SOCIAL DETERMINANTS OF REPRODUCTIVE HEALTH

AMONG MARRIED SLUM DWELLING WOMEN:

A CASE STUDY OF UTTARPARA SLUMS

Thesis submitted to The University of Burdwan

in partial fulfillment of the requirement for the Degree of
Doctor of Philosophy

GARGI LAHIRI

Under the Supervision of

Dr. Anirban Banerjee
Professor of Sociology

Department of Sociology
The University of Burdwan
Burdwan, 713104,
West Bengal, India
2017
 17th March, 2017

CERTIFICATE

This is to certify that Ms .Gargi Lahiri is registered under me as a Ph.D. scholar, (vide
Registration Certificate No.R/Ph.D. Regn/Sociology/A/929/1(4) dated 12.3.12) under the new
Ph.D. rules. She has worked on her Ph.D. thesis entitled: Social Determinants of Reproductive
Health among Married Slum Dwelling Women: A Case Study of Uttarpara Slums, under my
guidance and supervision. The thesis incorporates original research materials.

This is to further certify that Gargi has fulfilled all conditions for submission of her thesis.
She delivered her Ph.D. Seminar on 20th September, [Link] has also published research
papers related to her topic of research.

ANIRBAN BANERJEE
 TABLE OF CONTENTS
Page No.

ACKKNOWLEDGEMENT i
DECLARATION iii
PLAGIARISM DECLARATION iv
LIST OF TABLES v
LIST OF FIGURES xii
LIST OF PLATES xiii

CHAPTER 1: INTRODUCTION 1-38

1.1 INTRODUCTION TO THE RESEARCH AGENDA 1
1.1.1 Concept of Health 4
1.1.2 Concept of Social Determinants 13
1.1.3 Concept of Slum 15
1.2 ORIGIN OF THE PROBLEM AND APPROACH TO IT 20
1.3 MAGNITUDE OF THE PROBLEM 27
1.4 RESEARCH OBJECTIVES 30
1.5 RESEARCH QUESTIONS 31
1.6 CHOICE OF THE STUDY AREA 32
1.7 DATABASE 33
1.8 PROBLEMS FACED BY THE RESEARCHER 34
1.9 LIMITATIONS OF RESEARCH 35
1.10 ORGANIZATION OF THE CHAPTERS 36

CHAPTER 2: LITERATURE REVIEW 39-95

2.1 INTRODUCTION 39
2.2 SOCIAL DETERMINANTS 39
2.2.1 Literature on Age at Marriage and Reproductive Health 42
2.2.2 Literature on Mass Media and Reproductive Health 50
2.2.3 Literature on Literacy and Reproductive Health 56
2.2.4 Literature on Autonomy of Women and
Reproductive Health 59
2.2.5 Literature on Gender Roles and Reproductive
Health 67
2.2.6 Literature on Experience of Domestic Violence 75
2.2.7 Literature on Standard of Living Index and
Reproductive Health 77
2.2.8 Literature on Health Seeking Behaviour of Women 78
2.3 RESEARCH GAPS 82
CHAPTER 3: METHODOLOGY 96-125
3.1 METHODOLOGY 96
3.2 SELECTION OF SAMPLE SIZE 96
3.3 SELECTION OF THE STUDY AREA 97
3.4 SAMPLE DESIGN 102
3.5 RATIONALE FOR PURPOSIVE SAMPLING 102
3.6 CALCULATION OF RESPONSE RATE 104
3.7 MANGIONE‘S CLASSIFICATION OF BANDS OF RESPONSE RATE 105
3.8 METHODS OF DATA COLLECTION 106
3.8.1 Data Collection 107
3.8.2 Data Management 107
3.9 METHODS OF DATA ANALYSIS 108
3.9.1 Chi –Square Test of Independence 108
3.9.2 Measures of Association 108
3.9.2. A. Cramer‘s phi 108
3.9.2. B. Cramer‘s V 108
3.10 CONCEPTUAL FRAMEWORK 109
3.10.1. Variables Used 111
3.10.1. A. Description of Independent Variables 111
3.10.1. B. Description of Response Variables 119
3.11 FORMULATION OF HYPOTHESIS 122

CHAPTER 4: STUDY AREA 126-160

4.1 PROFILE OF HOOGHLY DISTRICT 126
4.1.1 Historical Background & Administrative Set Up 126
4.1.2 Demographic Features of the District 128
4.1.3 Socio-Economic Features of the District 128
4.1.4 Health Profile of the District 129
4.1.5 Important Infrastructural Facilities in District Households 131
4.2 PROFILE OF UTTARPARA KOTRUNG 135
4.2.1 Historical Background of Uttarpara & Uttarpara Kotrung
Municipality 135
4.2.2 Administrative Boundaries of the Uttarpara Kotrang
Municipality 139
4.2.3 Connectivity of Uttarpara by Rail, Road, and Air 140
4.2.4 Climatic Conditions 140
4.2.5 Status of Existing Water Supply 141
4.2.6 Status of Existing Sewerage Facilities 141
4.2.7 Demographic Profile of Uttarpara Kotrang Municipality 142
4.2.8 Work Profile of Uttarpara Kotrung Municipality (Census 2011) 148
4.2.9 Public Health under Uttarpara Kotrung Municipality 149
 [Link] Health Profile of the Population under Uttarpara Kotrung
Municipality 151
[Link] Hospitals & Nursing Homes of the Area 152
4.3 Slums of Uttarpara Kotrung Municipality 154
4.4 Selection of the Slums for Study 158

CHAPTER 5: BACKGROUND CHARACTERISTICS AND SOCIAL

DETERMINANTS 161-176
5.1 BACKGROUND CHARACTERISTICS OF THE RESPONDENTS 161
5.1(A) Age at Marriage 161
5.1(B) Literacy 163
5.1(C) Work Status 164
5.1(D) Household Monthly Income (Rs.) 168
5.1(E) Standard of Living Index 171
5.2 Autonomy 171
5.3 Mass Media Exposure 172
5.4 Gender Role Attitudes 174

CHAPTER 6: REPRODUCTIVE HEALTH 177-225

6.1 KNOWLEDGE OF VARIOUS ASPECTS OF REPRODUCTIVE HEALTH 177
6.1.1 Knowledge of Female Reproductive Cycle 177
6.1.2 Knowledge of STIs and HIV / AIDS 181
6.1.3 Knowledge of Various Contraceptive Methods 184
6.1.4 Knowledge of Family Planning Basics 187
6.1.5 Knowledge Regarding Induced Abortion 189
6.1.6 Knowledge of Pregnancy, Ante-natal, Delivery
and Post natal Care 192
6.1.7 Knowledge of Reproductive Health Rights 196
6.2 PRACTICE OF VARIOUS ASPECTS OF REPRODUCTIVE HEALTH 199
6.2.1 Family Planning Practices – Ever use and
Current use 200
6.2.1(A) Recommendations, Decisions for the use
of Contraceptive Methods and their
Place of availability 206
6.2.2 Practice of Institutional Delivery 207
6.2.3 Practice of Ante-natal Care by Currently
Pregnant Women 212
6.2.4 Interaction with Healthcare Providers 214
6.2.5 Self Reported Gynaecological Ailments 217
6.2.6 Treatment Seeking Behaviour 219
6.2.7 Reasons for Not Seeking Treatment 221
CHAPTER 7: SELECTED CASE STUDIES 226-240

CHAPTER 8: SUMMARY AND CONCLUSION 241-259

8.1 MAJOR FINDINGS 241
8.2 SCOPE OF FURTHER RESEARCH 255
8.3 CONCLUSION 256

APPENDIX-I 260
APPENDIX-II 279
APPENDIX-III 283

ABBREVIATIONS 284

GLOSSARY 288

BIBLIOGRAPHY 289
 ACKNOWLEDGEMENT

I would like to extend my sincere thanks and appreciation for my Supervisor

Dr. Anirban Banerjee, Professor and former Head, Department of Sociology, The
University of Burdwan. I would like to thank you for encouraging my research and
helping me develop as a Research Scholar. Without your priceless guidance this thesis
would not have been possible.

I would also like to thank all teachers in the Department of Sociology whose
invaluable comments and suggestions have helped me to further my study. I also
thank each of them for making my Pre-Submission Seminar an enjoyable moment.

I express my heartfelt thanks to Dr. Nirmalya Kumar Bhattacharyya,

Controller of Examinations (Acting), Indian Institute of Engineering Science and
Technology (Formerly Bengal Engineering and Science University), Shibpur, for his
selfless effort in helping me with the quantitative data analysis.

I would like to extend my deepest gratitude to Mr. Dilip Yadav, Chairman,

Uttarpara Kotrung Municipality for granting me the permission to visit the slums for
the conduction of this study.

I would like to thank Mrs. Mousumi Ghoshal, Town Planning Officer,

Uttarpara Kotrung Municipality, for helping me tremendously during my visits to the
slums and conduction of interviews. I express my heartfelt thanks to all the other
officials and staff of Uttarpara Kotrung Municipality for helping me whenever I
sought their help.

A very special note of thanks to Mr. Dilip Ghosh, Administrator, ―Mahamaya

Sishu o Matrimangal Kendra‖, Uttarpara for lending a helping hand at each step of
this study. I also thank the medical and administrative staff of ―Mahamaya Sishu o
Matrimangal Kendra‖, Uttarpara, for answering all my queries even during their busy
work schedule.

i
 Words would not be enough to express my heartfelt thanks to all the
Supervisors and Honorary Health Workers of the subcentres under Uttarpara Kotrung
Municipality. Had they not been there, even a word of this thesis would not have been
possible. Thanks for helping me access the slums, communicate with the slum
dwellers and interview them.

I whole-heartedly thank all the women of the slums who co-operated with me
during the interviews even at odd hours of the day.

A special thanks to my family. Thanks to my parents, my in- laws for all the
things they have done in order to make this report happen. Your sincere prayers have
helped me to move ahead. I would like to thank my son for sacrificing his mother for
long so that I could sustain my studies.

At the end, I would like to express my deepest thanks to my beloved husband

Mr. Soumen Nath who spent sleepless months in order to help his wife follow her
dreams. No word would ever be enough to acknowledge your toil and your support.
Thank you for being with me even when I lost faith on myself.

Gargi Lahiri

ii
 DECLARATION

I do hereby declare that the thesis titled “SOCIAL DETERMINANTS OF

REPRODUCTIVE HEALTH AMONG MARRIED SLUM DWELLING
WOMEN: A CASE STUDY OF UTTARPARA SLUMS” submitted by me is an
original work and that the thesis has not been submitted in any other University for
the award of any other degree.

Gargi Lahiri

iii
 PLAGIARISM DECLARATION

I do hereby declare that the thesis titled “SOCIAL DETERMINANTS OF

REPRODUCTIVE HEALTH AMONG MARRIED SLUM DWELLING
WOMEN: A CASE STUDY OF UTTARPARA SLUMS” is written by me and in
my own words except for certain definitions and quotations from various published
and unpublished sources, all of which have been clearly indicated and duly
acknowledged.

I have adhered to the standard rules concerning the referencing, citation and
use of quotations. I am aware that reproduction of materials from the works of others
without acknowledging the source can be treated as Plagiarism, as per the University
Regulations. Sources of any picture, table, map, used in the study and not a part of my
own observation or survey, has been indicated and acknowledged.

To rule out chances of plagiarism, I have used two of anti-plagiarism software

(1) Small SEO Tools – Plagiarism checker available at

[Link]

(2) The Quetext plagiarism detection software available at [Link]

Both the software have declared the writing to be unique and free from plagiarism.

Gargi Lahiri

iv
 LIST OF TABLES

Table: 1.2.1 Causes of Maternal Mortality 22

Table: 3.3.1.a - c Ward wise Name of the Slum Areas under

Uttarpara Kotrung Municipality (UKM) 100-101

Table 3.5.1 Distribution of Sample in selected Slums of UKM 104

Table 3.7.1 Mangione‘s Bands of Response Rate 106

Table: [Link] Guidelines for Interpreting Measures of Association 109

Table: [Link].A Exposure to Mass Media by Responses of Women 113

Table: [Link].B Categorization of Maximum and Minimum Scores 113

Table: [Link].C Categorization of Mass Media Exposure Scores 113

Table: [Link].A Women‘s Autonomy Variables 114

Table: [Link].B Categorization of Maximum and Minimum Scores 115

Table: [Link].C Categorization of Women‘s Autonomy Score 115

Table: [Link].A Gender Role Attitudes of Married Women

Respondents 116

Table: [Link].B Categorization of Maximum and Minimum Scores 117

Table: [Link].C Categorization of Gender Role Attitudes

According to Scores 117

Table3.10.1.4.A Standard of Living Index (SLI) 117

Table: [Link].B Categorization of Maximum and Minimum Scores 118

Table: [Link].C Categorization of SLI According to Scores 118

Table3.10.1.5.A Categorization of Monthly Income 119

Table: [Link].B Final Categorization of Household Monthly Income 119

Table: [Link].A Description of Independent Variables 121

Table: [Link].B Description of Response Variables 121

v
Table: [Link] Antenatal (ANC) and Post natal (PNC)
Checkups of Mothers during 2006-2008 130

Table: [Link] Total Number of Households in Rural and

Urban Hooghly 131

Table: [Link] Percentage Distribution of Various

Types of Households in Rural and Urban Hooghly 132

Table: [Link] Percentage Distribution of Households in

Rural and Urban Hooghly by Their Major
Source of Drinking Water 132

Table: [Link] Percentage Distribution of Rural and

Urban Households in Hooghly by Their
Drainage Connectivity for Waste Water Outlet 133

Table: [Link] Percentage Distribution of Rural and

Urban Households in Hooghly by Their
Available Latrine Facility 134

Table: [Link] Percentage Distribution of Rural and

Urban Households in Hooghly by
Their Main Source of Lighting 134

Table: [Link] Demographic Growth Data of Uttarpara

Ward wise (1991 – 2011) 142

Table: [Link] Ward wise comparison of specific

Demographic Features of Uttarpara
Kotrung (Census 2011) 146

Table: [Link] Ward wise comparison of Work

Participation Profile of Uttarpara
Kotrung (Census, 2011) 148

Table: 4.3.1 Service Delivery gap in Core Services

in City and Slums in West Bengal (%) 155

Table: 4.3.2 UKM Prioritized Slum Areas 156

Table.5.1.1 Age Composition: Percentage Distribution

of Age Composition of Respondent Women
(Surveyed Households) 161

vi
Table.5.1.2 Pooled Age Group: Percentage Distribution
of Pooled Age Group Composition of
Respondent Women (Surveyed Households) 162

Table.5.1.3 Religion: Religion Wise Distribution of

Respondent Women (Surveyed Households) 162

Table 5.1.4 Caste: Percentage Distribution of

Respondent Women Belonging to
Different Castes (Surveyed Households) 163

Table 5.1.5 Literacy: Percentage Distribution of

Respondent Women by Literacy
(Surveyed Households) 163

Table 5.1.6 Levels of Educational Exposure

Among Literates: Percentage Distribution
of Levels of Educational Exposure of
Literate Women (Surveyed Households) 163

Table 5.1.7 Work Status: Percentage Distribution of

Work Status of Respondent Women
(Surveyed Households) 164

Table 5.1.8 Work Status: Percentage Distribution of

Work Status of Literate Women
(Surveyed Households) 164

Table 5.1.9 Work Status: Percentage Distribution of

Work Status of Illiterate Women
(Surveyed Households) 164

Table 5.1.10 Percentage Distribution of Working

Women by Present Employer 165

Table 5.1.11 Percentage Distribution of Working

Women of the Slum Surveyed by Stages
of Life When They Started Working 165

Table 5.1.12 Percentage Distribution of Working

Women of Surveyed Slum by Their
Reasons of Joining Work 166

Table 5.1.13 Percentage Distribution of Working

Women by Working Hours Per Day 166

vii
Table 5.1.14 Percentage Distribution of Working
Women According to Various Monthly Incomes 167

Table 5.1.15 Percentage Distribution of Working

Women by Their Contribution to Family
Income 167

Table 5.1.16 Household Monthly Income of the Surveyed

Women 168

Table 5.1.17 Family Type: Percentage Distribution of

Family Type of Women (Surveyed
Households) 168

Table 5.1.18 Family Type and Work Status of Women

in Surveyed Households 169

Table 5.1.19 Marriage and Co-habitation Status 169

Table 5.1.20 Birth History of the Respondent Women 170

Table 5.1.21 Standard of Living of the Respondent Women 171

Table 5.2.1 Percentage Distribution of Women According

to their Type of Autonomy 171

Table 5.2.2 Percentage Distribution of Women

According to their Levels of Autonomy 172

Table 5.3.1 Percentage Distribution of Women

According to Their Exposures to Mass Media 173

Table 5.4.1 Percentage Distribution of Women

According to Their Gender Role Attitudes 174

Table [Link] Knowledge of Women Regarding Female

Reproductive Cycle 178

Table [Link] Percentage Distribution of Women who

know Female Reproductive Cycle by
Social Determinants (Background
Characteristics) 178

Table: [Link] Knowledge and Awareness of Women

Regarding STIs including HIV / AIDS 182

viii
Table: [Link] Percentage Distribution of Women
who know STIs including HIV / AIDS
by Social Determinants (Background
Characteristics) 182

Table: [Link] Knowledge of Women Regarding Various

Contraceptive Methods 185

Table: [Link] Percentage Distribution of Women who

know Various Contraceptive Methods
by Social Determinants (Background
Characteristics) 185

Table: [Link] Knowledge of Women Regarding Family

Planning Basics 187

Table: [Link] Percentage Distribution of Women who know

about Family Planning Basics by Social
Determinants (Background Characteristics) 188

Table: [Link] Knowledge of Women Regarding Induced

Abortion 190

Table: [Link] Percentage Distribution of Women who know

about Induced Abortion by Social Determinants
(Background Characteristics) 191

Table: [Link].a-b Knowledge of Women Regarding Pregnancy,

ANC, Child-Birth and PNC 192

Table: [Link] Percentage Distribution of Women who

know about Pregnancy, ANC, Child-Birth
and PNC by Social Determinants
(Background Characteristics) 194

Table: [Link] Percentage Distribution of Women according

to their knowledge of Reproductive Health
Rights (RHR) 197

Table: [Link]-2 Family Planning Practice by women:

Ever Used and Current Use of
Contraception 200

ix
Table: [Link] Percentage Distribution of Women according
to Family Planning Practice: Ever Use of
Contraception by Social Determinants
(Background Characteristics) 203

Table: [Link] Percentage Distribution of Women according

to Family Planning Practice: Current Use of
Contraception by Social Determinants
(Background Characteristics) 205

Table: 6.2.1.A.1 Recommendation, Decision for Use of

Contraceptives and Place of Availability 206

Table: [Link] Practice of Institutional Delivery and

Delivery at Home Attended by Skilled
Birth Attendant (Those who delivered
during the past 1 year) 208

Table: [Link] Percentage Distribution of Women with

regard to their Place of Delivery by
Social Determinants (Background
Characteristics) 210

Table: [Link] Practice of Ante Natal Care (ANC) by

Currently Pregnant Women 212

Table: [Link] Interaction with health care providers

during the last 6 months preceding the
survey 214

Table: [Link] Women who interacted with a

Healthcare Provider to discuss the
following in the last Six Months 215

Table: [Link] Percentage Distribution of Women Who

Interacted with Healthcare Providers
by Social Determinants (Background
Characteristics) 215

Table: [Link] Self Reported Gynaecological (Reproductive)

Ailments of Women During the Past 6 Months 217

x
Table: [Link] Percentage Distribution of Women by
their Symptoms of Gynaecological
Ailments 217

Table: [Link] Actions Taken by the Women who

Reported Symptoms of Gynaecological
Ailments 219

Table: [Link] Percentage Distribution of Women with

regard to their Treatment Seeking
Behaviour for Gynaecological Ailments
by Social Determinants (Background
Characteristics) 219

Table: [Link] Percentage Distribution of Women by

Reasons for Not Seeking Treatment
of Gynaecological Ailments 221

Table: [Link] Quality of Care Received from the

Health care Provider 223

Table: 8.1.1 - Relationship between Social Determinants

Table: 8.1.3 Variables and Knowledge of Reproductive
Health Aspects 245-247

Table: 8.1.4 - Relationship between Social Determinant

Table: 8.1.7 Variables and Practice of Reproductive
Health Aspects
248-251

xi
 LIST OF FIGURES

Figure: 1.1.1 Conceptual Framework of SDH inequities 4

Figure: [Link] State Share of Slum Population to Total

Slum Population of India (2001) 18

Figure: [Link] State Share of Slum Population to Total Slum

Population of India (2011) 18

Figure: [Link] Percentage of Slum Population (2001-2011) 19

Figure: 1.2.1 Global Causes of Maternal Mortality 22

Figure: 2.2.1 General Socio-Economic, Cultural and

Environmental Conditions 40

Figure: 3.1. Diagrammatic Representation of Research

Methodology 96

Figure: 3.3.1 Selected Wards of Uttarpara Kotrung

Municipality 99

Figure: 3.10.1 Conceptual Framework Relating Social

Determinants to Reproductive Health 110

Figure: [Link] Location of UKM under KMA 136

Figure: [Link] UKM under West Bengal Municipal Bodies 138

Figure: [Link] Caste wise male female population of

Uttarpara Kotrung (Census – 2011) 143

Figure: [Link] Religion wise Distribution of Population of

Uttarpara Kotrung (Census -2011) 144

Figure: [Link] Growth of Population in Uttarpara

Kotrung (Census 2011) 145

Figure: [Link] Literacy Rate of Uttarpara Kotrung

(Census 2011) 146

Figure: [Link] Work Profile of Uttarpara Kotrung

Municipality 148

xii
 LIST OF PLATES

Plate: [Link] Photograph of Uttarpara Kotrung

Municipality (UKM) 139

Plate [Link].1 Photograph of Uttarpara State General Hospital 153

Plate [Link].2 Photograph of Mahamaya Sishu o

Matrimangal Kendra 153

Plate 4.3.1 Photograph of a slum of Uttarpara 158

Plate 4.4.1 Photograph of a slum of Uttarpara 158

xiii
 CHAPTER 1

1.1. INTRODUCTION TO THE RESEARCH AGENDA

Post International Conference on Population and Development, Cairo (1994),1

the issues of reproductive health has begun receiving greater visibility all over the
globe. India is no exception as it began moving from the narrow realm of female
sterilization and contraception to a more holistic approach to women‘s health. ―But
the overall health status of women shows a grim picture with mortality and morbidity
related to reproductive causes being one of the highest in the world. 68,000 mothers
died in the year 2008 from causes related to reproduction.‖ (Paul et al., 2011, p.332).

The underlying causes of the reproductive mortality and morbidity are more
social than are health related and in most cases are preventable in nature. To reach the
Millennium Development Goal (MDG-5),2 every committed country is expected to
decrease the maternal mortality and attain universal access to reproductive health
care. It was given in two targets: Target 5A – To reduce the Maternal Mortality Rate
(MMR) by three quarters from 1990 to 2015 & Target 5B – To achieve universal
access to reproductive health care by 2015.

