their lifestyle than those who did not (32 versus 36 women).Therefore, while education does appear to have a positive impact on pregnancy lifestyle, literacy alonedoesnotappeartobetheconclusivefactor(Fig.34).56.2%ofwomenwhohadsomeeducationaboutdietreportedchangingtheirpregnancylifestyle,suggestingthathavingsomeinformationspecificallyaboutdietislikelytobringaboutsomechange.

Fig.34:Lifestyleduringpregnancyandliteracy


NutritionContrarytoinitialinformationaboutdietintheslumcolonies,resultsfromthesurveysuggestamainlyvarieddiet includingvegetables,meats, fish, lentilsandrice.41%ofwomendidreporteatingoccasionalfastfoodand 56% reported eating chips and cookies (Fig. 35). Of those who ate fast foods the age range peakedbetween31-40yearsold.Womenof20yearsandyoungerandwomenover50atetheleastamountsoffastfoods(Fig.36).1respondentonlyatericeand2ateonlyriceandvegetables:theydidnotcommentonthereasonforthis.48%ofwomenhadsomeeducationaboutdiet,usuallyinaschoolenvironment.

Fig.35:Dietofrespondents

Fig.36:Agesofrespondentseatingfastfood


Alcoholandsmoking92ofthe100respondentsreportedthattheydidnotdrinkalcohol(Fig.37).Amongstthewomenwhodiddrink3drankbeer,1drankwineand4drankliquor(spirits).2oftherespondentsdrankaroundorabovetheweeklygovernmentadvice.50%ofwomenwhodiddrinkwereintheagerangebetween31to40yearsold(Fig.38)It isworthmentioningthatafewveryintoxicatedwomenmaynothavebeenapproachedatthetimeof thesurveyduetosafetyconcerns. It isnecessarytobeawarethatunlikethewest, in Indianculturewomendrinkingtoexcessortobecomeintoxicatedisnotthesocialnorm.

Fig.37:Respondentsalcoholconsumption

Fig.38:Agesofrespondentswhoconsumealcohol

55% of respondents communicated that someone else in their household drank alcohol (Fig. 39). Thenumber of family members who drank in each household were either none (43%) or 1 (48%) ofrespondents (Fig.40).Of thedrinkers inhouseholds,62.3%were thewoman’shusbandand18.3%weretheirfather,indicatingthatonthewholementendtobethedrinkersintheslumcolony(Table12).


Fig.39:Householdalcoholconsumption

Numberofresponses

%Responses

%Respondents

Husband 38 62.30%

100%

Child1 3 4.92%Child2 3 4.92%Child3 1 1.64%Child4 0 0.00%Maleparent 11 18.03%Femaleparent 3 4.92%Other 2 3.28%

Totalnumberwhodrinkalcoholresponsesquestion

61 Totalresponses 55 100.00%


Total 55 100.00%

Table12:Doesanyoneelseinyourhouseholddrinkalcohol?

Fig.40:Numberoffamilymemberswhoconsumealcohol


Smokingamongstwomendidnotappeartobeaproblem,withonly8%ofrespondentssayingthattheydidsmoke(Fig.41).6ofthe8respondentswhosmokedwereintheagerangesof30-40and40-50(Fig.42).Ofthosewho did smoke, 66.6% smoked 10 or fewer cigarettes or beedi cigarettes per day (Fig. 43). BeedicigarettesarecommonlysmokedinIndiaandareathinlyrolledcigaretteoftobaccoflakeandsometimessome herbs or spices, which are rolled in leaf which is tiedwith string. 3 respondents chewed paan ortobacco.Paanisapreparationofarecanutandsometimestobaccowrappedinabetelleaf,itischewedforits stimulant and psychoactive effects, after chewing it is either spat out or swallowed.No respondentsdisclosed any use of cannabis. Thismay have been due to the illegal nature of the activity and fear ofpunishment if disclosed, despite the researchers’ assurance of confidentiality. 49% of respondents livedwithsomeonewhosmoked (Fig.44),of these61.5%weretheirhusbandsand15.38%weretheir fathers(Fig. 45), again indicating that men tend to smoke more than women in the slum colony. It will beinteresting to correlate these findingswith themiscarriage rate in the slum colonies (to follow). Passivesmokinghasbeenfoundtoincreasethemiscarriagerateby11%(Pinelesetal,2013).

Fig.41:Smoking

Fig.42:Agerangeofrespondentswhosmoke


Fig.43:Quantitysmoked

Fig.44:OtherHouseholdmemberssmokewhosmoke

Fig.45:Householdmemberswhosmoke


IncomeandexpenditurePaidworkwascommonamongsttherespondentswith51.5%ofwomenreportinghavingajob(Fig.46).Mostcommonlywomenworked asmaids (35.8%) or inwaste collection (20.7%). Other paidwork consisted ofworkinginashop,beingatailorandbeingalotteryticketvendor(Fig.47).55%ofwomenreportedhavingajoint incomewith theirhusbands in thehousehold (Table13),although31%ofwomenwerenotawareofhowmuch their husbandearned, suggesting thatmenmaybeworkingbutwomendonot seeoruse themoneyorlackcontroloverhowitisused.31%ofwomenandtheirhusbandswerejointlypaidbetween5000-9999INR(78.54-157.08USD/59.27-118.5GBP).Thelowestreportedjointincomewasbetween1000-1999INR(15.70-31.40USD/11.85-23.69GBP).1familyhada joint incomeof20000INRormore(314.21USD/237.33GBP).Thissuggestsavariedincomewithintheslumcommunity.Husbands’jobsvaried,from12wastecollectionworkers,10autorickshawdrivers,5coolieworkers(dailywagelabourworker)(Table14).Womenappeartobeearningsimilarwagestomen,aswellasdoinghouseworkandbringingupchildren,whichisthetraditionalroleofthewomaninIndianculture.