Though much progress has been achieved around the globe in the field of
maternal health ever since the 1990s, the progress is unevenly distributed across the
countries. The MMR has been cut to almost half (45%) globally since year 1990. 71%
of women all over the world gave birth attended by skilled birth attendants in 2014,
which is a marked increase from 59% in 1990 and there were about 2,89,000 maternal
deaths in the year 2013 globally. As regards to the second target, the progress is
relatively slow and only half of the number of pregnant women receives full
recommended ante natal care across the globe. The MMR in India during 2007 - 2009
was 212 deaths per 1 lakh live births. However, it is observed that the rate was not
uniform across all the states in India. There had been poor, medium and high

1
Report of the International Conference on Population and Development (ICPD), Cairo, 5-13
September 1994, United Nations Publication Sales [Link].18
2
The Millennium Development Goals (MDG) Report 2015, United Nations, New York:
Retrieved from [Link]/millenniumgoals

1
performing states. Despite vast efforts on the part of the Government, many women
still lack access to maternal and reproductive health. Sanneving et al., 2013 in a study
analyzing the maternal and reproductive health in India in the context of (MDG-5)
opined that women‘s ability to access and avail health care is determined by social
factors. It is the social arrangement in which a woman lives determines her access to
health care.

The World Health Organization (WHO) termed these factors as the ‗Social
and Structural Determinants‘ of health. ―It is these determinants which act as
stumbling blocks for India to reach the MDG-5 targets.‖3 Women‘s unequal access or
sometimes complete lack of access to healthcare gives rise to health inequities.
Inequities refer to both unequal and unfair distribution of health due to unfair social
arrangements. Stark gender disparities are manifested in India in the form of unequal
sex ratios, high maternal mortality, and higher female infant and child mortality rates.
All these are results of women‘s unequal access to all resources including health care
(Jejeebhoy, 1997).

In India, overwhelming sexual relationship and activity and childbearing is

initiated in young females within the context of marriage (Ram, Sinha, & Mohanty,
2006). Women are married early and usually have premature sexual experience.
Women continue their married conjugal life often ignorant of their sexual and
reproductive rights. Indian women are generally subjected to tremendous pressure by
her husband‘s family to bear children immediately after marriage. Her decision-
making power in sexual relationship is curtailed. She even has less autonomy in
household decision making. The only way she can enhance her status is to prove her
fertility by giving birth to a son.

Research found that across India there is a strong son preference among all
socio-economic groups. A woman may thus be a victim of repeated pregnancies till a
son is born. Women‘s devaluation both inside and outside home acts as an
impediment to her ability to express a health care need and seek care. The case is all
the more sensitive when it comes to reproductive health. Speaking openly to husbands

3
Glob Health Action 2013, 6: 19145 - [Link]

2
and other family members about reproductive ill health is still not acceptable and is
considered as a matter of shame among most Indian females. Reproductive ill health
is thus borne silently by most women. Home remedies are often used by women in
case of gynecological and obstetric morbidities. It is when the home remedies fail and
things turn worse women resort to medical help. Even in cases where treatment is
sought, only a handful of women are found to undergo the full course of treatment.
This is particularly true among poor women. All of these results in ill maternal and
reproductive health of women.

It is clear from the above discussion that it is the social factors which
determine whether a women would be ill or well more than the medical factors.
Women‘s health thus needs to be studied in the context of her social, economic,
political, physical and psychological well being. The male and the female anatomy
vary and accordingly their vulnerability to different diseases varies.

The female anatomical structure makes her more prone to various diseases in
comparison of her male counterpart and the diseases of the reproductive system are
the principal among them. Her health is often dependent on men. She often has very
less or no knowledge about her reproductive health and the rights she is entitled to in
order to protect it. Her unequal social position with respect to man gives rise to health
inequities. With due recognition of the inequities, The Commission on Social
Determinants of Health (CSDH) 4 developed a conceptual framework of Social
Determinants of Health (SDH) inequities.

4
A Conceptual Framework for Action on the Social Determinants of Health - Social
Determinants of Health Discussion Paper 2 (Policy and Practice), World Health
Organization, Geneva, 2010

3
Figure: 1.1.1 CONCEPTUAL FRAMEWORK OF SOCIAL DETERMINANTS
OF HEALTH (SDH) INEQUITIES

Source: Social Determinants of Health Framework (WHO, 2010)5

With the above realities in background, the present research will study the social
determinants of reproductive health of poor women in an urban slum. In this context it
is necessary to have a clear understanding of the meanings of the terms reproductive
health, social determinants, and urban slums.

1.1.1 CONCEPT OF HEALTH

―Health is a state of complete physical, mental and social well being and not
merely an absence of disease and infirmity‖ (WHO, 1946).6 Reproductive health is a
one of the most crucial part of general health upon which rests the concept of human
development. Reproductive Health addresses the human sexuality, reproductive
processes, functions and systems at all stages of human life. It reflects the health

5
Solar O, Irwin A. “A conceptual framework for action on the social determinants of health.”
Social Determinants of Health Discussion Paper 2 (Policy and Practice). 2010
6
World Health Organisation (1946) Constitution, Geneva:WHO.

4
during childhood, is very crucial during adolescence and adulthood, which in turn
determines the health of both men and women beyond the reproductive years. It then
stretches to affect the health of the future generations. A mother‘s health and
nutritional status during childbearing and her ability to access health care services
determine the health status of her offspring. Reproductive health is of concern
throughout the lifetime of both men and women but assumes greater significance in
women during their years of reproduction.

Although the origin of most reproductive health problems is during the

reproductive years, but, earlier reproductive life events is often reflected in the old
age. Reproductive health problems are not limited to women. Men too are affected,
though the intensity and vulnerability is less than their women counterparts. However,
men have a wide role to play in the conservation of women‘s reproductive health and
overall reproductive health of both because of their decision-making powers in
reproductive health matters. 7 The International Conference on Population and
Development Program of Action (1994) was an ambitious statement containing about
200 recommendations on various areas of health, development and social welfare. It
stated that "reproductive health ... implies that people are able to have a satisfying
and safe sex life and that they have the capability to reproduce and the freedom to
decide if, when and how often to do so. Implicit in this last condition are the right of
men and women to be informed and to have access to safe, effective, affordable and
acceptable methods of family planning of their choice, as well as other methods of
their choice for regulation of fertility which are not against the law, and the right of
access to appropriate health care services that will enable women to go safely
through pregnancy and childbirth and provide couples with the best chance of having
a healthy infant.... Reproductive health includes sexual health, the purpose of which is
the enhancement of life and personal relations, and not merely counseling and care
related to reproduction and sexually transmitted diseases." 8 This definition of
Reproductive and Sexual Health also includes issues such as the elimination of gender

7
Guidelines on Reproductive Health, United Nations Population Information Network
8
Report of the International Conference on Population and Development (ICPD), Cairo, 5-13
September 1994, United Nations Publication Sales [Link].18

5
based violence, abolition of harmful practices against women, coercion and abuse and
gender inequalities.

The ICPD also outlined the roles and responsibilities of the males towards
reproductive and sexual well-being of couples. It highlighted that all efforts should be
made to emphasize the fact that men are equal partners with their wives and should be
actively involved in all matters relating to family planning, ante natal, delivery and
post natal care, maternal and child health, prevention of sexually transmitted diseases
including HIV/AIDS, prevention of high risk and unwanted pregnancies. ICPD also
emphasized the role of men towards shared control and contribution to family income,
health and nutrition and educational advancement of the children and equal treatment
of children of both the sexes (Vikash Kumar KC, 2006). This clearly reveals the fact
that the reproductive health of men and women are determined not only by their
availing certain health services but also by their education, income, nutrition levels
and equal treatment of men and women in the society. So, reproductive health is not
only a medical event but is a social phenomenon as well.

The ICPD’s Twenty-Year Goals (1995-2015)9 can be summarized as

 Provision of universal access to a full range of safe and reliable family planning
methods and related reproductive health services.
 Reduction of infant mortality rates to below 35 infant deaths per 1,000 live births
and under-5 mortality rates to below 45 deaths of children under age 5 per 1,000
live births.
 Closing the gap in maternal mortality between developing and developed
countries. Achieving a maternal mortality rate below 60 deaths per 100,000 live
births.

9
UNITED NATIONS POPULATION INFORMATION NETWORK (POPIN)
UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)

6
 Increasing life expectancy at birth to more than 75 years. For countries with the
highest mortality, aiming to increase life expectancy at birth to more than 70
years.
 Achieving universal access to and completion of primary education; ensuring
widest and earliest possible access by girls and women to secondary and higher
levels of education.

A central feature of the Program of Action is the recommendation to provide

comprehensive reproductive health care, which includes family planning; safe
pregnancy and delivery services; abortion where legal; prevention and treatment of
sexually transmitted infections (including HIV/AIDS); information and counseling on
sexuality; and elimination of harmful practices against women (such as genital cutting
and forced marriage). In order to attain a good sexual and reproductive health, the
World Health Organization (WHO) 10 in 2004 outlined five components:

 Ensuring contraceptive choice and safety and infertility services

 Improving maternal and newborn health
 Reducing sexually transmitted infections, including HIV, and other
reproductive morbidities
 Eliminating unsafe abortion and providing post-abortion care
 Promoting healthy sexuality, including adolescent health and reducing harmful
practices.

Evans et al (1987) defined reproductive health as ―the ability of women to live

through the reproductive years and beyond, with reproductive choice, dignity and
successful child bearing and to be free from gynecological diseases and risks‖ (cited
in Mulgaonkar, 1996, p.136). It is only after the ICPD that the concept of reproductive
health became conspicuous globally, chiefly among the policy makers and health
advocates. Another term which is often used interchangeably with reproductive health
is sexual health. ―Sexual Health is a state of physical, emotional, mental and social

10
UN Millennium Project 2006, Public Choices, Private Decisions: Sexual and Reproductive
Health and the Millennium Development Goals.

7
well being in relation to sexuality; it is not merely the absence of disease, dysfunction
or infirmity‖ (WHO, 2006a). 11 It requires a positive and respectful approach to
sexuality and sexual relationships, as well as the possibility of having pleasurable and
safe sexual experiences, free of coercion, discrimination and violence (FWCW,
1995)12. ―Sexual health is the integration of emotional, intellectual, and social aspects
of sexual being in order to positively enrich personality, communication, relationships
and love. The three fundamental principles of sexual health are: 1) capacity to enjoy
and control sexual and reproductive behavior; 2) freedom from shame, guilt, fear, and
other psychological factors that may impair sexual relationships; and 3) freedom from
organic disorder or disease that interferes with sexual and reproductive function.‖13

Sexual and Reproductive Health are often segregated in policy and practice.
According to O‘Rourke (2008), the two terms are often integrated based on the
rationale that sexual and reproductive health are inherently interconnected, as sexual
health is vital for, and therefore, part of reproductive health (as cited in Social
Determinants of Sexual and Reproductive Health, 2011 Report, developed by
Women‘s Health West for the Western Region Sexual and Reproductive Health
Working Group). Following the International Conference on Population and
Development, Cairo, 1994 and the Fourth World Conference on Women, Beijing,
1995, countries endorsed a number of global goals and targets for better Sexual and
Reproductive Health. Many of these goals and targets were quantifiably and explicitly
defined and set as targets to be achieved by incorporating them in the National Health
Policies by different countries. Then, it was felt that there was a need to set up
indicators with respect to these goals and targets so that countries are able to monitor
and evaluate the goals achieved.

11
World Health Organization (2006a). Constitution of the World Health Organization - Basic
Documents, Forty-fifth edition
12
Reports of the Fourth World Conference on Women Beijing, 4-15 September 1995
13
Introduction to Reproductive Health and the Environment (Draft for review), Retrieved
from [Link]/ceh

8
 Accordingly, WHO convened a meeting of the UN agencies in May 1996 to
examine the issue of reproductive health indicators to reach a consensus on the short
list for global monitoring- There was a proposed short listing of 15 reproductive
health indicators 14 as follows-
1. ―Total Fertility Rate (TFR)
2. Contraceptive Prevalence Rate (CPR)
3. Maternal Mortality Ratio (MMR)
4. Percentage of women attended, at least once during pregnancy, by skilled
health personnel (excluding trained or untrained traditional birth attendants)
for reasons relating to pregnancy
5. Percentage of births attended by skilled health personnel (excluding trained
and untrained traditional birth attendants)
6. Number of facilities with functioning basic essential obstetric care per 500000
- population
7. Number of facilities with functioning comprehensive essential obstetric care
per 500000 Population
8. Perinatal Mortality Rate (PMR)
9. Percentage of live births of low birth weight (< 2500 g)
10. Positive syphilis serology prevalence in pregnant women (15 - 24)
11. Percentage of women of reproductive age (15 - 49) screened for haemoglobin
levels who are anaemic
12. Percentage of obstetrics and gynaecology admissions owing to abortion
13. Reported prevalence of women with Female Genital Mutilation (FGM)
14. Percentage of women of reproductive age (15 - 49) at risk of pregnancy who
report trying for a pregnancy for two years or more
15. Reported incidence of urethritis in men (15 - 49)‖.

The above list is not a comprehensive list of indicators for Program monitoring and
evaluation but a list of those indicators which can provide a general overview of the
reproductive health situation in any given setting. In order to get a total picture of the

14
Monitoring Reproductive Health: Selecting a short list of national and global indicators
WHO/RHT/HRP/97.26

9
reproductive health in any country, thirteen (13) priority areas were identified
which are crucial in any discussion of reproductive health indicators:
1. Abortion
2. Violence against women
3. Access to care
4. Quality of care
5. Antenatal care
6. Postpartum Care
7. Adolescent reproductive health
8. ‗Male factor‘
9. Reproductive health policy
10. HIV/AIDS
11. Reproductive Tract Infections
12. Preventative behavior
13. Cervical cancer

An additional indicator, HIV prevalence in pregnant women aged 15 - 24 years was

also discussed. The concept of Reproductive Health Index (RHI) emerged out of the
thoughts that a uniform construction of index across all countries will help in the
comparison of reproductive health status among countries. Several studies have
shown the construction of RHI by taking various variables. Reproductive health is
multi-dimensional in nature, so, it requires framing of a composite index by taking
into consideration several indices.

A study by (Parchure, Basu, Adak, & Bharti, 2011) named ―Differentials in

Reproductive And Child Health Status in India‖ based the RHI on five variables-
Total Fertility Rate (TFR), Infant Mortality Rate (IMR), Birth Order, Delivery Care
and Female Educational Attainment. 5 separate indices were computed and finally
RHI was arrived at by giving equal weights to each of the five indices. The value of
RHI ranged from 1 to 100. According to the value of RHI, they classified the states of
India into 3 categories-

10
 1. Progressive States – Kerala, Goa, Tamil Nadu, Himachal Pradesh, Tripura,
Sikkim, Andhra Pradesh, Karnataka, Jammu and Kashmir and West Bengal.
2. Semi Progressive States – Assam, Uttaranchal, Orissa, Haryana, Manipur.
3. Backward States – Uttar Pradesh, Jharkhand, Madhya Pradesh, Chhattisgarh,
Rajasthan, Meghalaya, Nagaland and Arunachal Pradesh.

An earlier study by (Ramanathan, 1998) argued that some of the 7

reproductive variables taken for construction of RHI by Population Foundation of
India should be changed. The seven variables taken were – Total Fertility Rate (TFR),
Age specific Fertility Rate for the age group 15 - 19 years, Birth order, Type of
attention at birth, Perinatal Mortality Rate, Couple Protection Rate due to sterilization
and Educational Attainment. She argued that this index was more appropriate for
measuring the status of Family Planning Program than the reproductive health status
of women. She identified that out of the seven variables, four measured fertility and
family planning. Since TFR was seen not to have a linear relationship with
reproductive health, it was replaced by Maternal Mortality Rate (MMR). Similarly,
she suggested the Age Specific Fertility Rate to be replaced by proportion of girl‘s
continuing education within ages 15 - 19 years. This variable, according to her, will
reflect women empowerment through education and lack of exposure to risk of early
childbearing. Another debatable variable according to the author was the CPR due to
sterilization. In India, sterilization was at once forced (during emergencies) and there
are instances of death and other complications due to sterilization conducted in camps
in different parts of India. Thus, sterilization cannot be an indicator of good
reproductive health on the premise that it is often forced on couples directly or
indirectly or both by the State in the absence or paucity of other contraceptive
choices. Two decades have passed since the ICPD and the world statistics on
Reproductive and Sexual health has shown remarkable progress. The main metrics15
used for measuring success in the field of family planning services – I. Increase in
Contraceptive prevalence between the years 1990 and 2012 and II. Unmet need for

15
Willard Cates, Jr. and Baker Maggwa for the FHI 360 Team, FHI ANNUAL REPORT
2011 Retrieved from [Link]

11
contraception decreased globally. Both of these have been largely driven by huge
changes in the developing countries.
It is now widely recognized that investments in sexual and reproductive health can
make significant contributions to global health and development including the
achievement of the Millennium Development Goals (MDGs). Four MDGs 16 are
directly related to reproductive health –

•Goal 3: Promote gender equality and empower women

• Goal 4: Reduce child mortality
• Goal 5: Improve maternal health,
• Goal 6: Combat HIV/AIDS, malaria & other disease

According to (Spielberg, 2007) a little investment in Reproductive and

Sexual Health can help in the following –

1. Reduce poverty – having fewer children with more time between successive
births puts lesser demands on households and communities. Women having
the power to decide when and whether to give birth create opportunities for
them to engage in activities like education and employment thereby reducing
poverty and contributing to growth.

2. Further Primary Education especially for the girl child- limited number of
children in the family enables parents to invest more on the children specially
the girls whose education is often sacrificed because of limited resources.

3. Promotion of women’s rights and gender equity – Reproductive health

rights shall ensure that women and men make free and informed choice which
in turn shall promote gender equality. The power of women to decide when to
bear a child and how to limit and space the number of children will help to
empower them and contribute to their development.

16
Population, Reproductive Health and the Millennium Development Goals, Messages from
the UN Millennium Project Reports, June 2005

12
 4. Save lives and help build a strong nation – investing in Sexual and
Reproductive Health and providing timely, necessary and effective
reproductive health services and information will help to avert maternal
deaths, deaths due to unsafe abortions, vulnerability of women due to various
STIs specially HIV/AIDS.

Despite the fact that a lot can be achieved by investing in reproductive and
sexual health, still there are a number of challenges which pose hindrances in
achieving Reproductive and Sexual Health17 for all –

1. About 24% married women or women with a live-in partner still have an unmet
need for family planning.
2. Rise of the adolescents in the global population pose a serious challenge in terms
of reaching the messages of reproductive and sexual health to them.
3. Low male involvement in reproductive and sexual health seen through adoption of
limited number of family planning methods by them. Use of Male condoms
constitutes only 6% of total modern contraceptive use throughout the globe.
Family planning is still largely seen as a female‘s responsibility.
4. Maternal health is still poor in many areas of the globe and advancements in the
area had been painfully slow.

1.1.2 CONCEPT OF SOCIAL DETERMINANTS

Social Determinants of health are ―The conditions in which people are born,
grow, live, work and age, including the health system‖ 18 . According to Raphael
(2004), Social Determinants of Health are the economic and the social factors that
determine health. The quality of these shows the societal distribution of resources

17
Sexual and Reproductive health for All. Reducing poverty – UNFPA: Retrieved from
[Link]/sites/default/files/pub-pdf/uarh_report_2010.pdf
18
World Health Organization, Health Sector Reforms in India: Initiatives from the States II

13
among the population (Bryant, 2006) 19 . These societal factors go by various titles
such as prerequisites for health, determinants of health and social determinants of
health among others (Health Canada, 1998; Wilkinson & Marmot, 2003; World
Health Organization, 1986). The most important factors appear to be income, housing
and food security, availability of health and social services, employment security and
working conditions (Raphael, 2004). Some of the social determinants include20 –

 ―Availability of resources to meet daily needs

 Access to education, economy and job opportunities
 Access to health care services
 Quality of education
 Social support
 Social norms and attitudes
 Exposure to crime, violence, social disorder
 Socioeconomic conditions
 Literacy
 Access to mass media and emerging technologies (cell phones, internet and
social media)
 Availability of community based resources in support of community living
and opportunities for recreational and leisure time activities.‖

The Social Determinants approach to Health is important in that they have a bearing
on shaping health outcomes. Also studying, analyzing and acting on the important
social determinants can bring about a positive change in the health outcomes and help
remove health inequities. They are also crucial in conceptualizing and delivering of
health programs.21
It is now a recognized fact that the way in which people are born, grow, live,
work and age determine the burden of diseases and health inequities within a country

19
Bryant, T. ―Towards a New Paradigm for Research on Urban Women‘s Health‖. 2006
20
[Link]/2020/topics-objectives/topic/social-determinants-of-health
21
A Social Determinants Approach to Maternal Health, UNDP, 2011

14
and across countries of the globe.22 These are referred to as the Social Determinants
of Health- a term which encompasses the social, political, economic, cultural, and the
environmental aspects of health. In 2008, WHO in its final report on the Commission
of Social Determinants of Health made recommendations on 3 critical areas of Social
Determinants –

1. Improving daily living conditions

2. Tackling inequitable distribution of power, money and resources
3. Measuring and understanding the problem and assessing the impact of
action

These recommendations were adopted by the member states at the World Health
Assembly in May 2009 through a resolution ‗WHA62.14‘ 23 on ―Reducing health
inequities through action on social determinants of health‖. This resolution called all
member states and the WHO secretariat and the International community to act on the
recommendations and align all work on the social determinants with renewal of
primary health care.

1.1.3 CONCEPT OF SLUM

Section 3 of the 1956 Slum Area Improvement and Clearance Act defines
slums as ―Those areas where buildings are in any respect unfit for human habitation
by reasons of dilapidation, overcrowding, faulty arrangements and designs of such
buildings, narrowness or faulty arrangement of streets, lack of ventilation, light,
sanitation facilities or any combination of these factors which are detrimental to
safety, health and morals‖.

22
[Link]
23
Final Report, World conference on Social Determinants of Health, Rio De Janeiro, Brazil,
2011

15
The UN Habitat defines a slum by ―lack of durable housing, insufficient living area,
and lack of access to clean water, inadequate sanitation and insecure tenure‖24. The
Central Statistics Organization defines slums as ―An area having 25 or more kutcha
structures, mostly of temporary nature, or 50 or more households residing mostly in
kutcha structures huddled together or inhabited by persons with practically no private
latrine and inadequate public latrine and water facilities‖.25

―In 2002, the United Nations operationally defined slums as communities

characterized by insecure residential status, poor structural quality of housing,
overcrowding, and inadequate access to safe water, sanitation, and other
infrastructure‖.26 According to the UN Agency, UN Habitat, a slum is a rundown area
of the city characterized by substandard housing, squalor and lacking in tenure
security. The concept of slums varies from one country to another. Sometimes even in
the same country they are called by different names as in India. The 2001 Census in
India was the first Census to independently enumerate the population in slum and non
slum areas. Dharavi in Central Mumbai houses the largest slum in India and Asia.
Slums are the results of rapid urbanization in a country. India is facing rapid
urbanization and it has put tremendous pressure on demand for basic services,
infrastructure, education, employment, affordable housing especially on the poor
segment of the urban population. According to 2011 Census, 31.14% of the Indian
populations are urban residents. The projections for the future show that the
percentage is likely to rise to 50% by 2051. This will be followed by the growth of
more slums in the cities.27 Out of 4041 statutory towns in India, 2613 towns have
reported slums and about 6.5 crore people are said to inhabit these slums. The Census
have categorized slums into 3 types-

24
Primary Census Abstract For Slums, 2011, Office of the Registrar General & Census
Commissioner, India, New Delhi, 30-09-2013
25
[Link], available from [Link]
26
Report, United Nations Human Settlements Program, 2003
27
Handbook of Urban Statistics 2016, Government of India, Ministry of Urban Development

16
1. ―Notified slums – are those which are notified as ‗slums‘ in towns and cities by the
State, Union Territory Administration, or, Local Government under any Act including
a Slum Act.

2. Registered slums – all areas recognized as ‗Slums‘ by the State, Union Territory
Administration, Local Government, Housing and Slum Boards, which may not have
been formally declared as notified.

3. Identified slums – a compact area of at least 300 persons or, 60-70 households in
poorly built congested houses, with inadequate infrastructure and lack of sanitary
facilities and drinking water. These areas should be identified by the Charge Officer,
and inspected by an officer nominated by the Directorate of Census Operations. These
facts should be recorded in the charge register".28

The 2011 Census reports that the state of West Bengal has 129 statutory towns and
122 towns are said to house slums. The total slum population in West Bengal
according to Census 2011 is 65,494,604. There are 22,535,133 notified slums,
20,131,336 recognized slums and 22,828,135 identified slums in West Bengal. It has
been found from the Census of 2001 and 2011 that the state share of slum population
to total slum population in India has increased from 8.9% to 9.8%.29

28
Primary Census Abstract For Slums, 2011, Office of the Registrar General & Census
Commissioner, India, New Delhi, 30-09-2013
29
Handbook of Urban Statistics 2016, Government of India, Ministry of Urban Development

17
Figure: [Link] State Share of Slum Population to Total Slum Population of India
(2001)

Source: Census of India 2001

Figure: [Link] State Share of Slum Population to Total Slum Population of India
(2011)

Source: Census of India 2011

18
Figure: [Link] Percentage of Slum Population (2001-2011)

The Kolkata Municipal Development Authority (KMDA) has categorized slums

under Kolkata Municipal Area (KMA) into 2 basic categories –

1. ―Registered slums – these are the ones which are recognized by the Municipal
Corporation and land titles handed over to the slum dwellers on a lease basis or given
on rent.

2. Unregistered slums – these are basically formed on encroached lands.

A study on socio-economic profile of various households under the KMA in the year
1996-97 revealed that 45% of the households live in slum like settlements‖.30

30
An Impact Evaluation Study of BSUP Program Intervention in Kolkata Metropolitan Area,
KMDA, Sep 2012.

19
1.2 ORIGIN OF THE PROBLEM AND APPROACH TO IT

The forerunner of what is called reproductive health today can be traced back
to the steps taken by UNFPA during the 1960s for reducing fertility. Contraceptive
pills along with Intra Uterine Devices (IUDs) and other long term hormonal methods
were used on a large scale in developing countries in order to control their population
boom. Almost all developing countries including India took recourse to family
planning programs to restrain population growth. The success of these program were
judged in terms of numeric goals and targets- number of family planning acceptors,
couple years of protection, number of tubal ligations performed. All these were
generally carried on in isolation from other areas of health and development. The
International Conference on Population and Development (ICPD), Cairo, 1994,
marked a revolution in the area of reproductive health. It drifted from its narrow scope
of female sterilization and contraception to a more holistic approach to women‘s
health. ―Three elements particularly provided the impetus for this paradigm shift-

 Growing movement and criticisms by women on over emphasis on control of

female fertility to the exclusion of their other needs.
 Global pandemic HIV/AIDS, which kindled the idea that there is a need to
respond to other consequences of sexual activity except pregnancy.
 Articulation of the concept of reproductive rights‖31.

ICPD called for women empowerment, a key to social justice and improved quality of
life. It emphasized on the entire life cycle of men and women rather than focusing
only on the reproductive years alone. ―It viewed reproductive health as three
interconnected domains-

 Universal human right

 Promoting women empowerment by seeking to address the underlying causes
of gender inequality and inequity
 Health service provision

31
Nigel Parton: Social Theory, Social Change, and Social Work. Retrieved from
[Link]

20
Thus, a movement was started leading to a more holistic approach to men and
women‘s reproductive health from population control and demographic targets‖.32
Reproductive ill health affects men and women differently. This variation is mostly
attributable to social factors rather than their biological constitution. Most societies
across the globe view women as the ―Weaker Sex‖ and they are subject to unequal
treatments from their male counterparts. WHO and the World Bank has estimated that
36% of all healthy years of life lost among women of reproductive age in developing
countries are due to 3 reproductive health conditions – maternal mortality and
morbidity, STIs , HIV and AIDS. For men this figure stands at 12%.
A global report on maternal and child health show that about 1600 women die
every day from pregnancy related complications, out of which nearly 90% of the
deaths occur in Asia and Sub Saharan Africa. Ross (2004) estimated that 25% - 33%
of all deaths of women in the reproductive age in developing countries are a result of
pregnancy and childbirth complications. According to IPPF (2002)33 report that one in
tenth women giving birth is a teenager and every minute 40 women face unsafe
abortions and 190 women face unplanned pregnancy worldwide. Equally appalling is
the outcome of pregnancy. UNICEF reports estimate that about 4 million babies die
before they reach one month of age and another 4 million are the victims of stillbirth.
―90% of these incidents happen in the developing countries (Vikash Kumar KC,
2006)‖.
The nature of six major causes of maternal death worldwide – sepsis,
prolonged or obstructed labour, eclampsia, malaria and anaemia, excessive bleeding
and unsafe abortion reveals that all of them are largely avoidable. Their avoidable
nature points out the fact that they have their roots grounded in the inequities in an
unjust society where women and men are viewed and treated differently.
Therefore, identifying and working on the underlying causes of inequity can
lead to sustainable health development. Here lies the importance of social
determinants which play a crucial role in determining who will be ill or well, whose
behaviors are risk prone and whose health needs will be addressed. A probe into the
social determinants approach to health will help in conceptualizing the problem better.

32
McDonald, Kelly. (2004). ―Introduction: What is Reproductive and Sexual Health?”
Retrieved from [Link]
guides/reproductive-health/alldocuments: accessed on 02.02.2014
33
International Planned Parenthood Federation Report- London, 2002

21
Table: 1.2.1 Causes of Maternal Mortality

Causes of Maternal Mortality % of Maternal Mortality Risk that Could Be

Eliminated

Antepartum hemorrhage 14.2

Postpartum hemorrhage 4.8-11.7
Infection 8.0
Unsafe abortion 14.0
Eclampsia 3.1-8.0
Obstructed Labor 19.0
All Leading Causes 63.1-74.9
Source: Reproductive Health Part 1: Introduction to Reproductive Health & Safe
Motherhood Laurel A. Spielberg, MPH, [Link] Dartmouth Medical School
December 2007

Figure: 1.2.1 GLOBAL CAUSES OF MATERNAL MORTALITY

Source: Reproductive Health Part 1: Introduction to Reproductive Health & Safe

Motherhood Laurel A. Spielberg, MPH, [Link] Dartmouth Medical School
December 2007

22
In a rapidly globalizing world, millions continue to experience profound inequities in
health, living, working and even dying in conditions of poverty, exclusion and
disenfranchisement. Experience in Cuba, Brazil and Thailand have shown that the
greatest successes of health system reforms have addressed the wider determinants of
health inequities as a national priority. The WHO Commission on Social
Determinants of Health (SDH) 2008 report defines health inequities as ―Systematic
differences in health that are avoidable by reasonable action and are quite simply
unfair.‖ These systematic differences can be terminated by action on the SDH. The
report affirms that health inequities arise not only from within but also from beyond
the domain of health, through other social determinants, including the ―unequal
distribution of power, income, goods and services, globally and nationally, the
consequent unfairness in the immediate, visible circumstances of people‘s lives – their
access to healthcare, schools and education, their conditions of work and leisure, their
homes, communities, towns or cities and their chances of leading a flourishing life‖.34
The Social Determinants of Health are for the most part responsible for health
inequities – the unfair and avoidable differences in health status seen within and
between population groups. Reproductive health, as with other areas of health is
influenced by a complex interplay of biological, psychological and social
determinants (O‘Rourke, 2008 as cited in Social Determinants of Sexual and
Reproductive Health, 2011 Report, developed by Women‘s Health West for the
Western Region Sexual and Reproductive Health Working Group). Sexual and
reproductive ill health accounts for almost 20% of the global burden of disease for
women and 14% for men (Hunt & Bueno de Mesquita, 2010, as cited in Social
Determinants of Sexual and Reproductive Health, 2011 Report, developed by
Women‘s Health West for the Western Region Sexual and Reproductive Health
Working Group).

According to World Health Organization, ‗5, 85,000‘ women die every year,
over 1600 every day from causes related to pregnancy and childbirth. India is no
exception to this as the country‘s mortality and morbidity data from reproductive
causes is one of the highest in the world. The underlying causes of reproductive

34
World Health Organization, Health Sector Reforms in India: Initiatives from the States II

23
mortality and morbidity are more social than are health related and in most cases are
preventable in nature. Studies of various emerging international literature suggest that
many sexual and reproductive health problems are preventable (Temple-Smith &
Gifford, 2005; Pitts, 2005; Shuttleworth, 2004, as cited in Social Determinants of
Sexual and Reproductive Health, 2011 Report, developed by Women‘s Health West
for the Western Region Sexual and Reproductive Health Working Group). The WHO
also insists that sustainable prevention is achievable only through strategies and
initiatives which work to redress the social determinants of reproductive and sexual
health. Studies have shown that interventions which fail to account for social
determinants are less likely to witness tangible health improvements, more so among
the disadvantaged communities. Of all the Human Development indicators, that for
sexual and reproductive health reveal the largest gap between low income and
developed countries and accounts for the starkest difference between rich and poor
people within countries.

In 2010, WHO released ―Social Determinants of Sexual and Reproductive Health:

Informing Future Research and Program Implementation Report‖. The report
examined the complex way in which the social determinants of sexual and
reproductive health exacerbate global health inequities. WHO maintains that social
determinants of sexual and reproductive health work ―at different levels to influence
exposure to the risks of unintended pregnancy or STI, care seeking behavior and
access to and use of preventive services, care and treatment‖ (WHO, 2010:10). The
report insists that merely intervening on people‘s lifestyle and behavior would not
solve the problem of reproductive health inequities, rather interventions should aim at
redressing the social conditions that result in poor health outcomes. This is
particularly true among the disadvantaged communities, such as the urban slums. The
slum dwellers experience widespread social isolation, are often illiterate and lack
negotiation capacity to demand improved public services. They are particularly
vulnerable to the many health risks that occur as a consequence of poor living
conditions. Their health indicators are much worse than urban averages and similar to
or worse than those of rural populations (Health, 2010 as cited in Shukla, J. 2011).

24
The growths of cities have always been accompanied by the growth of slums. The
Industrial Revolution in Western Europe resulted in the migration of people from
villages to the cities in large numbers and it gave rise to a new abode called slums.
Slums created new conditions of ill health due to overcrowding, poor housing and
unsanitary environment coupled with poverty35. India‘s slum population more than
doubled, from 43 million in 2001 to 93 million in 2011 in ten years and it is projected
to grow at 5% per year, adding nearly two million every year, according to official
Government data. Slums are thus considered as the fastest growing segment of the
urban population. Traditionally in India it was observed that alleviation of poverty is
an important precursor in improving the general health of the people. But, later it was
realized that urban public health needed to be viewed in a different manner. In urban
areas, a marginal increase in income of the urban poor does not guarantee those better
living conditions due to wide disparities which make decent accommodation, clean
water and air unaffordable. Certain necessities of life like drinking water, cooking
fuel, housing space etc are commodities in the urban areas and thus the urban poor are
driven towards the margins of the urban space where living conditions are most
degraded and of little economic value. The urban areas show stark differences in
income and wealth. High purchase power of the rich people drives up the prices of the
food, healthcare goods, and making them unaffordable for the urban poor. Though a
surprising fact but it is true that the, rich even consume much of the share of public
goods as water, healthcare, infrastructure etc. which is particularly subsidized by the
Government for the poor. This gets reflected in the health status of the urban poor. In
a study undertaken to investigate urban variations in health service access, women‘s
visits to health services for prenatal check-ups were compared. The analysis showed
that the wealthiest 20% of the Population received about 25% of the actual
government health spending while the poorest 20% received only 15% (Urban
Poverty, 2009 as cited in Shukla, J. 2011).

35
Healthcare In Urban Slums in India, The National Medical Journal of India, vol. 20, No. 3,
2007

25
A study of malnutrition and levels of stunting among children below 5 years of age
shows the conditions faced by the urban slum dwellers which have a bearing on their
health status. The study revealed that the percentage of stunting among slum dwelling
children in Mumbai were almost similar to their poverty stricken tribal counterpart in
Thane district. Notable in the study is the conclusion formed by the researchers that
high levels of stunting in urban slums were not related to food scarcity but to social
and environmental factors such as access to healthcare, clean drinking water, repeated
childhood infections, mother‘s nutrition and her ability to breastfeed. A review of
studies on the situation of reproductive and child health in urban areas show a
consistent difference in ANC coverage, mode of delivery and immunization of
children in slum and non-slum areas. This establishes the rationale for a social
determinants perspective of reproductive and sexual health in India since there are
huge differentials among and between classes and castes, gender gaps and wide
regional variations in both disease burden and care seeking behavior from the health
care providers. India‘s mission to attain Universal Health Coverage requires that
every citizen of the country has equitable access to affordable, accountable and
appropriate quality health services in the form of Preventive, Pro-motive, Curative
and Rehabilitative Health Care as well as services addressing wider determinants of
health. Thus, it is clear that the mission will remain unattainable if the financially
insecure, the socially excluded or the politically marginalized do not have access to
health services or to social determinants affecting health such as food, housing,
income security. In other words, for health coverage to be universal, the drivers of
health inequity i.e., the social determinants must be addressed. India‘s approach to
health reforms has also stressed on Social Determinants perspective to health and
highlighted nutrition, access to safe drinking water, education, as well as poverty and
marginalization as key determinants of health in India.36

According to Factsheet of German Development Corporation, ―Urbanization

and Sexual & Reproductive Health and Rights‖, the urban slums represent a

36
Foundation for Action on Social Determinants of Health in India: High level Expert Group
Report on Universal Health Coverage for India; Retrieved from: uhc-
[Link]/reports/hleg-report-chapter – [Link]

26
characteristic which is called ―Feminization of poverty‖. It has been noted that the
number of female headed households in urban slums are rising over the years. Women
are found at much disadvantageous positions in terms of their access to income,
education, living conditions and the like. These women are engaged mostly in the
urban informal sector where income security is less. They are often sandwiched
between the dual burdens of domestic work and the workplace. They are often treated
badly in their private environment. Gender related attitudes, domestic violence;
harmful traditional practices make them vulnerable to pandemics like HIV/AIDs. The
birth rates in urban slums are often found to be higher than their rural counterparts.
Lack of adequate information, accessibility, availability and affordability of health
care services limits their use of modern methods of contraception, antenatal care and
skilled attendance at birth. This acts as a major impediment to sustainable
development. Sustainable development includes all measures that affect future
generations, long term health and protection of the environment. It also encompasses
quality of life, equal opportunities and other social and cultural dimensions of human
well being. Places like urban slums lacking adequate infrastructure, under constant
threat of eviction pose a serious blow to the health and well being of persons
inhabiting such a place.37

1.3. MAGNITUDE OF THE PROBLEM

Sexual and reproductive ill health includes mortality and morbidity related to
pregnancy and childbirth, STIs, HIV and AIDS and reproductive tract cancers. It
accounts for at least 20% of the burden of global ill health among women of
reproductive age (15 - 44 years) and some 14% for men.

Some glaring facts of sexual and reproductive ill health are38 -

37
Bulletin of Medicus Mundi Switzerland, No. 110, Nov.2008
38
World Population and Need to Provide Contraceptives and Services, 2013. Retrieved from
[Link]
and-services

27
  Every day, 800 women die due to preventable pregnancy and childbirth-
related complications at the prime of their lives, mostly in Africa and South
Asia. For each woman who dies, 20 more suffer serious injuries or permanent
disabilities.
 An estimated 222 million women in the developing world are not using a
modern method of contraception but would like to prevent pregnancy—
resulting in 80 million unintended pregnancies, 30 million unplanned births
and 20 million unsafe abortions. Globally, the contraceptive prevalence rate
for use of modern methods is 57%, while in the least developed countries it is
as low as 30%.
 One in three girls in developing countries will be married without their
consent before they are 18 years old.
 Every year, 16 million adolescent girls give birth. Maternal mortality is the
leading cause of death for this age group in low and middle-income countries.
 Despite progress, 34 million people are currently living with HIV or AIDS,
with 2,400 young people infected every day.
 An estimated 499 million new cases of curable sexually transmitted infections
occur annually.
 As many as 7 in 10 women experience physical and/or sexual violence in their
lifetimes, and the first sexual experience of up to one third of them is forced.
 Adolescent girls and young women are especially at risk of violence. Up to
50% of sexual assaults are committed against girls under 16; 60 million girls
are child brides; and 140 million women and girls have undergone female
genital mutilation, which is most often practiced before the age of 15.39

A look into the data regarding various reproductive health indicators presents a grim
picture worldwide and particularly in the developing countries including our own.
Each year, an estimated 210 million women become pregnant, of which 8 million
experience life threatening complications related to pregnancy and many more
develop long term physical and psychological ill health and disabilities. More than

39
Policy Recommendations for the ICPD Beyond 2014: Sexual and Reproductive Health &
Rights for All 2013 High-Level Task Force for ICPD.

28
half a million women die each year from during pregnancy and childbirth from
complications that can almost be treated effectively. A woman‘s lifetime risk of dying
due to maternal causes is 1 in 16 in Sub Saharan Africa, 1 in 94 in Asia, 1 in 160 in
Latin America, compared to 1 in 2800 in developed countries (DFID, 2004).
According to the World Health Organization, 585,000 women die every year, over
1,600 every day, from causes related to pregnancy and childbirth. The Planned
Parenthood Federation of America quotes estimates that of the annual 46 million
abortions worldwide, some 20 million are performed unsafely, resulting in the deaths
of 80,000 women from complications, accounting for at least 13% of global maternal
mortality, and causing a wide range of long term health problems. An estimated 120
million women who wish to limit or space births are prevented from doing so due to
lack of access to information and family planning services (WHO, 1998).40 Some 340
million curable and new cases of STIs occur every year globally in addition to a
million numbers of incurable yet preventable viral STIs, including 5 million HIV
infections (WHO, 2003). STIs enhance HIV/AIDS and are rapidly spreading in
women of reproductive age accounting for 40% of all new HIV infections worldwide
(Tinker, Finn, and Epp, 2000). Out of 38 million HIV infected people a year, 17
million are women and 2 million are children infected through mother to child
transmission. Fewer than 1 in 5 people at risk have access to prevention information
and services (DFID, 2004). In 2010, more than 220 million women worldwide had an
unmet need for modern contraception. Since the demographic force of the young
population is expanding, the number of women who will desire contraception is
projected to increase substantially over the years. The burden will mainly be on the
developing countries. Currently, the Asian continent has the largest absolute number
of women in the reproductive age (15 – 44 years) with an unmet need for
contraception (Cates & Maggwa, 2014). Dismal is the picture of infant and neonatal
deaths also. About 3 million babies die within the first week of life and 2.7 million
stillbirths are all attributable to poor health of mother, inadequate ANC services and
lack of skilled attendance at birth. Spacing between births is another problem area in
reproductive health. It has been seen that short birth intervals risk lives of women and

40
World Health Organization (1998), Ottawa Charter for Health Promotion, Geneva

29
children (DFID, 2004). The National Family Health Survey (2005-2006) data of India
shows that still half of our women lack proper care during pregnancy and delivery.
The disparity between urban and rural women is especially pronounced, with 74% of
urban women having at least three Ante Natal Care visits compared with 43% of rural
women. Births assisted by a health professional increased to 48% from 42%, with
75% of urban women but only 39% of rural women in NFHS-3 receiving professional
assistance. Institutional births increased from 34% to 41%, but most women still
deliver their children at home. Though there are vast disparities across the urban –
rural divide, but the plight of the urban poor are not much better than the rural
population. Given the large number of people living with HIV in India, new findings
from NFHS-3 on the extent and sex differentials in knowledge of HIV/AIDS are of
concern. Only 80% of men and 57% of women have ever heard of AIDS. Further,
only 68% of men and 35% of women know that consistent condom use can reduce the
chances of getting HIV. A disturbing feature of women‘s reproductive health in India
is that the numbers of pregnant women who are HIV positive are increasing over the
years. In States like Maharashtra and Tamil Nadu, the ante natal checkups show that a
little (Gupta, 2009) more than 5 % of the expected mothers are HIV positive and there
is substantial risk of transmitting the virus to the child. The NFHS – 3 data of the state
of West Bengal shows the fertility rate at 2.3, 25.3% of women aged 15-19 are
already mothers or pregnant, the total unmet need for contraception is 8%, 10.7% of
women receive complete ANC, rate of institutional delivery is 42% and 47.6% of the
births are attended by a trained personnel. 37.7% of women are nutritionally deficient
with BMI below normal. Only 50.2% of the ever married women in the state have
heard about AIDS and only 29.3% knew that consistent condom use can reduce the
chances of HIV/AIDS.

1.4. RESEARCH OBJECTIVES

The major research objective is to see how social factors like age at marriage,
literacy, household income, Standard of Living Index, employment, autonomy, gender
role attitudes, mass media exposure determine reproductive and sexual health of

30
women in terms of their knowledge of female reproductive cycle, family planning
basics, HIV/AIDS and other STIs, ANC, delivery, PNC and induced abortion. The
study also seeks to find out the effect of the above mentioned social factors on
reproductive health practices in terms of ever and current use of contraceptives,
practices concerning ANC, delivery and PNC, induced abortion, reporting of
gynaecological and obstetric morbidities and treatment seeking behaviour. Other
objectives are -

I. To know the socio-economic and demographic profile of women in the study

area.
II. To determine the knowledge and awareness of women with regard to common
gynaecological ailments, STIs including HIV/AIDS, family planning basics,
various contraceptive methods and induced abortion.
III. To determine women‘s level of understanding of their reproductive health
rights.
IV. To study the practice of family planning methods by women in terms of their
ever use and current use.
V. To study the practice of Ante Natal Care, Delivery and Post Natal Care by
currently pregnant women and those who delivered one year prior to the study.
VI. To study the type of health interventions available in the study area and health
seeking behavior of women with respect to their reproductive health.
VII. To gain an understanding of the factors which affect utilization of
reproductive health care services among these women.

1.5. RESEARCH QUESTIONS

In order to achieve the above objectives the following research questions have
been examined.