Fig.46:Paidwork

Fig.47:Typeofwork


Womenreportedspendingthegreatestamountsoftheirmonthlyearningsonfood(26%),loans(29%)and‘other’(43.7&),ofwhichtheydescribedasutilitybills(50%),privateeducationfortheirchildren(26%),hospitalbills(10%)andmedicines(10%).Privateeducationwasnotanexpectedexpenditureforwomenintheslumcolonyandmayexpresstheimportancethatwomenfeeleducationnowhasfortheirchildren(Table15).

Expenditure Numberofresponses

%Responses

%Respondents

Food 93 26.04%

96.00%

Rent 26 8.33%Alcohol 24 2.08%Smoking 30 0.00%Transport 33 1.04%Clothing 48 1.04%Loans 63 29.17%Other 42 32.29%

Totaltypesofexpenditure 359 100.00%Totalresponses 96


Total 100 100.00%

Table15:Whatistheitemthatyouspendthegreatestamountofyourincomeon?

Numberofresponses

%Responses

%Respondents

Yes 29 55.77%98.11%No 23 44.23%



Total 53 100.00%Table13:Doyouhaveajointincome?

Typeofwork Numberofresponses

%Responses

%Respondents

Accountant 2 3.13%

100.00%

Autorickshawdriver 10 15.63%Cooliework 5 7.81%Driver 5 7.81%Loading 3 4.69%Painter 2 3.13%Lotteryticketvendor 8 12.50%Stonemason 2 3.13%WasteCollection 12 18.75%Watchman 2 3.13%Other 13 20.31%



Total 64 100.00%

Table14:Whatworkdoesyourhusbanddo?


LimitationsThis was the first time the Birth For Change team had carried out a survey of this kind and, althoughconsiderablethoughtandtestingwentintoit,inthepreliminarystagestheremayhavebeensomeminoranomalies in data collection. It is not considered that they are of high significance. The role of andinvolvementofthelocalteaminthisprojectarevitaltothesustainabilityoftheongoingprojectandinputtothiscommunity.Suchsurveysshouldtakeaflexibleapproachanditisexpectedthatsomevariationswillbenecessaryasaresultoflearningduringtheprocess.

ConclusionThissurveyprovidesabaselinesnapshotintosomeoftheaspectsofawomen’sbackgroundinthissouthIndian slum community. Some striking findings are the lack of education around menstruation in thiscommunity,notonlyinformalsettingsbutalsofrommothertodaughter,possiblyduetothediscussionofwomen’s bodily functions not being seen as culturally or socially acceptable. When menstruation isdiscussed,themainfocusisonpersonalhygieneandnotonthefertilityandreproductivemeaningofthemenstrualcycle.Ifmothershavenotreceivededucationaroundthisthenitwillnotbepossibleforthemtopassinformationontofuturegenerations.

Womenappeartobeawareofavailablecontraceptionbutfiguresshowthattheyarenotusingit.Itwouldbeofinteresttofindoutwhythisisandhowfamilysizenumbersappeartobelesswhenthisisthecase,takingintoaccounttheuseoftuballigation.

Dietwas found tobemore variedandhealthy than initially assumed.Breastfeeding rateswerepositive,withveryfewwomenchoosingtoartificiallyfeedtheirbabies.Thiscarriesthelikelihoodofimprovingthehealthofthechildrenoftheslumcolonyfromtheirbirth.Moreinformationaboutchildren’shealthinthispopulationinrelationtobreastfeedingandchildhooddiseaseswouldbeconstructive.

Alcoholandsmokingamongstwomeninthispopulationappearstobeminimal.Thesurveysuggeststhatmentendtodrinkalcoholandsmokemorethanwomen. Itwouldbeof interest to look further intotheeffectsofhouseholdsmokersanddrinkersonthewellbeingofwomenandtheirchildren.

It isencouragingtoseethatdietandgeneraleducation insuchan impoverishedpopulation isexceedingexpectations.However,theknowledgeandunderstandingbehindlifestylechoiceswouldappeartoneedfurtherimprovement.Womenappeartohavelimitedknowledgeorunderstandingaboutdietandlifestylechangesforahealthypregnancy,theirbirthsandtheprocessesinvolvedingivingbirth.Whichinturn,mayaddtoalackofchoiceandcontrolinthebirthingenvironmentandtherisingratesofcaesareansectioninCochin.

Thesurveyhashighlightedtheimportanceofinformationgatheringabouteachpopulation,initialfindingsduringpreliminarytalksatthebeginningofthisprojectappeartohavebeenpartlyinaccurate.Findingsofthissurveyallowsustomoveforwardwithamorefocusedviewforthispopulationofwomen.Empoweringthesewomenthrougheducationandanincreaseintheirroleindecisionmakingabouttheirownhealthisvitaltopositivechangesinwomen’shealthinIndia.

Keyrecommendations• Followingfindingsofthissurvey,healthclassesandahealthclinichavebeencommencedwithin

theslumcolonywiththeaimofaddressingthehealthcareandeducationaccessneedsandimprovingthehealthliteracyfordaytodayuseforthewomenintheslumcolonies.

• Specificfocusshouldbepaidtoprovidinginformationaboutmenstruation,contraception,pregnancy,birthprocessesandprocedurewhichappeartobethemainareasinwhichinformationandeducationarelacking.


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Documents

Maternal Health Survey · Maternal Health Survey, Kerala, India ... slightly later date than other questions ... This may have been associated with the dowry system in India which