I. What is the current reproductive health status of the women?

II. What is the understanding of reproductive health rights among the women and
how are they exercising such rights?

31
III. Do age at marriage, education, employment, standard of living, household
income, autonomy, exposure to mass media, gender role attitude really have a
bearing on their reproductive health?
IV. Where do women go to seek advice and care regarding their reproductive
health?
V. Why women often do not seek care when it comes to reproductive ailments?
VI. What is the availability, affordability, acceptability of health care to the
women?

1.6. CHOICE OF THE STUDY AREA

For my study, I have chosen a town located within the ambit of Kolkata
Metropolitan Authority (KMA). Uttarpara is a town located in the Serampore
subdivision of the district of Hooghly. It is a town on the banks of river Hooghly,
about 10 km away from Kolkata, within the ambit of Uttarpara Kotrung Municipality.
Uttarpara Kotrang Municipality was established in 1853. As per
2001 India census, Uttarpara Kotrung had a population of 150,204. Males constitute
52% of the population and females 48%. There are about 67 registered slums in
Uttarpara Kotrang Municipality spreading over areas of Uttarpara, Bhadrakali,
Kotrang, Hindmotor and Makhla. According to the 2001 Census, the total slum
population of Uttarpara is 10214 spread over 1158 households. Each slum differs in
the characteristics of their inhabitants and their socio-economic compositions, religion
and culture.

All slums are not equal and neither are their inhabitants. Some are affluent
slums whereas others represent conditions of absolute poverty, co habitation of man
and animals in one room and ill health. The Uttarpara slums thus represent all the
typical characteristics of an urban slum. Slums are the neglected pockets in urban
areas which co-exist with the affluent areas but their existence is often unnoticed by
all. The choice of Uttarpara slums as the place of my study was motivated by the
following. Firstly, certain wards housing slums in Uttarpara suffer from problems of
poor drinking water supply, poor sanitation facilities, kutcha roads, kutcha drains,

32
water logging of roads and houses during rains. All these conditions breed certain
diseases among the inhabitants and it was presumed that the reproductive health of the
slum dwelling women will not be satisfactory under these conditions. This created an
urge to study the reproductive health of women in Uttarpara slums. Secondly, I am a
resident of Uttarpara for the last 33 years. So, it was presumed that I shall have the
ease of communicating with the people in the area and the opportunity to watch them
closely. Moreover the sample chosen will feel at ease to speak to somebody who
belongs to the locality rather than an outsider on a very sensitive issue like
reproductive health. Thirdly, Uttarpara, being just 10 kms away from Kolkata
typically represents characteristics of urban life. It houses a number of slums where
the population is heterogeneous representing varied social and economic
backgrounds. The place‘s vicinity to Kolkata attracts a number of people from outside
states to reside here. Both men and women in the slums are mostly engaged in the
informal unorganized sector. Interacting and interviewing such people with diversity
will certainly help me to go to the depth of the problem.

1.7. DATABASE

The study area has been chosen as the slums lying within the Uttarpara
Kotrung municipality. Secondary data regarding the study area was collected from
various sources- Census 2011, Primary Census Abstract 2011, and District Statistical
Handbook of the Hooghly district, Draft Development Plan Main Book of Uttarpara
Kotrung Municipality 2011, District Human Development Report, 2010, websites of
Kolkata Metropolitan Development Authority, Institute of Local Government and
Urban Studies. Some secondary data related to the area and specific to the slums were
collected from the Municipal office of Uttarpara Kotrung, the health centres and
subcentres in the area and the Mahamaya Sishu O Matrimangal Kendra. The various
registers maintained in the subcentres by the Honorary Health Workers (HHWs)
provided a rich source of secondary data on reproductive health.

There were also numerous literature surveys from various libraries and websites to
gather information relevant to the topic under study to form the theoretical and
conceptual framework.

33
Primary data was collected by survey of slum households identified by means of a
non random sampling method called purposive sampling.

1.8. PROBLEMS FACED BY THE RESEARCHER

 The very nature of the survey method has certain inherent disadvantages.
Those were common in this study also.
 The first difficulty I faced in the conduction of this study was the fact that
there was absence of any data in the Municipality regarding the total number
of married women in the slums. So, I had to take the list of slums from the
Municipality and approach the slum households with the help of Honorary
Health Workers who helped me identify the potential respondents.
 Moreover, a number of HHWs aged above 60 years were terminated from
their service by the Municipality. This hindered the data collection method as I
was totally dependent on them to go to the slums.
 The HHWs were engaged in a number of other activities like voter card
rectification, ADHAR card enrolment, Control of Vector Borne Diseases
which prevented them to take me to the slums. This caused an unnecessary
delay in data collection.
 Data collection was also hindered by Municipal Elections, Lok Sabha
Elections and the BSUP Project in the slums during which I was not allowed
to visit the slums.
 A considerable portion of the respondent women were engaged in the informal
sector, so, it was very difficult to get them to answer the questions. I had to
visit the slums often at odd hours to ensure the respondent‘s availability.
 Sometimes, it was seen that it was difficult for the respondents to recall remote
past events pertaining to their reproductive health. Thus, information
regarding ante natal care was taken from currently pregnant women only and
information on delivery and post natal care was taken from those who
delivered within one year prior to survey. Women were also asked to report
their reproductive ailments during the past six months only as asking them to

34
 report ever occurred ailments were often responded with unreal, concocted
stories.
 A section of the respondents were disinterested in answering the questions
since the survey was for academic purpose only and did not entail any
monetary or other benefits to them.
 Although at the time of survey the 2011 Census have been already
enumerated, the Municipality could not furnish me with any ward level data
with basic information on the slums.

1.9. LIMITATIONS OF RESEARCH

1. The major limitation faced in the conduction of this study was the fact that
there was absence of any data in the Municipality regarding the exact number
of persons inhabiting the different slums of Uttarpara. So, there was an
absence of the sampling frame in the first place. The researcher had to take the
list of slums from the Municipality and approach the slum households with the
help of Honorary Health Workers (HHWs) who acted as the key informants in
identifying the potential respondents. This forced the researcher to go for a
non-probability sampling method (purposive sampling) to choose the potential
respondents.

2. The results of this study needs to be viewed cautiously since the scope of
generalization is limited due to purposive sampling.

3. This study provides information on the reproductive health of the respondents

only at the time of conduction of the study. No comparisons could be made
since there was absence of any earlier database regarding their health status in
the municipality.

4. Though the sample size is fairly large in the study, yet the valuable inputs
from those who remain excluded might have been missed.

35
1.10. ORGANIZATION OF THE CHAPTERS

The chapters of this research paper shall be organized as- Chapter 1 will
provide a brief introduction to the research agenda together with the magnitude of the
research problem, objectives of research, research questions, rationale for the choice
of the study area, database and research limitations. Chapter 2 will deal with review of
existing literature and aim to find out the gaps in research. Chapter 3 will provide a
detail of the research methodology specifying the site where the study will be carried
on, determination of sample size, sample design, methods of data collection and how
the data will be subject to analysis. It will also provide a conceptual framework of the
study and the formulation of the research hypothesis. Chapter 4 will deal with the
description of the study area by providing geographic details of the district along with
socio-economic characteristics, demographic characteristics and health status of the
population. This will be followed by the details of the town Uttarpara by its history,
geography, socio-economic, demographic and health status of its inhabitants. Chapter
5 will document the background characteristics of the respondents and selected social
determinants of health. This chapter will discuss the age at marriage, literacy and
levels of education, work participation, monthly household income, gender role
attitudes, autonomy, mass media exposures, Standard Of Living Index of the
respondents, all of which have a major bearing on their reproductive health. Chapter 6
will focus on the reproductive health of the slum dwelling women by documenting
their knowledge and practice of reproductive and sexual health. Chapter 7 will feature
selected case studies of slum dwelling women and health care providers as obtained
through qualitative study. Chapter 8 will document the results of the study and
provide a concluding note to the study by giving recommendations on the basis of
findings of study.

REFERENCES

Cates, J. W., & Maggwa, B. (2014). “Family Planning Since ICPD – How Far We
Have Progressed?” US: Pubmed, Vol. 90(6):14-21
DOI:10.1016/[Link].2014.06.025 accessed on 25.04.2015

36
DFID. (2014). “Department for International Development: Department Report”.
London: House of Commons, The Stationery Office Limited

Gupta, S. K. (2009). “Health Seeking Behaviour and Reproductive Rights of

Antenatal Women in Delhi”. Retrieved from
shodhganga:[Link] accessed on 06.02.2014

Jejeebhoy, S. (1997). “Addressing Women‟s Reproductive Health Needs: Priorities

for the Family Welfare Programme”. Economic and Political Weekly,
Vol. 32(9), 475-484

KC, Vikash. Kumar. (2006). “Men‟s Participation in Women‟s Reproductive and

Child Health Care: A Study of Western Hill Region, Nepal”. Retrieved from
Shodhganga:[Link] accessed on 14.09.2015

Mulgaonkar, V. (1996). “Reproductive Health of Women in Urban Slums of

Bombay”. Social Change, Vol. 26(3 & 4): 137-156

Parchure, N., Basu, R., Adak, K., & Bharti, P. (2011). “Differentials in Reproductive
and Child Health Status in India”. Italian Journal of Public Health, Vol. 8(4)

Paul, et al. (2011). “Reproductive health, and child health and nutrition in India:
metting the challenge”. The Lancet, Vol. 377(9762): 332-349.
doi:10.1016/So140(10)61492-4 accessed on 08.02.2014

Ram, F., Sinha, R., & Mohanty, S. (2006). “Marriage and Motherhood: An
Exploratory Study of the Social and reproductive Health Status of Married
Young Women in Gujrat and West Bengal, India‟. New Delhi Population
Council.

Ramanathan, M. (1998). “Reproductive Health Index: Measuring Reproduction or

Reproductive Health?” Economic and Political Weekly, Vol. 39(49): 3104-
3107

Raphael, D. (2004). “Social Determinants of Health: Canadian Perspective. Chapter

1 – Introduction to the Social Determinants of Health”. Toronto: Canadian
Scholar‘s Press Inc.

Sanneving et al. (2013). “Inequity in India: The case of Maternal and reproductive
Health”. Globe health Action, Vol. 6:19145,
[Link]/10.3402/gha.v6i0.19145: Retrieved from
[Link] accessed on 02.05.2015

37
Spielberg, L. A. (2007). “Introduction to Reproductive Health & Safe Motherhood”.
Dr. P. H. Dartmouth Medical School, Prepared as Part of a Education Project
of the Global Health Education Consortium and Collaborative Partners

Tinker, Anne., Finn, Kathleen., and Epp, Joanne. (2000). “Improvinc Women's
Health: Issues & Interventions”. Health, Nutrition, and Population, The
World Bank

Wilkinson & Marmot. (2003). “Social Determinants of Health: The Solid Facts”. 2nd
Edition, WHO, Europe, WHO Library Cataloguing in Publication Data

38
 CHAPTER 2

2. LITERATURE REVIEW

2.1 INTRODUCTION

A literature review is a description, summary and analysis of available literature

relevant to a particular field or topic. It gives an overview of what has been said or
established on a particular topic, what are the strengths and weaknesses of such
findings and helps in finding out the gaps where research has not been able to provide
answers. It is not a primary research, but rather it reports on other Researcher‘s
findings. It provides a theoretical base to the research topic. An extensive review of
existing literature from India as well as other countries was done on the study topic.

2.2 SOCIAL DETERMINANTS

Till a few years from now, the social determinants of health were only considered by
the academicians and usually overlooked by the health policy makers. 41 Nowadays, it
has become a common notion among health researchers that health of persons and
populations are strongly determined by a number of social factors. WHO (2003)
stated that ―medical care can improve the survival rate and prognosis of diseases but it
is the social and economic conditions that determine who will be well or ill.‖
However, nonmedical and non behavioral factors influencing health of individuals
and populations originates back to the 19th Century. During the 19th Century, Rudolf
Virchow and Friedrich Engels pointed out that social, political and economic forces
affect health and well being and breed diseases and cause early death (as cited in
Raphael, Social Determinants of Health: Present Status, Unanswered Questions and
Future Directions, 2006). The interest of the researchers on social determinants
generally grew out of the differences seen in experiences of health and illness by
people belonging to different socio-economic strata. The publication of Black Report

41
Julia Brassolotto, Dennis Raphael, & Navindra Baldeo. (2013). “Epistemological barriers
to addressing the social determinants of health among public health professionals in
Ontario, Canada: a qualitative inquiry.” Taylor & Francis online, p.321-336,
[Link]

39
and Health Divide in the United Kingdom triggered interest of many to the fact that
how material resources of life affect health and well being in individuals. Another
factor which stimulated research on social determinants is the differences in the health
status of the population across different nations. In 1986, the Ottawa Charter for
Health Promotion identified peace, shelter, education, food, income, stable ecosystem,
sustainable resources, social justice and equity as prerequisites for health. Dahlgren
and Whitehead gave their Rainbow model in the year 1992 to explain social
determinants of health (as cited in Raphael, Social Determinants of Health: Present
Status, Unanswered Questions and Future Directions, 2006). The Rainbow model is
shown in the picture below.

Figure: 2.2.1 General Socio-Economic, Cultural and Environmental Conditions

Source: Dahlgren, G. (1995). European Health Policy Conference: Opportunities for

the Future. Vol. 11 – Intersectoral Action for Health, Copenhagen: WHO Regional
Office for Europe

40
Dahlgren and Whitehead‘s framework (shown above) shows that an individual‘s
health status is determined by a number of different factors which operate at different
levels ranging from the hereditary factors to lifestyle factors to societal factors to
environmental factors. They considered that all these above mentioned factors interact
to manifest themselves in the form of health, ill health and inequities.

Tarlov in the year 1996 showed how inequalities on the part of housing quality,
education, social acceptance, employment, income can get translated into disease
related processes. He took into account both the material conditions and the cognitive
appraisal of these conditions as compared to others in causing ill health. Various
bodies have defined social determinants of health by taking into account various
social, economic, political factors. The Canadian Institute of Advanced Research have
identified income and social status, education, employment and working conditions,
physical and social environment, hereditary characteristics, personal health practices
and coping skills, healthy child development, health services, as determinants of
health. Some of the determinants discussed above fall under the category of social
determinants. A British Working Group was assigned to identify different social
determinants of health identified the following - Social gradient, social exclusion,
early life, stress, social support, work, unemployment, addiction, food and transport
(as cited in Raphael, Social Determinants of Health: Present Status, Unanswered
Questions and Future Directions, 2006).

Raphael‘s (2004) analysis of a number of studies led to the identification of eleven

(11) key social determinants of health – early life, education, aboriginal status, food
security, employment and working conditions, health care services, housing, income
and its distribution, social safety net, social exclusion, unemployment and
employment security. Studies suggest that the social factors also intersect with the
health of individuals. There are 3 categories of factors-

1. Individual factors – related to psychology, biology, employment, education

and food security.
2. Closer to home factors – deal with communities, psychosocial factors,
culture, health, education system and leadership.

41
 3. Remote factors – deal with policy, social norms and structure.
Some studies suggest the following individual, household and community factors as
crucial to reproductive health (as cited in Lule, E. et al., 2005).

1. Individual factors – age, parity, nutritional status, marital status, use of health
services, dietary, sanitary and sexual practices, lifestyle, etc.
2. Household resources – control of income, education, knowledge, health care
demand.
3. Community factors – cultural, gender norms, community institutions, social
capital, environment and infrastructure.

It is a well acknowledged fact that the social factors affect men and women differently
in most of the societies around the world. The gender related discrimination has
resulted in stunted general health of women, with reproductive health in particular.
The research has attempted to study the following few social factors in affecting the
reproductive health of women in the reproductive age group.

This study is an attempt to see the effect of a number of social determinants on the
reproductive health of women in slums. Literature survey has been done extensively
on all of the selected determinants and they are discussed in the following sections.

2.2.1 LITERATURE ON AGE AT MARRIAGE AND REPRODUCTIVE

HEALTH

“Married adolescents have been largely ignored in development and health agendas
because of the perception that their married status ensures them a safe passage to
adulthood. Nothing could be further from the truth.”

Thoraya Ahmed Obaid, UNFPA Executive Director

(From International Women‘s Health Program website, Para 6)

The phrase ―early marriage‖ refers to the marriage of boys and girls before they enter
the legal age of marriage. Many countries have fixed a particular age of marriage. In
India, the marriageable age for girls is 18 years while that for the boys is 21 years.

42
Despite the law, instances of early marriage are not uncommon in many countries.
Many youth throughout the world are forced into marriage at an early age. They are
deprived of their right to choose and give an informed consent to their marriage. This
is a gross violation of the Human Rights. ‗The Right to Free and Full Consent‘ to a
marriage is recognized under the Universal Declaration of Human Rights, 1948. Early
marriage has serious physical, intellectual, psychological impacts on the health of
both boys and girls. It limits the opportunity of education and personal growth of both
boys and girls. The effect is more profound on the girls. The percentage of girls and
boys getting married in the age range of 15-19 years are found to be highest in
different countries of Sub Saharan Africa and Asia. However, Middle East, Latin
America and the Caribbean countries also show a significant number of child brides
and grooms.42

Age at marriage is crucial because the earlier the marriage, the greater the likelihood
of more children and greater the health hazards of the young mother and the child. A
estimate of 2002 shows that about 52 million girls below 18 years of age were
married with approximately 25,000 being married every day. The study estimated that
with this rate the number was likely to reach 100 million by [Link] data on
early marriage reveals that the rate is highest in South Asia where 48% of the girls
aged 15-24 years get married before 18 years of age. The figures stand at 42% for
Africa and 29% for Latin America and the Caribbean.43 According to IIPS India 2000,
in the year 1998-1999, 17.8% and 47.6% of girls were married in India by age of 15
years and 18 years respectively. Data from countries like Bangladesh, Pakistan, and
Nepal also show a significant portion of girl children get married at tender ages.
According to PRB 2000 and World Bank Report 2003, about 49% of women aged 20-
24 years gave birth by the age of 20 years. The figures stand at 63% for Bangladesh,
52% for Nepal and 31% for Pakistan (as cited in Sharma, Abhilasha. 2009).

WHO estimates that the risk of death following pregnancy is twice as great for
women between 15 and 19 years than for those between ages 20 and 24. However,
research shows that the age below which giving birth is physically risky for a woman
42
Early marriage Child Spouses Innocenti Digest, No. 7, March 2001, UNICEF
43
UNICEF. Early marriage: a harmful traditional practice. New York: The Fund; 2005

43
varies significantly depending upon the general health conditions and access to
prenatal care. The risk has not been found to be much for women with good
nutritional status and extensive access to prenatal care (Islam 1999, as cited in Lule E,
2005). However, in developing countries like India the above does not hold to be true.
In India anemia and malnutrition are the rule of the day with 56% of married and 58%
of pregnant women (NFHS 3)44 suffering from anemia. Anemia can be attributed to
nutritional deficiencies in these women. In a similar manner, mothers who receive
complete Antenatal Care are still low. Thus, early child-bearing coupled with
nutritional deficiency and lack of proper antenatal checkups contributes not only to ill
health of the mother but also the unborn baby. This is echoed in the findings of
Women‘s International Network (2000) that early marriage is significantly linked to
high maternal mortality and morbidity. Adolescents are far more susceptible to
suffering from anaemia than women who are above 20, which greatly increase the risk
and complications linked to pregnancy. A too narrow pelvis in early mothers can
cause prolonged or obstructed labor leading to cerebral damage of the infant and also
death of the mother. Early marriage also leads to unplanned early pregnancy which
can lead to abortion. Deaths of adolescent mothers below the age of 20 years due to
complications arising from unsafe abortions are a leading cause of death worldwide. It
has been estimated that about 2 million adolescent mothers are victims of unsafe
abortion every year in developing countries (Hirsh and Barker 1992; Singh and Wulf
1993, as cited in Sharma, Abhilasha. 2009).

Temin et al., (1999) found that reproductive tract infections can lead to major
complications during pregnancy in case of married adolescents. RTIs can also result
in infertility, general weakness and is often a predisposing factor to HIV/AIDS (as
cited in Sharma, Abhilasha. 2009).

There are other ill effects of early marriage on reproductive health of women. A study
in Africa by Bayisenge (2010) found that young girls after marriage are often forced
into having sexual intercourse with older husbands which results in a tremendous
deleterious effect on the physically, psychologically and sexually immature girls. A

44
National Family Health Survey - 3. FactSheets. (2005-2006). India.

44
pressure is exerted on them to prove their fertility as early as possible and is thus
prone to early childbearing often ignorant of contraception. The young age of girls at
marriage puts them to the risk of contracting STDs and HIV/AIDS. When the age
difference between the girl and her husband is more, she is unlikely to negotiate safer
sex or demand fidelity from the husband. Lack of autonomy with higher levels of
violence for girls in an early marriage also results in unwanted pregnancies, unsafe
abortions. Another study on Africa by Nawal M. Nour (2006) found ill health
consequences of child marriage in Africa. She studied health consequences in the
form of risks of transmission of HIV/AIDS and other STIs associated with early
marriage, young girl‘s vulnerability to cervical cancer, ill health of both the mother
and the offspring and increase in maternal and child mortality as a result of child
mothers bearing and delivering children. She opined that it is mainly poverty which is
the main driving force for child marriage in Africa. Other factors are securing the
girl‘s chastity and preventing pre-marital sex. Parents of girls in abject poverty marry
off their daughters against hefty dowry to older men. Almost everywhere in Africa,
girls are married to men who are 5-14 years older than them. These men in most cases
have had multiple sexual partners before marriage and know about HIV/AIDS.
Though it is a common belief that child marriage can prevent premarital sex and
therefore a girl‘s vulnerability to unprotected sex, HIV/AIDS, the reality is different.
Statistics show that married girls are more vulnerable to HIV/AIDS than unmarried
girls. Sub Saharan Africa show that married girls in the age range 15-19 years are 2-8
times more vulnerable than boys of their age to get infected with HIV. The author
cited several studies conducted in the African continent to show that married young
girls get infected by their older polygamous husbands to HIV/AIDS. These girls being
financially dependent on their husbands cannot demand for their HIV testing, condom
use by their husbands or abstain from unprotected sex. Child marriage, poor health
care access and polygamous husbands are also risk factors for another deadly disease
of young girls in Africa- cervical cancer or HPV. HPV has become endemic in Sub
Saharan Africa. The young girls are pressurized by their husbands to prove their
fertility soon after marriage as a result of which they become pregnant early, even
before their body is physically prepared to bear the burden of a foetus. High death
rates are also reported from young girls who become mothers. Obstructed labour is

45
the chief cause of death of these child mothers whose pelvis is too narrow to deliver a
foetus. Other reasons are post-partum hemorrhage, eclampsia, malaria, and HIV
infection. Sometimes those who survive obstructed labour develop fistulas. Unless the
fistula is surgically repaired the girls are unable to lead a normal life and bear further
children. The ill fate is not restricted to these young married girls but is also
transmitted to the next generation. The children born to these mothers are generally
preterm, have low birth weight and often do not see their first birthdays. The infant
mortality rates are found to be 70% higher in mothers who are less than 20 years of
age than their older counterparts. Bott and Jejeebhoy (2000) while giving the
overview of the findings of 2000 Mumbai Conference on Adolescent Reproductive
and Child Health in South Asia summarized the effects of early marriage,
childbearing, health effects on the mother and child and many more in South Asian
countries. They found that a large number of women marry as adolescents in countries
like India, Nepal and Bangladesh. Researchers have shown that about 50% of the
women aged 20 -24 get married by the age of 15 in Bangladesh. The rate stands at
24% for India and 19% for Nepal respectively. On the contrary, it is found that the
boys in these countries rarely marry as adolescents. Kulkarni (1999) finds the rate to
be 6% among the males in India according to NFHS 2. The sexual debut of adolescent
girls in most countries of South Asia is usually after marriage. Kulkarni reports that in
India for women aged 25-49 years, the age of cohabitation with their husbands is 17
years but the age varies widely across the states in India. In Andhra Pradesh, it is as
low as 13 years while in Goa it is 23 years. There are many social and cultural norms
governing early marriage in these countries. Bott and Jejeebhoy (2000) found that
countries like India, Sri Lanka, Bangladesh, Nepal, and Pakistan show conservative
attitude towards the mixing of young boys and girls. The society condones mix up,
love marriages and pre-marital sex. The young girl adolescents in these countries
report that even speaking to a boy or accepting his love proposal may be a reason of
disgrace to the girls‘ family. Consistent with this view is researcher Rashid‘s findings
of interview of Bangladeshi adolescents who disapprove the concept of ―love‖ and
feel that a girl should always marry a person chosen by her parents. They also
described the heavy punishments which are levied on a girl once she is discovered to
be in love and have sexual relations with a boy. Rashid conducted a Focus Group

46
Discussion with mothers of adolescent girls in the Nilphamari district of Bangladesh
where girls are married as early as 11 years. The reasons cited for this early marriage
is the fear that daughters may fall in love and elope, become pregnant due to
premarital sex or be a victim of rape. All the cited reasons are enough to ruin the
status of the entire family.45 In many cases, family finance, death of father, or having
many daughters lead to early marriage of girls as reported by Chowdhury (2003).
These finding show that the factors that pressurize a family to marry the daughters
early are common even across continents. The African studies have also shown the
same factors to be true for early marriage of girls. Kulkarni‘s study using NFHS data
showed that only 13 % of married adolescents have ever used any method of
contraception with a meager 8 % currently using it at the time of survey. She found
that a large unmet need for contraception exists specially with the need to space
births. She also found that about 7% of all sterilized women and wives of sterilized
men were adolescents. It points out the lack of knowledge among the adolescents
regarding contraception and particularly long term reversible methods. Malnutrition,
stunted growth, anaemia, was common among ever married adolescent women which
got reflected in the health status of the children born to them.

The Infant Mortality Rate (IMR) and the Neonatal Mortality rate (NMR) were both
found to be higher with adolescent mothers than mothers who were older as reported
by Kulkarni. Thus, both the health of the mother and the health of the new born are a
matter of serious concern to the State. The study found that only 2 out of every 5 ever
married adolescent women have heard about HIV/AIDS. This again poses a serious
threat to their health since young adolescents are threateningly vulnerable not only to
premature unintended pregnancies but also to HIV/AIDS and other STIs. Ignorance of
these deadly diseases prevents them from recognizing symptoms and seeks
appropriate health care. Pachauri and Santhya in their study on Adolescent
Contraceptive behavior in Asia found that there is a large gap between the knowledge
of contraceptives and their use (as cited in Bott and Jejeebhoy (2000). They presented
figures indicating the awareness of condoms among married adolescent girls in

45
Sabina Faiz Rashid. Communicating With Rural Adolescents about Sex Education:
Experiences from BRAC, Bangladesh

47
Bangladesh, India, and Pakistan at 85%, 59% and 18% respectively while use of
contraceptive methods by married adolescent girls are at 33%, 8% and 6%
respectively in Bangladesh, India, and Pakistan. Mathur et al. (2003) found that early
marriage limits a girl‘s education and narrows her ability to seek economic
independence. Early marriage is also associated with the health care seeking
behaviour of girls. Mathur (2003) found out that in India a significant number of
young married girls do not want to get pregnant at early ages and bear the burden of
repeated pregnancies. They usually resort to sterilization in their early 20s or choose
unsafe abortions. These are the results of ignorance and lack of options for effective
temporary contraception measures. Lack of knowledge and options are often
compounded by the restrictions imposed on the girl‘s mobility, decision-making
power etc. Borua and Kurz (2001) found that in India whether a married young girl
will seek health care for herself when necessary depends upon her husband and her
mother in law (as cited in Mathur et al., 2003).

Santhya et al. (2010) conducted a study on married women in the age group of 20-24
years from 5 Indian states and compared the marital, health and other outcomes
between women who married early and who married late. They defined early
marriages as those that have occurred before 18 years of age and late marriages as
those who married at 18 years and above. Age at marriage was considered as the
independent variable. They took three measures of the reproductive health of women
– whether the women have used contraceptives to delay her first pregnancy, whether
they had institutional delivery for their first child and whether they ever had a
miscarriage or stillbirth. Women who married early differed significantly with women
who married late with respect to all the three sexual and reproductive health
outcomes. It was found that only 3% of the early married women used contraceptives
to delay their first pregnancy compared to 11% of late married women. 45% of the
women who married early had their first delivery at a health care facility as against
70% of women who married late. 17% of women who married early were likely to
have a miscarriage or a stillbirth compared to 9% women who married late. These
findings are similar to like studies carried out in Indian settings. They concluded that
in India soon after marriage there is a huge pressure of the family on the women to

48
prove their fertility as early as possible. Their contact with the health care personnel is
also limited. So, women who married early are less likely to use a contraceptive
method to delay pregnancy. Women who marry early are also less likely to have an
institutional delivery for their first child. This is attributed to the ignorance of women
with regards to sexual and reproductive health matters and ignorance of the place to
go to in case of sexual and reproductive health problems.

In another study on “Early marriage and sexual and reproductive health risks:
Experiences of young women and men in Andhra Pradesh and Madhya Pradesh,
India”, Santhya, Jejeebhoy and Ghosh (2008) penned the experiences of married
young men and women in 2 Indian states of Andhra Pradesh and Madhya Pradesh.
They studied sexual experiences before, within and outside marriage in case of both
young men and women. They found that the sexual experience was often coercive in
nature for a significant number of young women whether the relationship was before,
within or outside marriage. The uses of condoms in all three cases were significantly
low. This indicated increased vulnerability of these youth to HIV/AIDS as a result of
unprotected sex. The risk of HIV/AIDS was also seen to aggravate with either
inadequate or absence of care seeking for genital tract infections. The study found that
in both the states young women were vulnerable to early and unplanned pregnancies.
Very few women were reported to use contraceptives to delay or prevent pregnancy.
It was found that majority of the women resorted to sterilization as the only available
form of contraception after giving birth at below 18 years of age. This points out to
the fact that women are ignorant about temporary methods of contraception. The
young women in both the states showed poor pregnancy related experiences with
respect to antenatal checkups, delivery by trained birth attendants and visiting a health
care facility for pregnancy related complications. The utilization of maternal and
reproductive health services among married adolescents is found to be significantly
low everywhere.

IIPS 2000 data in India show that only 68.3% of would be adolescent mothers receive
antenatal care, only 33% have institutional delivery and in 41.6% of the cases the
births are attended by trained professionals. Dismal is the state of post natal care also.

49
A meager 18.1% of the adolescent mothers have their health checkups done two
months after delivery (as cited in Sharma, Abhilasha. 2009).

2.2.2 LITERATURE ON MASS MEDIA AND REPRODUCTIVE HEALTH

Information, Education and Communication (IEC) have become strong tools to

transform human behavior in the recent era. Though theoretical basis says that there is
no clear cut relationship between mass media exposure and reproductive health
behavior yet, it is an undeniable fact that media does inform and educate people.
Right information is given by media; the persons who can access it can have a faster
change in behavior than those to whom it is inaccessible.46
Communication experts hold the view that the use of ―enter-educate‖ approach i.e.,
use of entertainment components of mass media like song, drama to deliver an
intended message is more likely to drive a change in the behavior (Kincaid et al.,
1992) Based on this premise, several developing countries have employed the mass
media in disseminating the knowledge concerning family planning and other areas of
reproductive health. Circulation of family planning messages in media and
contraceptive behavior has shown remarkably strong relationships in countries like
Guatemala (Bertrand et al., 1987) and Nigeria (Piotrow et al., 1990).

Several papers on the impact of mass media on human behavior in developing

countries have shown remarkable results in altering behaviors especially in the field
of family planning and reproductive health. Studies from countries like Kenya,
Ghana, and Nigeria show that the association between media promotion of family
planning and reproductive behavior cannot be ignored. Success of mass media
interventions is reflected in the promotion of vasectomies in Brazil, Africa and
Guatemala (Piotrow and Kincaid 1988; Kincaid, Merritt et al. 1996; Dunmoye,
Moodley et al. 2001; Penteado, Cabral et al. 2001), encouraging testing and
prevention of HIV (Anon, 2006; Rahman and Rahman 2007; Chandra, Jamaluddin et

46
Stephen O. Kwankye and Eric Augustt: Media Exposure and Reproductive Health
Behaviour Among Young Females in Ghana

50
al, 2008; Marum, Morgan et al. 2008; Muula, 2008) and the prevention of STIs in the
broader concept (Kim and Marangwanda 1997; Jato, Simbakalia et al. 1999; Babalola
and Vonrasek, 2005; Bertrand and Anhang, 2006).

A Tanzanian study in 2002 also revealed that mass media exposure significantly
increased the likelihood that a man or woman would discuss about female condom
with their partners and such discussion would in turn increase the intention to use the
same in future.

Mass media campaigns promoting family planning have proved successful in places
as far afield as Mexico (Vernon, 1978), Zimbabwe (Adamchak and Mbizvo, 1991),
Nepal (Boulay, Storey et al. 2002; Barber and Axinn, 2004), Uganda (Gupta, Katende
et al, 2003), Ghana (Hindin, Kincaid et al, 1994), Bangladesh (Lieberman, 1972;
Kabir and Amirul Islam, 2000; Mazharul Islam and Saidul Hasan. 2000), Iran
(Lieberman, 1972), and India (Apte 1988; Kulkarni, 2003). In Nepal, for example,
Barber and Axinn found that ―exposure to mass media is related to...preferences for
smaller families, weaker son preference, and tolerance of contraceptive use‖ (Barber
and Axinn, 2004, p. 1180).

Advertisements, short skits, musical pieces on particular themes influence viewer‘s

behavior. Soap operas have been instrumental in addressing social issues like the
HIV/AIDS, rape, need for child spacing, family planning, child marriage etc. in
Africa and Egypt.

Howe, Owen-Smith et al. (2002) found that in Britain, a storyline in the longest
running soap Coronation Street sharply increased the number of smear tests
performed for detection of cervical cancer within 19 weeks after the story line. The
telenovela ‗Accompany Me‘ in Mexico is a remarkable example for dissemination of
the idea of Family Planning way back in 1977-78. According to PMC (2009), the
single most contributor to the Mexican Population success story is attributed to
‗Accompany Me‘ and four more soaps on Family Planning. The success of operas in
generating awareness about family planning is echoed in studies from St. Lucia and
Tanzania. In both the places, the radio soap operas has been successful in influencing

51
the listeners to increase their awareness of contraceptives, adopt small family norms
and talk to spouses and peers about various methods of contraception. IBGE (2004)
and Kent (2009) found that telenovelas in Brazil also was instrumental in bringing a
decline in fertility rates and adoption of family planning norms. However,
Researchers like Dunn (2001) and La Ferrara et al. (2008) opine that mass media do
not play a direct role in lowering the fertility rates. The telenovelas and other
edutainment programmes highlight the poor economic state of the country and poor
plight of less educated workers and at the same time the novella images of middle
class urban mass with less children and capacity to fulfill children‘s demand for
material things in life creates an urge in the minds of the masses to opt for fewer
children and enjoy all comforts of life. La Ferrara et al., however, sought to test more
robustly the hypothesis that ‗constant exposure to smaller, less burdened television
families may have created a preference for fewer children and greater sensitivity to
the opportunity costs of raising children‘. Thus, it can be concluded that mass media
indeed plays a major role in conveying information related to family planning,
stimulate sharing of thoughts regarding contraceptives among spouses and peers and
in forming an ideal reproductive behavior.47

Studies on mass media and reproductive behavior have been conducted in the Indian
subcontinent also. An analytical study on Demographic and Health Survey in India,
Pakistan and Bangladesh in 1999 extensively studied media exposure and
reproductive behavior of ever married women of reproductive age. Two types of
media exposure was studied- the first relating to general exposure to radio, television
etc and the second relating to media messages specifically on the topic of family
planning and reproductive health. The study was unique since it interviewed the
husbands also in Bangladesh and Pakistan which allowed an analysis of married men
and married women simultaneously. The results revealed a direct association of mass
media exposure and reproductive behavior in all the 3 countries holding constant the
age, number of children, urban-rural residence, religion and other socio-economic

47
The Future of Human Reproduction: Working Paper #7 Mass media and reproductive
behaviour: serial narratives, soap operas and telenovelas. Stuart Basten, PhD, St. John‘s
College, Oxford & Vienna Institute of Demography, June 2009

52
variables. Both types of exposure were found to be independently associated with
reproductive behavior. Approval of family planning and ever use of contraceptives
were most consistently related to media variables. A major disadvantage of this cross
sectional study was the difficulty in determining the time sequence and the cause and
effect relationship.48
It has been seen that Behaviour Change Communication (BCC) campaigns that use
multiple media go a long way in adopting contraception and reducing fertility. Use of
multiple mass media is said to reach a larger audience and help to reinforce a
particular behavior. Kane et al. (1998) and Jato et al. (1999) in studies at Mali and
Tanzania have confirmed the above view by showing that the more types of media
sources to convey family planning messages, the greater the likelihood of
contraceptive knowledge and adoption among women.

A study conducted at Uganda by Gupta, Katende and Bessinger (2003), to assess the
effect of BCC campaigns on family planning on men and women revealed that
reported exposure to BCC messages in the media was strongly associated with the use
of a modern contraceptive method and the intent to do so in near future among the
non users. This was found to be true in both the sexes.

BCC Campaigns are said to have an effect on the knowledge of STIs and use of
condoms to prevent the diseases. In 2003, Bessinger, Katende, and Gupta showed that
in Uganda multiple media exposure like radio, Television, poster and printed
materials focusing messages on HIV/AIDS and other STIs have a significant
influence on acquisition of knowledge about the disease and likelihood of using
condoms for preventing the disease. With the increase in the number of mass media
channels through which STI messages were disseminated, the likelihood of condom
knowledge and disease prevention also increased. The study concluded that BCC
exposure played a clear role in enhancement of knowledge about STIs but use of
condom i.e., safe sex practice depended largely on the content and channel of
messages. A worth finding fact was the revelation that the channel and content of

48
Westoff, Charles F., and Akinrinola Bankole. (1999). Mass Media and Reproductive
Behavior in Pakistan, India, and Bangladesh. Analytical Reports No. 10. Calverton,
Maryland: Macro International Inc.

53
messages affected men and women differently in their use of condoms during the last
sexual encounter.

The BCC interventions have been successful in disseminating knowledge about

contraceptives, HIV/AIDS and Immunization among the Indian population. However,
certain aspects of sexual and reproductive health like safe abortions have been
neglected by the BCC campaigns. In a cross sectional study by Banerjee et al. (2012)
on availability of safe abortion services among women of Bihar and Jharkhand, it was
suggested that BCC campaigns must be used as a necessary tool to convey messages
to women regarding abortion, its legal status, local availability of safe abortion
services so as to decrease maternal mortality and morbidity from unsafe abortion
services.

Young women or adolescents have always been at a larger risk of suffering from
sexual ill health and it has been regarded as one of the biggest threats to public health
in all countries across the globe. Thus, young women‘s access and exposure to media
plays a significant role in transforming their sexual behavior and practice of safe sex.
An interesting study of young women in Ghana showed positive relationship between
media exposure and reproductive health behavior. The study used a number of
dependent variables like sex initiation and timing of marriage, knowledge of
ovulatory cycle, child bearing and termination, knowledge and use of contraceptives
and effect of exposure to media (Radio, T.V., and Newspaper) on all these. It was
seen that a regular access to radio, T.V., and newspaper led to a delay in initiation of
sex and late marriage in young females. Knowledge of contraceptives and their use
and knowledge of ovulatory cycle also showed positive relationship with increased
exposure to media. Exposure of a young woman to the media led to giving birth to
less number of children and hence small family sizes. However, the study showed that
access to media did not significantly affect a woman‘s decision to terminate a
pregnancy. It would be significant to mention that the effect of all three types of

54
media on the outcomes were not the same.49

The Department of Health and Family Planning in India has long been instrumental in
broadcasting television and radio messages on family planning. But, question remains
that whether messages that are specifically intended towards family planning has an
effect over and above the general media exposure. An analysis of NFHS (1992-1993)
survey on media exposure of women shows that those who have got very recent
exposure to family planning messages on radio or television have a significant
positive effect on current and intended future use of contraception. This suggests that
the Government should continue and intensify efforts of broadcasting family planning
messages on radio and television along with women‘s general media exposure in
order to enable women understand the importance of contraception and a small family
size. In countries where illiteracy among women is high educating via entertainment
is a cost effective way to disseminate knowledge. This requires universal access of
women to media like radio and television irrespective of their physical location (rural
or urban) in the country. This calls for increasing the incomes of the poor people so
that they can afford a radio or television and universal electrification in the country.

Access to and availability of health information is a very important parameter in

raising awareness about health. A study using the Demographic and Health Survey
data in Ghana 50 in 2008 have investigated whether family planning information
disseminated through radio and television affect maternal reproductive health
decisions. The study concentrated on 3 reproductive health services – use of
contraceptives, antenatal visits and delivery care. The analysis showed that the
likelihood that a woman will go for a skilled delivery increased with her viewing
family planning information on television. Similarly, likelihood for antenatal visits
also increased in case of women who received such information on television.
Notable in the study was the fact that women in urban areas were more exposed to

49
Stephen O. Kwankye, and Eric Augustt. (2007). Media Exposure and Reproductive Health
Behaviour Among Young Females in Ghana. Regional Institute for Population Studies
(RIPS), University of Ghana, Legon, Accra, Ghana
50
Asmahl, Emmanuel. E., Twerefou, Daniel. K., & Smith, Jessica. E. (2013). Health
Campaigns and Use of Reproductive Health Care Services by Women in Ghana. American
Journal of Economics

55
family planning messages and this accounted for their positive reproductive health
behavior. On the contrary, women who lived in remote areas were less exposed to
health campaigns transmitted through radio or television and this became evident with
their much lower utilization of reproductive and maternal health care services. This
result has similarity with the previous study conducted in India. It was also found that
wealth and education determined a woman‘s access to various media like television
and radio.
A very interesting study conducted by Jensen in India during 2001-2003 showed the
impact of cable television on the status of women in the country. It is to be noted that
during the years the cable television was introduced in Indian villages at a very rapid
pace. Exposure of rural Indian women to cable television rapidly transformed their
status which was manifested in terms of greater autonomy, lower fertility, lower son
preference and lower acceptability of spousal abuse. In terms of magnitude, the
effects are quite large - for example, the introduction of cable helps to decrease the
differences in attitudes and behaviors between urban and rural areas by 45% to 70%.
Further, these effects were almost instant, impacts became evident in the first year
following cable introduction. The result is consistent with existing work on the effects
of media exposure, which typically found rapid changes (within a few months, in
many cases) in behaviors like contraceptive knowledge, contraceptive use, pregnancy,
latrine building and perception of own-village status (Pace, 1993; Valente et al., 1994;
Kane et al., 1998; Rogers et al., 1999; Johnson, 2001).

2.2.3 LITERATURE ON LITERACY AND REPRODUCTIVE HEALTH

Establishment of a relationship between education and health has been a priority work
area for researchers in both developed and developing nations. Education and literacy
is considered to be the key determinants of health (Kickbusch, 2001). Caldwell, 1986;
Bledsoe et al; 1999; Sen, 1999; Nussbaum, 2000 studies show a positive impact of
education and literacy on health and well-being of women and their children (as cited
in Kickbusch, 2001). A report on The State of World‘s Mothers by Save the Children
in 2000 identified adult female literacy rate as one of the 10 key factors having a
bearing on a women‘s well-being. The report also pointed out that a mother‘s level of
education correlates closely with a child‘s risk of dying before 2 years of age. The

56
countries which show a high women well-being also have a 90% literacy level of their
women. Literacy and higher levels of education improves access to resources,
awareness and information about health, health risk and health seeking behaviour.
Education can also help to increase knowledge about various contraceptive measures
which finally affects the overall reproductive health through its effect on fertility
outcomes (Ganguli, 1998) or directly influence reproductive health through use of
contraception and prevention of sexually transmitted diseases. Bhat (2002) underwent
an empirical test to see how mother‘s schooling affects her fertility, child survival,
mother-child interaction and social attitudes (as cited in “Does Schooling of women
translate to positive health outcome: A study of rural North India?”).51 The study
results showed that mothers having beyond primary level schooling background were
more frequent and effective users of health services than mothers who lacked such
schooling exposures. The study of rural north India show that with at least 8-10 years
of schooling responsiveness to information show a significant effect leading to health
promoting behaviour. Print and audio-visual media are found to be more receptive in
case of educated women.

Studies indicate a strong association between women‘s education or literacy levels

and use of reproductive and maternal health services. Celik and Hotchkiss, (2000) in a
study in Turkey found that the educational attainment and lower parity levels are
significantly associated with the choice of modern home delivery as opposed to a
traditional home delivery (as cited in Lule et al, 2005). Evidence from Punjab shows
that education contributes to a women‘s self confidence and improved maternal skills,
increase their exposure to information and alters the way others respond to them
(DasGupta, 1990), (as cited in Lule et al, 2005). Studies suggest a relation between
female education and fertility. However it depends upon the stage of fertility
transition of a particular country. In the early phase of fertility transition, childbearing
declines first among the better educated and last among the least educated. In the later
phases, these differentials begin narrowing till a convergence is reached (Cleland,
2002, as cited in Lule et al, 2005).

51
Retrieved from [Link] accessed on 25.06.2014

57
A helpdesk report on women‘s literacy and links between maternal health,
reproductive health and daughter education in UK in the year 2010 have found that -

 Educated women are more likely to use health clinics and return to the clinic
if their children's overall health does not improve.
 Educated women generally tend to begin their families at a later age and have
fewer, healthier children.
 A one percent rise in women's literacy is three times more likely to reduce
deaths in children than a one percent rise in the number of doctors. For
women, 4 to 6 years of education led to a twenty percent drop in infant deaths.
 Women with more education generally have better personal health and
nutrition.
Better housing, clothing, income, water, and sanitation were found in women with
some level of education (DFID, UK, 2010).
Berkman et al. (2004) found that in US adverse health outcomes like low health
knowledge, increased incidence of chronic illnesses and low utilization of preventive
health services were all associated with low literacy levels. Ratzan et al. (2000)
demonstrated that a mother‘s literacy level is directly associated with the incidences
of infant and child mortality in developing countries.

Health literacy is the newest concept in the field of education to affect health
positively. WHO on their 7th Global Conference on Health Education defined Health
literacy as the cognitive and social skills which determine the motivation and ability
of individuals to gain access to, understand and use information in ways which
promote and maintain good health. Health literacy means something more than just
being able to read pamphlets and successfully seek treatment. Health literacy
empowers men and women by improving their access to health information and their
capacity to use it effectively. The Centre for Health Care Strategies Inc. (2000) stated
health literacy as the ability of individuals to read, understand, and act on health care
information (Kickbusch, 2000).

The link between health literacy and reproductive health are well documented. A
study by Mcginn and Allen (2006) among adult women in Guinea showed that after

58
participation in a Reproductive Health Literacy (RHL) Project the respondent‘s
current use of modern contraceptive methods increased. There was also a dramatic
increase in ‗boldness‘, a word used to denote empowerment. Majority of the women
reported that they felt ‗more bold‘ after the RHL project.

2.2.4 LITERATURE ON AUTONOMY OF WOMEN AND REPRODUCTIVE

HEALTH

The word autonomy originates from the Greek word ―autonomos‖ where ―auto‖
means self and ―nomos‖ means law. Hence, the literal meaning of the word autonomy
is ―one who gives oneself one‘s own law‖. It is the capacity of a rational individual to
make an informed decision without coercion.52

Autonomy in most researches uses measures reflecting women‘s degree of control in

their lives with emphasis on control over financial resources, decision-making power
and the extent of freedom of movement. Autonomy has a significant effect on the use
of reproductive health care utilization. Dyson and Moore defined it as ‗decisions
about oneself or family members‘ (Dyson and Moore, 1983:45). Gabrysch and
Campbell in a 2009 study showed that autonomy affects a large number of personal
issues of women. If it is limited it diminishes a woman‘s control over material
resources, personal activity and even mobility/transport decisions. In Dyson and
Moore‘s view, autonomy indicates technical, social, and psychological ability to
obtain information and to utilize it in decision making processes involving one‘s
private concerns and those of one‘s intimates. The concepts of women‘s status and
autonomy are multidimensional (Mason 1984; Mahadevan, et al. 1989; Jejeebhoy
1995, 1996). Jejeebhoy regarded information autonomy, decision-making autonomy,
physical autonomy, emotional autonomy, and economic autonomy as various
dimensions of autonomy. He found that a women‘s autonomy is largely influenced by
gender stratification, patriarchal society in which she lives and her educational level.

Several studies conducted in different settings have measured various dimensions of

women‘s autonomy. Sathar, Callum, and Jejeebhoy (2001), and Mason et al. (1995)

52
[Link]

59
employed several indicators of women‘s autonomy, mobility, participation in
household decision-making, and control of financial resources in five Asian countries,
namely India and Pakistan Malaysia, the Philippines, and Thailand. Jejeebhoy (1996:
1) stated that education is one of the important factors that influences on women‘s
autonomy in both egalitarian and agrarian societies. Education leads to greater
autonomy providing women with greater opportunity to delay their age at marriage,
their contraceptive use, and as a result, to control their fertility.

According to Jeejebhoy‘s study (1995 - 96), women with higher autonomy are likely
to involve in their marriage decisions leading to a higher age at marriage, obtain
family planning information, practice them in their reproductive lives and regulate
their fertility (as cited in Chavoshi et al., 2004). MacDonald (2000) in his study found
that low fertility results from significant improvements in the lives and positions of
women in the society. However, a view on the contrary also exists. It is supported by
the studies of Saikia, Steele, & Dasvarma (2001) who found that despite high levels of
autonomy among women in a matrilineal society in the indigenous communities of
north east India, women had highest fertility levels. Morgan et al also found that the
impact of autonomy on the fertility levels of muslim and non-muslim women in
different countries of South east Asia was not significant. Thus, it can be concluded
that the socio-cultural milieu of different settings have a considerable impact on
women‘s autonomy and the extent it affects fertility. Saikia, Steele, and Dasvarma
(2001) concluded that in a strong traditional society high female autonomy may
encourage them to produce more children (as cited in Chavoshi et al., 2004).
Chavoshi in his study on women autonomy and fertility and contraceptive behavior in
four regions of Iran found that controlling all other variables, three autonomy
variables – freedom from threat, having private income and control over economic
resources have a significant effect on fertility. He noted that women who enjoyed
freedom from threat of husbands were 17 % more likely to have low fertility as
compared to those who were exposed to threats, or, beaten by husbands. It was further
seen that the odds of having lower fertility was 1.3 times higher in women who had
private incomes than women who did not have a private income. The impact of
autonomy on contraceptive use was found to be different. Two autonomy variables –

60
freedom of mobility and decision making regarding buying of household items were
found to affect contraceptive use, controlling other variables. Those women who
enjoyed freedom regarding buying of household items were 47% more likely to use
contraceptive methods than those who did not enjoy that decision making freedom.
Similarly, women who enjoyed freedom of mobility were 34% more likely to use a
contraceptive method than women who could not move freely.

Different autonomy measures are used by different researchers to measure women

autonomy. The different measures for example, unaccompanied mobility, ability to
take decisions regarding household purchases, access to economic resources, own
income and the like are seen to affect the reproductive behavior differently. Several
studies in India have found that a woman‘s autonomy and empowerment has a
significant influence over her fertility control and use of contraception. Jeejebhoy
(2002), Mason and Smith (2000) and Malhotra et al. (1995) found that women
enjoying more autonomy have equal, if not more say in decisions regarding their
fertility preferences and contraceptive use. Women having greater autonomy are less
dominated by their husband‘s preferences of fertility and family planning. It was also
seen that couples who had frequent communications among themselves are less likely
to dominate the wives regarding decisions pertaining to reproduction and
contraception (as cited in Khan and Ram, 2009).

A study by Mumtaz, Z., and Salway, S. (2005) in Pakistan found that there exist no
relation between a woman‘s unaccompanied mobility and her use of contraceptive
methods and fertility preference. In contrast, women‘s accompanied mobility plays a
role in her antenatal care uptake and found to reflect the strength of a woman‘s social
resources.

Likewise, a study in Zimbabwe by Hindin, M. J. (2000) found that women‘s decision

making autonomy was not associated with the use of modern contraceptives. He
found that women who had no decision making autonomy had only 0.26 children
more than their autonomous counterparts. This points out to the fact that fertility
behavior cannot be explained with the help of decision making autonomy alone.

61
A study conducted by Woldemicael (2007) in Ethiopia and Eritrea sought to find the
role of women‘s decision making autonomy on seeking maternal and child health care
services. Several autonomy indicators were put to study along with socio-economic
indicators. The study showed that woman‘s sole decision making autonomy in visiting
relatives or family had an impressive effect on her seeking antenatal care and her
child‘s immunization. However, other decision making indicators were found to have
less significant effect on health seeking behavior when socio-economic factors were
controlled. The researcher concluded that certain health seeking behavior is more
dependent on socio-economic indicators like education and employment. The study
results revealed that most socio-economic indicators have a strong influence on
decision making autonomy and health seeking behavior. So, it is not only the
autonomy but also the socio-economic indicators like education and employment that
should be studied in order to see health care utilizations by women.

Another study on Ethiopia by Haile, A. & Enqueselassie, F. (2006) showed that only
literacy among the taken autonomy variables had a significant effect on a couple‘s
contraceptive use. It further found that a husband‘s involvement and fertility were the
major determinants of a couple‘s contraception use when all the other indirect
variables were adjusted. Studies from Bolivia, Peru and Nicaragua also support the
multidimensional nature of autonomy with education and other socio economic
factors being the most important of them.

Khan and Ram (2009) conducted a study on 418 women in a district of Madhya
Pradesh to find the relation between 3 aspects of women autonomy- outside mobility,
access to economic resources and involvement in household decisions over their
fertility and contraceptive use. Findings reveal that husbands are generally more in
favour of mobility of their wives within the same locality than outside the locality.
Approval and current use of family planning by both the couples are positively
associated with women‘s unescorted mobility outside. The results remain same even
after controlling socio-economic and demographic factors. Both the spouses‘
education, at least one of them a professional worker and a higher standard of living

62
has a bearing on access to economic resources. Cases where both the spouses are
educated, one of them a professional worker and those belonging to the highest
quintile with a high standard of living are said to have more opinion and experience of
devising a number of ways to economic access of women. The study reveals that
couples who have experienced access to economic resources are more likely to desire
for the 2 child norm. Desire for additional child is seen to be negatively associated
with women‘s greater access to economic resources. Son preference has no strong
association with a women‘s increased access to economic resources. All these are
supported by both the spouse‘s opinion and experience. Both current as well as future
uses of family planning are significantly and positively influenced by a women‘s
access to economic resources. This is also supported by their husband‘s opinion.
Household decision making is another important dimension in women‘s autonomy.

Khan and Ram (2009) found that husbands‘ perception of their wives‘ role in decision
making is much more than the wives‘ reported cases of their household decision
making. Nearly half of the couples participating in the study were in favour of
women‘s participation in household decision making. This study showed a major
disparity in Women‘s participation in decision making (6 out of 10 ) and them being
the final decision maker (1 out of 10). Women who participate in household decision
making are likely to desire an ideal family size of up to 2 children.

Visaria (1991) in her study to find the relation between female autonomy and fertility
behavior in 4 districts of Gujarat found that the use of family planning were highest
among women enjoying moderate income autonomy and lowest among women
having no control over money matters. She used 3 dimensions of autonomy – access
to and control over money, perception of freedom enjoyed to perform family chores
and contact with the natal kin. Though the levels of autonomy and fertility control of
women in the 4 districts varied but the principal finding remained the same from all
the districts. Women who enjoyed lower autonomy faced restrictions regarding their
use of family planning and thus had more number of children in contrast with those
who enjoyed moderate autonomy.

63
Bloom, Wypiz, and Dasgupta (2007) conducted a study of women autonomy and its
effect on maternal health care utilization in North Indian city of Varanasi. One
interesting finding of the study is that after controlling other socio-economic factors,
each dimension of women autonomy (freedom of movement, control over finances
and decision making power) was seen to increase with a woman‘s close ties with the
natal kin. It also showed that living with the mother in law and close ties with the
natal kin had a strong impact on the woman‘s interpersonal control. The study
demonstrated that women with greater freedom of movement obtained higher levels
of antenatal care and were more likely to use safe delivery care after controlling other
socio-demographic factors. Thus, women‘s autonomy as measured by the women‘s
freedom of movement was a major determinant of maternal health care utilization
among poor to middle income women. This study had another notable finding. The
effect of women‘s education on antenatal and pregnancy care utilization was found to
be nearly equal to the effect of women‘s interpersonal control over such utilization.
The authors concluded that policies intended towards increasing maternal and child
health care utilization should therefore go beyond increasing educational
opportunities alone, in Varanasi.

Studies conducted by various researchers in Bangladesh however points out that

education are an important predictor of utilization and choice of F.P. services.
Cleland, Kamal and Slogget (1996) used the Bangladesh Fertility Survey Data 1989
to assess the effect of schooling and autonomy on contraceptive use. Autonomy was
measured by the women‘s mobility outside homes and their decision making power in
household and reproductive health areas. The findings showed that there was an
increase in self reported mobility and decision making scores for every level of
schooling from none to primary to higher education levels. Notable was the fact that
mother‘s education was a strong predictor of both mobility and decision making
scores. It was observed that schooling had a large and statistically significant effect on
the use of both traditional and modern methods of contraception. It was seen that
schooling was not significantly related to sterilization. More educated women
preferred reversible methods of contraception than sterilization.

64
Kamal conducted a study on women‘s autonomy and uptake of contraception among
Bangladeshi women using the BDHS data 2004. He compared his findings with that
of the earlier BDHS data and found that dimensions of autonomy like women‘s
mobility and her decision making power used to have a significant effect on fertility
control earlier. But these factors were no more significant at the time of his study in
regulation of women‘s fertility. Instead, her working status is a powerful indicator in
her contraceptive uptake which even super cedes her and her husband‘s level of
education. Thus, in the contemporary Bangladeshi society, autonomy of women is
best represented by her working status. The author opined that the policy makers
should thus create more and more employment opportunities for women in order to
increase their uptake of contraception to regulate their fertility.

Kamal in a later study using the BDHS 2011 data studied the effect of autonomy as a
determinant of contraceptive use and method choice. He used 4 indicators of
autonomy- (i) women‘s employment and economic decision-making power; (ii)
health care and FP decision-making power; (iii) freedom of movement; and (iv)
women‘s attitude toward partner‘s violence. This study documented low autonomy of
women in Bangladesh. However, a strong association of autonomy related to
employment and economic decision making power and health care and FP decision to
the choice and adoption of contraception was seen. The other two indices of
autonomy were seen to have a weak association with choice and adoption of family
planning. The women with higher autonomy were more found to use any
contraceptive method and use either modern or traditional methods than women with
low autonomy.

A study by Shabana and Martin (2005) in Pakistan examined the effect of women
autonomy on contraceptive use and whether autonomy had a mediating effect on
women‘s education and contraceptive use. The authors used the data from Pakistan
Reproductive Health and Family Planning Survey 2000. They used two autonomy
indicators- decision making autonomy and movement autonomy and assessed their
effect on contraceptive use. The study found that both autonomy scores were skewed
towards lower autonomy. The decision autonomy was found to be significantly
associated with contra captive use even after controlling a number of socio-economic

65
variables. This finding is in tune with most of the studies in South East Asia.
However, the movement autonomy was seen to be not associated with contraceptive
use after controlling other socio-economic variables.

The result is similar to the study conducted by Mumtaz and Salway (2005) discussed
earlier in the section that a women‘s freedom of mobility has very little to do with
their uptake of reproductive health services. One notable finding of the study is that
the impact of women‘s education on her contraceptive use is independent of her
movement and decision making autonomy.

A similar effect of education on contraceptive use independent of movement and

decision making autonomy is echoed in Riyami et al., study (2004) conducted on
women in Oman. The study analysed the effect of women empowerment on unmet
need for contraception. The study used two indicators of women empowerment –
women‘s decision making power and their freedom of movement.

Riyami et al. (2004) found that education is the key to a women‘s status in Oman.
Oman has a universally accessible primary health care system in place with free
distribution of contraceptives to all married couples. The unmet need for
contraception was found to be nearly 25% among women in the study group but it
decreased considerably with a women‘s level of education and paid employment. He
study pointed to the fact that even with low level of autonomy a women‘s almost
universal access to family planning services in the primary health care centre‘s show
that education is more a determinant for meeting contraception needs. It was also
found that although educated women are more likely to use contraception, it is not
directly linked to autonomy.

In majority of the cases it was found that it was the husband‘s decision to use
contraception. This is a typical in all gender stratified societies which places limits on
an educated woman‘s ability to take major decisions. So, education and employment
do not necessarily enhance women autonomy if traditional bindings like wide gender
disparities remain strong.

66
2.2.5 LITERATURE ON GENDER ROLES AND REPRODUCTIVE HEALTH

―Gender perspective is an important part of studies concerning reproductive health.

Gender is defined as the socially constructed roles, responsibilities, activities assigned
to men and women in a given culture, location or time‖. 53
Earlier Sociologists‘ definition of gender embodied the biological and social aspects
of differences between men and women. Modern day sociologists have moved from
the above distinctions to define gender as the way societies are organized. They
emphasize more on the way societies are organized around the social and biological
differences between men and women rather than merely the differences which
distinguish them (as cited in Riley, Nancy E. 1997).

Gender shapes the lives of people in all societies. It determines our schooling, the
roles we play and the power and authority we command in the society. It also
determines how men and women live, bear children, and bring them up and what type
of medical care they receive. All over the globe in all societies the role, power and
position enjoyed by men and women are not equal. Women suffer in various aspects
of their lives because of this inequality. This inequality manifests itself in different
forms in different countries. In developed nations like U.S, it is seen as ―Glass
Ceiling‖. In developing and poor nations like Africa and Asia it is manifested as early
marriage of girls, little spacing between subsequent births, poor maternal and child
health, greater maternal morbidity and mortality.

Gender roles are learned and are different across different cultures. They are
amenable to changes over time. The Programme of Action, Cairo (1994), placed
women‘s needs at the centre of all population and development issues. It gave women
the rights of making autonomous decisions regarding their reproductive health as well
as the right to get quality services for satisfying their needs related to reproductive
health. It pointed out to the fact that a woman‘s health is determined by the social,
cultural, economic and political environment in which she lives. It thus became
necessary to study the women‘s roles, responsibilities and activities inside their

53
Marilyn Lauglo. “Gender, Reproductive Health, and Reproductive Rights”. World Bank
Institute. Paper prepared for Adapting to Change Core Course, September 1999

67
houses as well as outside. So is the need for seeing the role of gender in attaining
good reproductive health. Gender influences the way men and women perceive
themselves, the way in which they think and behave. Throughout the globe women
are seen to be in a socially disadvantaged position as compared to men. This further
necessitates the importance of learning about the gender inequalities which has a great
impact on the reproductive health of women. It is the gender factor which defines the
status of women in their family and community, determines her reproductive health
choices and her health seeking behavior. Moser (2001) found that in many countries
the traditional gender roles prevent couples from discussing sexual matters, avoid
harmful sexual practices etc, which ultimately contributes to reproductive ill health of
both the couples (as cited in Oladeji, D. 2008).

Thus, it is an undeniable fact that gender has a powerful influence on all matters
related to reproductive health. Study by Oladeji (2008) conducted among 300
Nigerian Men and women showed that there existed a significant relationship between
gender roles and norms and reproductive behavior. He used a self responding
questionnaire containing six independent variables on gender roles and norms –
contraceptive use, birth spacing, breastfeeding, family size, extra –marital sexual
partner, pre-natal care. The study results indicated that when these independent
variables are taken together, they were found to be effective in predicting
reproductive behavior, relationship and decision making among couples.

Santow (1992) in a paper presented at ICPD showed that how women‘s and their
children‘s health is affected by their roles and positions in society. According to
Santow, women are at an inferior position in the family but, they are designated as
―custodians of family health‖. Gender difference in the family is manifested by little
things like lesser allocation of food for the women in the family. In traditional
societies the women are the persons who eat less and eat last. As a consequence, their
health deters. He mentioned that the young adult women who are expecting, or,
lactating or both get the smallest share of family food and hence are the worst
sufferers. Women suffer from nutritional deficiencies which get more complicated
with pregnancy.

68
Men significantly affect women‘s reproductive health either being health policy
makers, health care administrators or health care providers at the macro level or,
being a husband, or, sexual partner or father of a girl child at the micro level
(Dudgeon and Marica, 2004).

Nearly all aspects of female reproductive health depend on men. Contraceptive

methods like condom use, withdrawal and male sterilization vasectomy are directly
under their control. The female family planning methods are also influenced by their
approval or disapproval of the method. Ezeh (1993) and Bankole (1995) concluded
from a large number of surveys in Africa that men are the decision makers with
respect to their wives‘ use of contraceptives. The use of contraceptives by women is
largely dependent on the economic assistance men give to buy them. So, a woman has
to depend on her man to give her the moral, financial as well as the psychological
support to use contraceptives. Studies have found that the use of abortion services by
women also depend upon men. It is their decision to abort or parent the expecting
baby and provide financial assistance for either of them. Browner (1986 and 2000) in
his study in Peru and Columbia found that one third to one half of the induced
abortions is decided by the husbands rather than the wives (as cited in KC, Vikash
Kumar. 2006).

The most important aspect of a woman‘s reproductive health – motherhood, is also

influenced by her man to a large extent. Kay (1982) has identified men as the key
external factor affecting pregnancy outcomes. Men as husbands are responsible for
the type of antenatal, delivery and post natal care their wives receive. Thus, they play
a critical role in affecting maternal deaths arising out of pregnancy complications to a
large extent. In most societies, it is found that men are sexually more active than
women and engage themselves in risky sexual activities often outside marriage. This
puts their wives in greater risk of contraction of STIs and HIV/AIDS. Many of these
STIs which are transmitted to women through men can cause permanent infertility,
stillbirth, or, stunted growth of the foetus (as cited in KC, Vikash Kumar. 2006).
Dhillon et al., (2004) in a study of contraceptive behaviour and induced abortion in
rural India found that the husband was the decision maker in 42.8% of the cases for
terminating pregnancy and in 52.5% of the cases to decide the place of abortion. In

69
one-third of the cases the husband‘s objected the acceptance of post-abortion
contraception. Since, men are the major determining factor in the reproductive health
of women; it is for them to understand that they should act as equal partners in all
decisions regarding reproductive health with their wives rather than mere dictators.

Global researches over the years have shown that gender inequalities lead to health
inequities among men and women. This is more pronounced in developing countries.
All aspects of reproductive health like reproductive morbidities, choice and adoption
of family planning methods, matters relating to childbirth and pregnancy, health
seeking behavior are hard hit by gender inequality. Gender inequality intersects with
other social determinants such as race, ethnicity, socio-economic status to produce
health disparities between men and women.54

Ezeah and Achonwa (2015) in their study Gender Inequality in Reproductive Health
Services and Sustainable Development in Nigeria found that it is the patriarchal
structure which limits the access of women to social and economic resources which in
turn negatively affects her reproductive health. Lack of accessibility and non
utilization of family planning methods by women have contributed to the increase in
fertility rates in Nigeria. Non participation of men in family planning measures in the
form of not supporting their wives in adopting family planning methods and not
motivating them to take active part in all reproductive health matters are the key
factors responsible for women‘s reproductive ill health.

Women are found to have low status, position and freedom in male dominated
societies in most of the countries of the world. Their reproductive choice and decision
also are dependent on their husband‘s approval. Family planning requirements of
women are thus often influenced by their husband‘s approval of the same. Studies in
various countries have shown that husband‘s disapproval is the principal reason
behind the non-use of contraceptive methods by a vast majority of women. Spousal
communication plays a very vital role in reproductive decision making. Ideally, every
decision concerning the reproductive health and rights of couples should begin with a

54
WHO (2008). ―Gender Inequality in Reproductive Health Services and Sustainable
Development In Nigeria: A Theoritical Analysis‖.

70
fruitful discussion among the husband and the wife. Sadly enough, it is seen that in
most of the cases it is the husband‘s perception and approval of certain reproductive
health practices that plays a crucial role in the wife‘s reproductive health decision
making. There exists a large body of literature that shows the effect of spousal
communication on the reproductive health of both the spouses. Lasee and Becker
(1997) conducted a study to see the effect of spousal communication on the use of
contraceptives. He considered 3 dimensions of spousal communication in the study-
firstly, discussion between husband and wife regarding family size or family
planning, secondly, agreement between them regarding fertility preference and
approval of a particular method and finally each partner‘s perception of the attitudes
of the other. He found that of the 3 communication variables, the wife‘s perception of
the husband‘s approval of family planning was the most significant contributor to
current contraceptive use by wives. He further opined that one spouse‘s perception
about another spouse‘s approval of family planning is likely to be correct only if they
had a discussion on that issue previously. This affects the current contraceptive use
significantly.

A study was conducted by WI, Di Silva (1994) in Sri Lanka using 1985 data to show
the husband – wife communication and contraceptive behavior. He found that about
78% of the husbands and 74% of the wives have ever discussed family planning.
However, only 7% of the couples discussed it before the birth of their first child and
intensity of discussion increased with subsequent births. 25% discussed family
planning after the birth of the first child while 50% had discussions by the time of
birth of their second child. The discussions were found to be more in couples with
higher levels of education and also in case of love marriages. 55% wives who were
ever users reported that it was a joint decision to use FP methods, whereas 20% of the
wives reported it was the husband‘s decision. 11% of the husbands said that it was
their wives‘ decision to use such method whereas 25% of the wives reported that they
were the primary decision makers. It was seen that the consistency of agreement
between husband and wives‘ statement increased with increasing education level of
the wives.

71
Kane and Sivasubramaniam (1988) in their presented paper also showed similar
findings among couples in Sri Lanka. Their study reflected that there existed a high
degree of inter- spousal communication about family planning but the degree varied
with the age, education, working status of wife, place of residence, religion, number
of living children and desire for more children. The study reported that both husband
and wife were important source of information regarding the male and female
methods of contraception to each other. A significant portion of the husbands reported
that they learnt about the female methods from their wives, similarly, wives also
reported the .learning of the methods from their husbands. This way both were
important educators to each other. Similar to the study by Di Silva mentioned earlier,
this study also showed that the wives‘ level of education was directly proportional to
the frequency of husband – wife communication regarding contraceptive use.

A study of Men‘s participation in Women‘s reproductive and child health in western

hilly regions of Nepal by Vikash Kumar KC (2006) has shown that inter-spousal
communication and education are the most important determinants of men‘s
participation in women‘s reproductive health. Spousal communication enables
couples to know about each other‘s knowledge and attitude towards particular family
planning methods. They can also share their experiences of various methods and the
side effects associated with each of them. Such communication enables them to arrive
at a mutually agreed upon decision regarding contraceptive use. The study showed
that such communication helps to enhance the knowledge of men about
contraceptives and increase their use by 3.5 times. Similarly, discussion between
husband and wife regarding birth of their baby increases the likelihood of men to
accompany their wives during antenatal visits and at the time of delivery. It also
encourages institutional delivery. The study found that men who communicate with
their wives are 2 times more involved in maternal health care than men who do not.
Thus, the findings of this study is similar to those earlier studies discussed on inter
spousal communication and reproductive health of women. Another important
determinant of male involvement found by the study was the education level of the
husbands. Education makes men conscious about their general health and also the
reproductive health of self and their spouses. It was found that educated men were

72
more likely to have knowledge about contraceptive methods and adopted methods of
contraception. Educated men were also seen to take more care of their wife‘s health
during pregnancy and childbirth.

An increasing body of literature have shown that gender equality have a tremendous
influence on reproductive health. The status of women is influenced by the social,
economic and the political conditions in which they live and grow, have control over
their lives and can claim for their rights. All these in turn affect her reproductive
health (Dixon-Mueller, 1993; Hartmann, 1987; Howard, 1995; Orloff, 1993;
Petchesky, 2000; Sims & Butter, 2000). Sen (1994) found that the employment
structure favours men and puts women in a dependent relationship on men
economically. This dependence prevents women from opting out of an abusive
relationship with the men and having a better control in matters related to
reproductive health. It has been found in various studies that women who enjoy higher
socio-economic status are the ones who have better reproductive health (as cited in
Wang, Guang-zhen. 2007).

G. z. Wang (2007) explored the impact of gender equality on reproductive health of

women with economic and political development as background factors taking the
data from 136 developing countries. He used 9 variables of women‘s reproductive
health drawing from the WHO (1997, 2001) list of women‘s reproductive health
indicators. The variables were –

1. Infant Mortality Rate

2. Contraceptive prevalence

3. Births per 1000 women aged 15-19 years

4. Percentage of adults living with HIV/AIDS

5. Percentage of pregnant women who received antenatal care

6. Percentage of births attended by skilled birth attendants

7. Maternal Mortality Ratio

8. Percentage of underweight children under 5 years of age

73
9. Percentage of infants who are immunized against measles.

Gender equality was measured by 3 continuous variables –

1. Combined primary, secondary and tertiary gross enrollment rate for females,

2. Estimated female earned income and

3. Percentage of female literacy.

He took several economic and political development parameters as background

factors. His study led to 3 important findings. His study underscored the proposition
that gender equality is pivotal to the promotion of reproductive health of women. This
finding is consistent with the previous studies which support the fact that integration
of gender equality in reproductive health promotion is a new concept. Social
Scientists opine that the gender equality approach is a right based approach essentially
centered on women. It starts with the situation a woman is in and her experiences, it
seeks to see the world from the distinctive vantage points of women and finally it
seeks to make a better world for women. Thus, the link between gender equality and
women‘s reproductive health helps to understand in-depth the social-structural roots
of reproductive health. Wang also found that economic development is directly linked
with women‘s reproductive health. This finding of his is also consistent with earlier
research findings on women‘s reproductive health which found that health of a
population increases with industrialization, particularly, women‘s reproductive health.
All modernized societies have spectacularly well reproductive health of women.
Wang found a statistically significant and positive relationship between economic
development and gender equality. The economic development approach to gender
equality identifies 3 interrelated dimensions- economic, institutional and ideological.
The economic relates to expansion of markets, institutional relates to changes in the
social structure while ideological relates to changes in the values on gender roles. Sen
(1999) opined that economic development is equal to enjoying more freedoms and
opportunities. Economic development gives people more opportunities to choose from
and exercise a greater freedom. Economic development also gives women workers the
opportunity to shift from traditional jobs to more technology driven ones which in
turn changes the gender role expectations. This also influences the Government to

74
frame policies that favour women‘s higher education and their involvement in
political decision making (as cited in Wang, Guang-zhen. 2007).

Cottingham and Ravindran (2008) found that though biologically men and women are
differently susceptible to certain conditions like STIs, yet gender dimensions can
specifically magnify such vulnerability through behaviours that are socially
acceptable or unacceptable, through access or its lack to essential resources, through
the ways the institutions perceive men and women and through the laws that may
unfold gender inequalities or not protect one sex or the other against injustices.

Colaco (2009) in his study of 2 north Indian states of Uttar Pradesh and Uttarakhand
found that gender equality factors were significantly and independently associated
with men‘s higher risk sex. This study was unique in the sense that it explored men‘s
attitude towards gender equality and their sexual behavior in contrast to multitudes of
study exploring only the women‘s attitude. It used variables as men‘s attitude to wife
beating, history of family violence, views on whether women have the right to refuse
sex with their husbands, whether women have the right to make household decisions,
and whether they should have financial autonomy. Men who have a history of family
violence, viewed wife abuse as justified and felt that women did not have the right to
refuse sex with their husbands are the ones who have significantly higher chances of
engaging in extra marital sex. These views are alarming with respect to the prevalence
of HIV/AIDS in the country.

2.2.6 LITERATURE ON EXPERIENCE OF DOMESTIC VIOLENCE

Violence against women is systematically entrenched in the cultures of most of the

societies and is perpetrated by men. Domestic violence is a form of violence against
women which occurs inside the household and often goes unnoticed. It is a result of
enjoyment of unequal power by men and women. It has profound effects on the
reproductive health of women.

Violence is responsible for breeding problems like long-term gynaecological and

psychological problems, unsafe sex, unintended pregnancies, resort to unsafe
abortion, maternal deaths, miscarriages, still births and low birth weight babies

75
(DFID, July 2004). Many studies have observed the link between perpetration of
violence- sexual coercion and/or, physical abuse to be more specific, and symptoms
of gynecologic morbidity. The physical trauma caused by physical and sexual
violence results in gynecologic morbidity. Sexual violence may cause vaginal or,
urethral trauma leading to an increased risk of infection (Campbell, 2002; Moore,
1999). Campbell et al. (2002) in a study relating to lifetime abuse in women and
gynecological problems found that, abused women were significantly more likely to
report STDs, vaginal bleeding, vaginal infection, pelvic pain, painful intercourse, and
urinary tract infections (UTIs), and sexually abused women experienced more
gynecological problems than physically abused women or never abused women.
Stephenson, Koenig and Ahmed (2006) in their study in north India found that 34% of
women who faced abuse (matched with husband‘s reporting of abuse) reported
gynecological problems.

In addition to the damage caused to the urethra, vagina and anus, abuse can also result
in STDs including HIV/AIDS (Campbell et al, 2006). Sexual behavior of male and
female partners also determines the risk of contracting HIV within an abusive
relationship. Studies have found that men who perpetrate violence against their
partners are more likely to have multiple sexual partners and thus pose increased risk
of acquiring and transmitting STIs (Moore 1999, Garcia-Moreno C. et al., 2002).
Silverman et al (2008) conducted a study in all the Indian states found that increased
prevalence of HIV infection among married Indian women was associated with
physical violence combined with sexual violence inflicted by husbands. Prevention of
Intimate Partner Violence (IPV) may thus be an effective method to reduce the spread
of HIV/AIDS.

Abuse limits a woman‘s sexual and reproductive autonomy. Women who have been
sexually abused are much more likely to use family planning clandestinely, to have
had their partner stop them from family planning and to have a partner refuse to use a
condom to prevent disease (Garcia-Moreno, C. et al., 2002).

Domestic Violence frequently begins or intensifies during pregnancy. Statistics reveal

that about 25% - 40% of all women who are battered are battered during pregnancy.

76
Studies show that physical abuse occurs in approximately 4-15% of pregnancies in the
U.S, Canada, Sweden, the U.K, South Africa and Nicaragua. Some studies indicate
that prevalence of Domestic Violence in developing countries to be 4% - 29% (Nasir
& Hyder, 2003). INCLEN 2000 study55 points out that it is the principal cause of
maternal mortality. An in-depth study of 121 maternal death reports that Domestic
violence is the second largest cause of death (16%) in pregnancy (Gantara, Coyaji and
Rao, 1998).

2.2.7 LITERATURE ON STANDARD OF LIVING INDEX AND

REPRODUCTIVE HEALTH

Standard of Living Index has been seen to affect reproductive health of women in a
number of ways. NFHS 2 (1998-1999), India, analyzed the various ways in which SLI
exerts its effect on the reproductive health of women. Women living in households
with higher SLIs were found to be better at practicing various measures to ensure their
reproductive well-being. The use of contraceptives were found to be higher in women
(61%) living in households with high SLI compared to women (40%) belonging to
households having medium or low SLI. The use of Government sponsored spacing
methods like pills and IUDs were more among women with high SLI (16%) than
women with medium (6%) and low (3%) SLI.

The use of ante natal care by pregnant women also revealed that the percentage of
availing the ANCs were higher for women with high SLIs. About 87% of women
belonging to high SLIs had their ante natal checkups done and 76% had it done by a
doctor. The tetanus toxoid coverage for the mothers also was seen to increase with
higher standard of living. Among those with low SLIs only 55% was seen to be
covered by tetanus toxoid showing that the coverage is poor among women belonging
to low socio-economic background. Similar was the findings in case of consumption
of iron and folic acid tablets. Consumption decreased with low SLI and vice-versa.

55
International Clinical Epidemiology Network (INCLEN). (2000). WorldSAFE and
IndiaSAFE: Studying the prevalence of family violence. INCLEN Monograph Series on
Critical International Health Issues, Monograph 9. Philadelphia: INCLEN.

77
The rate of institutional delivery and delivery by a skilled birth attendant showed an
increased incidence with increased household living standards. Post delivery checkups
also exhibited similar trends. It was found that the occurrence of reproductive health
problems (gynaecological illness) was more among women with low or medium SLIs
(40%-41%) than women with high SLIs (34%).

2.2.8 LITERATURE ON HEALTH SEEKING BEHAVIOUR OF WOMEN

―Health seeking behaviour of women can be defined as the decision to seek health
care in case of any physical, mental, emotional problem‖ (as cited in Gupta, S. K.
2009). The health seeking behaviour of women depends upon a number of factors.
Four such factors can be held responsible for the health seeking behaviour- social
factors, economic factors, behavioural factors and external factors (as cited in Gupta,
S. K. 2009).
The social and the economic factors have been discussed in the previous sections of
the literature review. Behavioural factors relate to the importance a woman assigns to
her own health. In developing countries like India it is seen that a woman gives less
priority to her own health but acts as the custodian of health for the entire family. A
matter like the reproductive aspects of health and a discussion about it is still a matter
of embarrassment to a large number of women in India. Thus, reproductive ill health
is borne silently by many Indian women thereby complicating their ailments.
However, even if the social, economic and the behavioural factors remain favourable,
a number of external factors stand as obstacle in obtaining good health. These factors
can be called the 4 As – Accessibility, Affordability, Availability and Acceptability of
health care. The cost of care and poor accessibility often victimize the poor
(Mulgaonkar et al 1994, as cited in Shukla, Jyotsana. 2011).

Services provided by the health care facilities need to be accessible, affordable,

acceptable and available with proper referral services in order to be utilized at their
utmost. Poor quality of care, unavailability of trained and skilled personnel,
unacceptable services, high level of expenditures, unresponsive attitudes of the
providers are the main reasons put forth by the women and their families for not
seeking care. According to Nayar (2007), availability and accessibility of health

78
services show wide differentials across different socio economic groups. The 11th
approach paper stated that education and curative health services are available in the
market for those who can afford to pay. Quality sources are expensive and beyond the
reach of the common people. Cost is often a big barrier than physical access to seek
care. The poor are reported to depend on the sale of assets if any and loans in order to
meet the cost of hospitalization (Enson and Cooper, 2004, as cited in Shukla,
Jyotsana. 2011).

Gupta (2008) in her study on health seeking behavior of women in ante natal clinics
in Delhi have found that care seeking behavior of women depends on their age,
education level, education, occupation and income levels of the husbands and the
family. Interviews of the researcher with the pregnant women reveals that monetary
constraints and family support are the biggest hurdles they face for seeking care.
Study found that majority of the women favoured Government hospitals in
comparison to private hospitals especially with regards to the high fees charged by the
latter. But, they complained about the poor infrastructure and lack of staff in the
Government hospitals to cater to the large group of care seekers. They also
complained about the impolite behavior of the staff of the Government hospital. A
major factor affecting the utilization of care is the quality of interaction a patient has
with the health care provider and the provider‘s attitude. Thus, it is desirable that the
health care providers should have a compassionate attitude towards the care seekers.

Bhanderi and Kannan (2010) undertook a study to find out the role of class, distance,
provider attitude and perceived quality of care as determiners for untreated
reproductive morbidity among slum dwellers of Rajkot city, Gujrat. Like previous
studies here also the rates of utilization of reproductive health services were limited –
out of the 57% women having reproductive morbidity, only one third sought
treatments. Remaining 66% of women with reproductive morbidity remained
untreated. It was found that women who were older were found to seek more
treatment than their younger counterparts. The reason behind this is quite obvious that
with age the knowledge about health and need for health care increases. The care
seeking rate was found to be low among women who were widowed, separated or
divorced. This was because of the embarrassment attached with reproductive

79
morbidities even in the absence of a partner. The rate of care seeking was also low
among the Muslim women in whose family there was a culture of silence regarding
sexual and reproductive ill health and discussing such matters with male health
providers forbidden by cultural norms. They found that women with longer durations
of illnesses were more likely to go untreated since they did not perceive the illness as
serious and worth requiring treatment. Women who lived near the health facilities had
higher treatment seeking behavior than women far from the health facility. This
shows that accessibility to a health care facility is a major determinant of health
seeking behavior. Greater distance is associated with greater time, cost, availability of
modes of transport and need to be accompanied by someone. All these contribute to
low utilization of health care services. Another determinant affecting care seeking
from the provider‘s side is the lack of female doctors in the health facilities. Women
in general, feel comfortable to open up about their sexual and reproductive health
problems in front of a female caregiver.

Islam, Montgomery and Taneja (2006) analyzed the health seeking behaviour of the
urban poor in the slums of Indore (India) and Manila (Philippines). In both these
places they found that the chief impediment to seek care from health facilities is the
financial constraint of the poor. They found that in highly monetized urban health
system the poor lack access to health care because of their inability to pay for it. Even
when the Government hospitals provide free treatment to the patients, they need to
pay for the medicines and the tests prescribed. Thus, the poor find it difficult to
adhere to the treatment schedule even if they manage to see a health care provider.
The researchers found that in Indore the urban poor depended on the private providers
for seeking outpatient treatment while in Manila, they depended on the public
providers. The reason for this difference was due to the fact that in India the quality of
care and distance of the Government providers discouraged the poor from availing
their services. On the other hand, the private health care in Manila was very costly.
But both the cities showed that the urban poor depended on the public providers for
immunization and family planning services since these were given free of cost on
scheduled dates. In both the cities the slum dwelling women showed a strong
preference for giving birth in home settings. This was due to the impersonality of the

80
hospital setting and insensitive treatment in the hands of the hospital staff in both the
cities. This gets reflected in the data which tells that 63% of the urban very poor in
India give birth at home compared to 78% of the very poor in Philippines.

Nagarkar and Mhaskar (2015) conducted a systematic review on the prevalence and
utilization of health care services for reproductive tract infections/sexually transmitted
infections by analysis of a total of 41 full text papers on India during the years 2000 –
2012. They found four factors affecting health seeking behavior – social and cultural
factors (feeling of shame, embarrassment, stigmatizing attitude, lack of control over
resources, lack of decision making power, did not perceive as abnormal and worth a
treatment), environmental factors (lack of accessibility, lack of knowledge, ignorance,
illiteracy), economic factors (poor socio-economic conditions, high treatment cost),
and health care facility factors (lack of privacy, absence of female doctors, poor
quality of care). Treatment utilization rates were found to be poor – in the range of
16% to 55% in studies where treatment was not provided as a part of the study.
Almost all treatment utilization studies analyzed depended on the reporting of
treatment used and lack evidence of treatment completion, cure rate, quality of care
and qualitative data on how barriers influence behavior.

Non seeking treatment behavior is common to other developing countries as well. Go

V. F et al. (2002) conducted a study on Vietnamese women who were victims of RTIs
to see their care seeking behavior. He found that 65% of women who reported RTI
sought some type of treatment from a medical venue. His analysis found that stigma
associated with STIs, not seeking informal advice, mildness of symptoms, absence of
perceived morbidity and short duration of symptoms were significantly associated
with ignoring RTI symptoms.

According to the report of The Commission on Macroeconomics and Health ―access

to medical care continues to be problematic due to locational reasons, bad roads,
unreliable functioning of health facilities, transport costs and indirect expenses due to
wage loss etc., making it easier to seek treatment from local quacks‖. The
Commission did not specify whether the above is true for urban or rural population,
but, studies on urban poor support the above view of the Commission. Gupta and

81
Guin (2015) carried out a study in four cities to see the health status and health access
of the slum dwellers. They found that Government facilities targeted towards these
urban poor are inadequate and inappropriate. The urban poor rely on private providers
for episodes of out-patient care more than the Government facilities. The picture is
reverse for inpatient care. Hospitalization data indicated a high figure for public
hospitals than private hospitals. This shows that for bigger expenses, urban poor still
prefer low cost facilities at public hospitals. Data collected on pregnancy and delivery
showed that despite the promotion of the Ministry of Health and Family Welfare on
institutional deliveries, 46% of the mothers delivered at home. Data on Ante natal
checkups showed that nearly half of the pregnant women had regular check up, while
25% had occasional checkups. There were women who never had any checkups at all.
The most cited reason for not having it was they did not think it was necessary.
Among other reasons were lack of knowledge about the ante natal checkups and
distance of the provider from their homes.

2.3 RESEARCH GAPS

The major gap that has been found is that health research has largely neglected the
role of social determinants of health, with reproductive health in particular, only with
few exceptions. There is lack of empirical research on the relationship between
women‘s reproductive health and social-structural variables. (Bird & Bauman, 1995;
Mann, Gostin, Gruskin, Troyen, & Fineberg, 1999; Stivens, 2000; Wittrock, 2000).
Lane (1994) considers ―research on reproductive health and women‘s human rights to
be a neglected area.‖ (p. 1310). Data on social determinants of reproductive health are
few in India and are mainly collected from non systematic surveys and opinion polls.
Social, cultural, economic, psychological and genetic factors which affect desire,
attitude, behaviour and practice are rarely investigated (Rao et al., 2012).
Reproductive ill health is often borne silently in Indian culture which pose further
difficulties relating to the diagnosis of the problem as well as in the health seeking
behaviour of the affected. Research gaps are also found in bringing out the
relationship between patriarchy, women‘s work and its effects on women‘s health.

82
 (Chatterjee, S., 2008, “Health status of Working Women: Comparative Study of Slum
and Non-Slum Residential areas in Delhi”). Other gap areas are-

 Data on reproductive health and constraints to good reproductive health are

limited.
 Only limited research has focused on women‘s status and use of reproductive
health services.
 Dearth of research outlining a poor woman‘s perception, need and decision-
making with regard to abortion.
 Limited research have been carried out regarding the barriers the urban poor
face to receive care.
 Studies on reproductive health of the slum population are limited in West
Bengal. Very little studies on reproductive health have been carried out
among the slum population in South Bengal municipalities. Uttarpara slums
are an example.

This research paper will begin keeping in mind the gaps in knowledge and seek to
address them.

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 CHAPTER 3

3.1 METHODOLOGY

This section describes the methodology adopted for the selection of study area
and sample size, description of dependent and independent variables and data analysis
methods. The research work is based on empirical study. The diagrammatic
representation of the methodology has been shown below-

Figure: 3.1. Diagrammatic Representation of Research Methodology

Source: Developed by the Researcher

3.2 SELECTION OF SAMPLE SIZE

To estimate the minimum required sample size in the survey, I have used
Cochran (1977) formula to calculate a representative sample for proportions:

96
 no = (z2 p q) / e2

Where,

 no : is the sample size,

 z : is the selected critical value of desired confidence level,
 p : is the estimated proportion of an attribute that is present in the population,
 q = (1 – p),
 e : is the desired level of precision.

Assuming the maximum variability, which is equal to 50% (p = 0.5) and taking 95%
+
confidence level with - 5% precision , the calculation for required sample size will
be-

p = 0.5, q = 1 – 0.5 = 0.5, e = 0.05, z = 1.96

So, no = [(1.96)2 (0.5) (0.5)] / (0.05)2 = 384.16 = 384

Since the sample size is calculated at 95% confidence level with margin of error
equals to (0.05), the sample size becomes 384, which does not need correction
formula of Cochran‘s. So, in this case the minimum representative sample size for my
study is 384. Hence, the minimum desirable sample size is 384.

3.3 SELECTION OF THE STUDY AREA

The study was conducted in the selected wards of Uttarpara Kotrung

Municipality (UKM). There are 67 slums under the UKM with approximate 5504
number of families residing in these slums. Due to time and resource constraints, it
was not possible for the researcher to visit and conduct survey of all the slums. The
selection of slum areas out of these 67 slums has been done on the basis of prioritized
service areas as identified by Quick Slum Survey of the UKM. The survey provided a
list of prioritized service areas together with the name of the slums and the wards
under which they fall.

This survey formed a part of the Slum Infrastructure Plan of the DDP Main Book of
UKM. The priority service areas were based on inadequate water supply, insufficient

97
drainage system, katcha roads, absence of street lights, community latrine,
unavailability of drinking water, deficiency of hand pumps, water logging of the area
due to overflow of adjacent water bodies. A detailed list containing the priority
service area with name of the slum and ward number has been provided in Chapter 4,
under slum scenario in Uttarpara Kotrung. Only those slums where services were
found to be inadequate according to municipal findings and needed infrastructure
development were considered in the study. Inadequate services like drinking water,
insufficient or absence of water supply for various uses, absence of latrines, water
logging, and lack of sanitation facilities in these slums signify that people are forced
to live in subhuman, unhygienic conditions. These conditions also breed a number of
illnesses in the people in these areas.

Since the research is based on the Social Determinants of Reproductive Health, it is

essential to understand the conditions, under which people are born, grow, live and
die and which have an important bearing on their health. It may be assumed that
people residing in these slums are more prone to illness and in general exhibit ill
health as compared to residents of slums which have better infrastructural facilities
and basic services. 30 slum areas were selected by the researcher based on the above
stated premise.

The researcher approached the Municipality for their permission to speak to the slum
dwellers on the research topic. A permission letter from the then Chairman, Smt. Aditi
Kundu was received which instructed all those functionaries of the Municipality
associated to slums and the health centre and sub-centres to provide all co-operation
to the researcher. A copy of the permission letter is attached in the Appendix III.

98
Figure:3.3.1 Selected Wards of Uttarpara Kotrung Municipality

3.

99
The names of the slums and the wards under which they fall are represented with the
help of the following table-

Table: 3.3.1.a Ward wise Name of the Slum Areas under Uttarpara Kotrung
Municipality (UKM)

Ward UKM Name of the Slum Areas Under Slum House

No. Slum UKM Hold Covered
Code under UKM
1 1 Kishori Khola Bastee 172
1 2 Itkhola Bastee 50
2 3 Bidhanpally Bastee 138
2 4 Jayantanagar Bastee 121
2 5 Jolapara Bastee 48
3 6 Govt. Colony bastee 248
4 7 Satphokar Bastee 76
5 8 Kuli Bastee 44
5 9 Harijan Bastee 35
6 10 B.B. Street Bastee 05
6 11 Jelepara Bastee 24
6 12 22 Plot Bastee 59
7 13 Oriya para Bastee 18
7 14 Adibashipara Bastee 11
7 15 Jhilpar Bastee 23
7 16 Railway Bastee 39
7 17 Khatal Bastee 24
7 18 Santal Bastee 14
8 19 Adibashipara Bastee 21
8 20 Shibtala Bastee 16
8 21 Shibtala Ghat Bastee 12
Source: DDP Main Book of Uttarpara Kotrung Municipality, 2011

Table: 3.3.1.b Ward wise Name of the Slum Areas under Uttarpara Kotrung
Municipality (UKM)

Ward UKM Name of the Slum Areas Under Slum House

No. Slum UKM Hold Covered
Code under UKM
9 23 Shimultala Ghat Bastee 44
9 24 LIC Bastee 89
10 22 Hranathpur Bastee 36
10 25 Bhadrakali Camp 243
10 26 School Bardi Bastee 34
10 27 Colony Bastee 38
10 28 Sarbamangala Bastee 48
10 29 Satmile Bastee 80
11 30 Mukti Babus Barrack 15
16 31 Ramghat Bastee 11
17 32 Khalpar Bastee 28

100
 Ward UKM Name of the Slum Areas Under Slum House
No. Slum UKM Hold Covered
Code under UKM
17 33 ChalkPara Bastee 23
17 34 Goabagan Bastee 07
18 35 Shalimar Bastee 11
18 36 Hindusthani Bastee 13
18 37 Goala Bastee 08
19 38 Railbridge Bastee 18
19 39 Rail Bastee 17
19 40 Harizon Bastee 19
20 41 Railpar Bastee 33
20 42 Marathi Bastee 86
20 43 Bangali Bastee 16
20 44 Shimapally Bastee 82
20 45 Singhpara Bastee 66
20 46 Benepukur Bastee 154
Source: DDP Main Book of Uttarpara Kotrung Municipality, 2011

Table:3.3.1.c Ward wise Name of the Slum Areas under Uttarpara Kotrung
Municipality (UKM)

Ward UKM Name of the Slum Areas Under Slum House

No. Slum UKM Hold Covered
Code under UKM
21 47 Roy ParaBastee 24
21 48 Paramanikpara Bastee 30
21 49 Mondalpara Bastee 29
21 50 Jelepara Bastee 30
21 51 Manashatala Bastee 30
21 52 Makaltala Bastee 51
21 53 Dhalipara Bastee 73
21 54 Harisabha Bastee 30
21 55 Harisaba Bastee 32
21 56 Pekera Bastee 124
21 57 Shalbagan Bastee 47
21 58 Kalitala Bastee 47
21 59 Jhilpar Bastee 57
22 60 Daluipara Pukurpar Bastee 102
22 61 Jelepara 54
22 62 Jelepara Bastee 15
22 63 Charaktala Bastee 60
23 64 Haranathpur Bastee 47
23 65 Tentultala Bastee 129
23 66 Haranathpur School Dhar Bastee 75
24 67 Railway Bastee 60
Total 3563
Source: DDP Main Book of Uttarpara Kotrung Municipality, 2011

101
3.4. SAMPLE DESIGN

After selecting the 30 prioritized slums located in the 11 wards of UKM, the
next step was to select the number of households and eligible ever married females in
the age range of 15-49 years from these households. The minimum required sample
size was 384, so, uniformly selecting at least 14 households from each of the 30 slums
and assuming that there is at least 1 eligible female in all 14 households would give a
sample size of 30x14 = 420. Sample size aimed was a little high than the minimum
requirement for this will allow sufficient room for non responses and incomplete
responses. Thus, 14 households from each 30 slums were purposively selected by the
researcher with the help of HHWs attached to the health sub-centres in the area to get
the desired sample size. The precondition for selection of households was that there
should be at least 1 ever married female in the reproductive age range of 15 - 49
years. Survey of 420 households (combination of nuclear and joint families) from the
30 slums led to a sample size of 543. But, 7 women among those surveyed could not
complete the interview due to lack of time on their part and it was not possible to go
back to them for the researcher. 5 women refused to respond after hearing the topic.
So, a total of 12 women were eliminated from the survey and the total sample size or
the total number of respondents came down to 531 (543-12). Before proceeding with
the questionnaire all the respondents were informed about the topic under study and
their informed consent to participate in the study was taken verbally. Written consent
could not be taken since a number of respondents could not read and write. They were
also told that they could stop answering any further question if they felt that their
privacy is being encroached by sensitive questions.

3.5. RATIONALE FOR PURPOSIVE SAMPLING

Purposive non random sampling is also known as judgment or judgmental sampling

(Babbie, 1990). The rationale behind choosing purposive sampling method is that this
type of sampling has the advantage of collecting information from a targeted group.
Secondly, it has the advantage of selection of individuals with specific characteristics
and thirdly, restricting the sampling to certain group. It also helps in picking up useful
cases for study. The study aimed to collect information from slum dwelling women

102
with specific characteristic of ever marriage and within the age group of 15 -49 years.
All these were satisfied by the purposive sampling method. According to Maxwell
(1997), purposive sampling is a type of sampling in which ―particular setting, persons
or events are deliberately selected for the important information they can provide that
cannot be gotten as well from other choices‖ (p.87). Babbie (1990) defines purposive
sampling as selecting a sample ―On the basis of researcher‘s own knowledge of the
population, its elements and the nature of the research aims‖ (p.97). He continues that
this method is useful if the researcher wants to study ―A small subset of a larger
population in which many members of the subset are easily identified but the
enumeration of all is nearly impossible‖ (p.97) Campbell (1955) opined that both
qualitative and quantitative methods can be used when samples are chosen
purposively. Zhen et al. (2006) suggested that ranking activities, questionnaires can be
used in case of purposive sampling. Martinez-Romero et al. (2004) advocated for
direct observations while Anderson (2004) suggested interviews for purposive
sampling. Albertin and Nair (2004) were in favor of Frequencies, and Chi Square
Tests. Belcher et al. (2004) recommended Analysis of Variance. Bah et al. (2006)
suggested Univariate Analysis and Cross Tabulation can be used with purposive
sampling. Researchers Bernard (2002) , Karmel and Jain (1987), Tremblay (1957)
opined that purposive sampling when used appropriately is more efficient than
random sampling in practical field circumstances because the random number of a
community may not be as knowledgeable and observant as an expert informant.
Seidler (1974), Snedecor (1939) opined that purposive sampling can be more realistic
than randomization in terms of time, effort and cost needed to find informants.
Zelditch (1962) opined that non probability methods can be as good as probability
methods in some situations. He added that to insist on randomized sample every time
is to run the danger of losing efficiency and failing to recognize the existence of
different types of information which can be extracted from a community in more than
one way. It is worth mentioning at this point that no data was available from the UKM
regarding the number of ever married females in the reproductive age group (15-49
years) in the slums. Only the data regarding total number of females in various wards
was available. The distribution of samples in the selected slums is represented by the
table below.

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Table 3.5.1 Distribution of Sample in selected Slums of UKM

Ward Name of the Prioritized Slum No. of Slum No. of No. of

No. of Area Under UKM HHs Respondent EMW
UKM Surveyed EMW Didn’t
(15-49 yrs) respond

2 Jelepara Bastee 14 19 -
2 Jayantanagar Government Colony 14 10 4
2 Bidhanpally Government Colony 14 12 2
5 Harijan Bastee 14 20 -
5 Kulipara Bastee 14 13 1
6 B.B. Street Bastee 14 17 -
6 22 Plot Bastee 14 16 -
6 Jolapara Bastee 14 17 -
7 Oriya para Bastee 14 22 -
9 Shimultala Ghat Bastee 14 21 -
10 Conoly Bastee 14 20 -
17 Chakpara Bastee 14 20 -
20 Singhpara Bastee 14 15 -
21 Jhilpar Bastee 14 16 -
21 Shalbagan Bastee 14 16 -
21 Poramanikpara Bastee 14 13 1
21 Dhalipara Bastee 14 17 -
21 Harisabha Bastee 14 12 2
21 Pekera Bastee 14 19 -
21 Manasatala Bastee 14 19 -
21 Makaltala Bastee 14 17 -
21 Mondalpara Bastee 14 18 -
21 Kalitala Bastee 14 12 2
21 Roypara Bastee 14 17 -
21 Jelepara Bastee 14 14 -
22 Charaktala Bastee 14 21 -
22 Jelepara Bastee 14 23 -
23 Tentultala Bastee 14 26 -
23 Haranathpur Bastee 14 24 -
23 Haranathpur Schoolpara Bastee 14 25 -
Total: 11 Total: 30 420 531 12
UKM: Uttarpara Kotrung Municipality / HHs: Households / EMW: Ever Married Women
Source: Field Survey Data

3.6. CALCULATION OF RESPONSE RATE

Rate of response in any research plays an important role to indicate the quality
of survey. Response rate is defined as the proportion of the eligible sample that has
completed a survey. The American Association for Public Opinion Research
(AAPOR) standards divided all outcomes of a survey into four categories –

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1. Interviews both complete and partial,

2. Eligible cases not interviewed (non respondents),

3. Cases of unknown eligibility,

4. Cases not eligible.

On the basis of this categorization, they have presented 6 formulae for calculating the
response rate. In this study I have used the standardized formula (RR5) developed by
the American Association for Public Opinion Research (AAPOR) in 1998 for
calculating the response rate. RR5 has been chosen since it assumes that none of the
individuals with undetermined eligibility are eligible. The different notations used in
the formula are-

RR = Response Rate

I = Complete Interview

P = Partial Interview

R = Refusal and Break Off

NC = Non-Contact

O = Others

In this study, I = 531, P = 7, R = 5, NC = 0, O = 0

Response Rate 5 (RR5) = I / [(I + P) + (R+NC+O)]

Or, RR5 = 531 / [(531 + 7) + (5 + 0 + 0)]

RR5 = 531 / 543

RR5 = 0.9779

Hence, Response Rate = 0.9779 x 100 = 97.8 % approx.

3.7. MANGIONE’S CLASIFICATION OF BANDS OF RESPONSE RATE

The Overall Response Rate (Calculated) was 97.8%. Mangione‘s Bands of Response
Rate (2008) Model rates this as an excellent response rate. A breakdown of response
rates can be seen in Table 3.7.1.

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Table 3.7.1 Mangione’s Bands of Response Rate

Over 85% Excellent

70-85% Very good

60-69% Acceptable

50-59% Barely acceptable

Below 50% Not acceptable

Source: Allan Bryman, “Social Research Methods”, Oxford University Press, p-225,
3rd edition, 1995

3.8 METHODS OF DATA COLLECTION

In this study, both qualitative and quantitative methods were used for the
collection of data. Quantitative method employed using a structured questionnaire and
qualitative information was collected from in-depth interviews with few women in the
study area and the Honorary Health Workers of the health subcentres. The
questionnaire (Appendix-I) used in the study was modified form of that used in NFHS
-2 and NFHS – 3. The questionnaire contained sections on women‘s socio-economic
and demographic backgrounds, their work participation and control over money
earned, gender roles and attitudes, marriage and cohabitation, reproductive history,
contraceptive practices, pregnancy, delivery and post natal care for currently pregnant
women and women who delivered during the past one year of the survey, knowledge
and practice of abortion, self reported gynaecological morbidities, knowledge and
prevention of HIV/AIDS and other STDs, treatment seeking behaviour. The
questionnaire was formed in English and then translated to local languages- Bengali
and Hindi. A pilot survey was conducted among 30 women from various slums of
UKM for pre-testing the questionnaire and various modifications were made in the
content of the questionnaire.

An in depth interview was conducted with a total of 32 of the sampled women and
HHWs to get qualitative information from them. Since, most of the women in the
sample were engaged in paid work as domestic helps and had to do all household

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chores back at home, they rarely had the time to speak elaborately about their
feelings, perceptions, practice of reproductive health and factors which affect such
practice. Moreover, women were reluctant to speak much without any consideration
in return. Most of the times, the researcher had to face questions like ―ato katha bole
ami ki paabo?” (What will I get by speaking to you about it at length?) Thus, the
qualitative method was restricted to in depth interview of 27 slum women and 5
HHWs from different slums and different subcentres respectively. Narratives from 12
such interviews have been added as ―Selected Case Studies‖ in Chapter 7. The
interviewees were assured that their right to confidentiality will be respected by the
researcher. Thus, all in depth interviewees in this study will be anonymous.

3.8.1 Data Collection

Data was collected by the researcher herself from the 30 selected slum areas
over a period of approximately 2 years. The data collection was done from October
2012 to November 2014 with several interruptions in between. Data collection was
not continuous over the two years and was interrupted by episodes of Municipal
election, Lok Sabha election, various health programs, BSUP - project in the slums.
During all these the researcher could not go to the slums for data collection. Data
collection was also interrupted due to preoccupation of the HHWs for voter card
correction, ADHAR card enrolment, program for control of vector borne diseases.
There was also a problem regarding the sudden termination of a number of HHWs
from their work as they were above sixty years of age. Most of them worked in the
capacity of Centre Supervisors and were responsible for the maintenance of all
records pertaining to family planning, ante natal care, and delivery history of women.
The researcher had to depend on the HHWs for visiting the slums since they acted as
the resource persons.

3.8.2 Data Management

Data collected from the completed questionnaires were coded and then subjected to
analysis. It was ascertained that during entering the respondents‘ information for
statistical analysis, no names of the respondents appeared on the questionnaires.

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3.9 METHODS OF DATA ANALYSIS

In this study, the unit of analysis has been taken as ever married females in the
reproductive age range of 15 – 49 years. Univariate analysis in terms of percentage
distribution has been done. Chi square test for Bivariate Analysis, and Cramer‘s Phi /
V for Measurement of Association are done for analyzing the data.

3.9.1 Chi –Square Test of Independence

According to Albert M. Liebetrau (1983) Chi –Square Test of Independence is a

Non Parametric test to determine the significant relationship between two variables
(nominal / categorical). In this method, the frequency of one nominal variable is
compared with different values of a second nominal variable. This data is displayed
in a Row (R) and Column (C) contingency table. Chi- square says whether there is a
significant relationship between the dependent and the independent variables. If a
significant relationship exists between the variables, then, Null Hypothesis (H0) is
rejected and Alternative Hypothesis (H1) is accepted. To reduce approximation
errors, Yate‘s correction has been applied to 2x2 contingency tables.

3.9.2 Measures of Association

According to Alan C. Acock and Gordon R. Stavig (1979) Measures of Association
calculate the strength of association of two variables. Two types of measures are
there-

 (A) Cramer's Phi– It is used to measure the strength of relationship between

two variables each of which has two nominal categories only.

 (B) Cramer's V- Cramer's V is a way of calculating correlation in tables

which have more than 2x2 rows and columns. It is used as post-test to
determine strengths of association after chi-square has determined
significance. Cramer's V varies between 0 and 1. Close to 0 it shows little
association between variables. Close to 1, it indicates a strong association.

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Table: [Link] Guidelines for Interpreting Measures of Association

Levels of Association Verbal Description Comments

Knowing the independent
variable does not help in
0.00 No Relationship
predicting the dependent
variable.
.00 to .15 Very Weak Not generally acceptable
.15 to .20 Weak Minimally acceptable
.20 to .25 Moderate Acceptable
.25 to .30 Moderately Strong Desirable
.30 to .35 Strong Very Desirable
.35 to .40 Very Strong Extremely Desirable
Either an extremely good
relationship or the two
.40 to .50 Worrisomely Strong
variables are measuring
the same concept
The two variables are
.50 to .99 Redundant probably measuring the
same concept.
If the independent
variable is known, the
1.00 Perfect Relationship.
dependent variable can be
perfectly predicted.
Source: [Link]
3A_content.htm

Gail Johnson (2015) author of “Research Methods for Public Administrators” in his
book concluded that there are some general guidelines for describing measures of
association but there is a lack of agreement among social scientists regarding which
is the best descriptor (p. 206). The above analysis was done with the help of a
statistical tool called Statistical Package for Social Sciences (SPSS).

3.10 CONCEPTUAL FRAMEWORK

This section will try to develop a framework which will reveal the relationship
between the variables used in the study. A variable, by definition is any entity that can
take on different values. So, anything that can vary can be considered to be a variable.
This study will involve the use of two types of variables- dependent and independent

109
variables. An independent variable is the one which can be manipulated either by self
or by nature while a dependent variable is the one which is affected by the
independent variables. An independent variable is also called predictor variable while
a dependent variable is called the outcome variable. In this study, the independent
variables are the Social Determinants and the dependent variable is the Reproductive
Health of slum dwelling women in the reproductive age group.

Figure: 3.10.1 Conceptual Framework Relating Social Determinants to

Reproductive Health

Source: Developed by the Researcher

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3.10.1 Variables Used:

Independent Variables:

A total of eight social determinants are taken in this study to see their
relationship with reproductive health. The eight independent variables used in this
study are –

Age at marriage

Age at marriage has two attributes – marriage below the age of 18 years (early
marriage) and marriage equal to and above the age of 18 years. Marriage, according
to National Sample survey Organization (NSSO) is defined as the legal union of
persons of opposite sex established by civil, religious, or other means recognized law
or social custom. Age at marriage is found to affect reproductive health of women in a
number of ways. Women who marry below 18 years of age are often ignorant about
their reproductive health rights, are unable to exercise those rights and thus are
victims of ill reproductive health.

Literacy

According to Ahuja (2005) Literacy has been measured by two attributes – literate
and illiterate. UNESCO has defined a literate person as ‗One who can with
understanding both read and write a short simple statement on his everyday life.‘
Following UNESCO, the Census Commission of India in 1991 defined literate person
as one who can read and write with understanding in any Indian language and not
merely read and write. In this definition the person in question should be aged seven
or above. So, one of the determining factors in literacy rate is that the population
should be aged seven or above.
In this study, the definition of literate has been taken as the one considered by the
National Sample Survey Organization (NSSO) in its 47th round. It defines a literate
person as the one ‗who can read and write with comprehension a simple message in
any language‘. An illiterate is the person who does not have the ability to read and
write with comprehension.

111
Work Participation

The NSSO defines work as any activity resulting in the production of goods and
services that add value to the national product is considered as an economic activity.
Activity status is defined as ‘the activity situation in which a person is found during a
reference period or at a point of time under reference, which occurs with the person’s
participation in economic and non-economic activities’. According to this, a person
can belong to any one or a combination of the 3 status below-

1. Working or being engaged in economic activity

2. Being not engaged in economic activity but either making tangible efforts to
seek work or being available for work if it is available
3. Being not engaged in economic activity and also not available for work. (Not
being in the labour force).
This study will consider the activity statuses 1 and 3 to determine the attributes
Working and Non working. NSSO also categorizes each of the above activity statuses.
Since the study will deal with slum dwellers, for activity status 1, the following
categories will be considered-

 Worked as regular salaried or wage employee

 Worked as casual wage labour in public and other types of work
 Worked as helpers in household enterprise

The above categories will constitute the Working group in the study. From activity
status 3, the following activity category will be considered -

 Attended domestic duties only

This category will constitute the Non working group for the study.

Mass Media Exposure

Newspapers, radio and television are the main sources of mass media. A significant
portion of the slum dwellers are exposed to radio and television almost daily. But, the
frequency of reading a newspaper or going for a movie once in a month is less. For
this study, exposure of the women to radio, television on a daily basis, newspaper

112
reading at least once a week and or, listening to topics of interest from somebody who
reads a newspaper in case of illiterate women have been considered. Based on the
responses of women, numerical codes ‗1‘ and ‗0‘ is assigned to each answer in ‗Yes‘
and ‗No‘ respectively. Response codes were calculated for each woman according to
the illustration below.

Construction of Mass Media Exposure Index

Table: [Link].A. Exposure to Mass Media by Responses of Women

Mass Media Exposure Responses of women

Yes = 1 No = 0
Listens to radio every day
Watches television every day
Reads newspaper once a week / Listens to
newspaper details of interest (if illiterate)
Total

Table: [Link].B. Categorization of Maximum and Minimum Scores

Maximum Minimum
Score: Score:
3 0

Table: [Link].C. Categorization of Mass Media Exposure Scores

Categorization of Score
Mass Media
Exposure
No Exposure 0
Exposure 1-3

Autonomy

Autonomy of a woman is defined as the capacity for a woman to achieve well being
and a role in decision making. However, there are no consensus among researchers
regarding the concept and measurement of autonomy. A substantial body of literature

113
shows that acquisition of autonomy in women is related to better negotiation in a
sexual relationship and leads to better reproductive care seeking behavior. Autonomy
has been studied under three categories in this study –

1. Decision making autonomy

2. Movement autonomy

3. Access to and control over economic resources.

Each of the categories is divided into subcategories. Women‘s responses to the

above subcategories are noted with dichotomous answers in ‗Yes‘ or ‗No‘.
The response Yes is coded as 1 while the response No is coded as 0.
Illustration of the categories and scoring procedure for this variable is given
below.

Construction of Autonomy Index

Table: [Link].A. Women’s Autonomy Variables

Women Reporting that they have the ability to do the Responses of

following women
Yes = 1 No = 0
Decision Making Autonomy
Ability to decide when to buy daily household items
Ability to decide about child‘s schooling
Ability to decide about own and child‘s health
Ability to decide when to visit a healthcare facility
Ability to decide when to have a child and adoption of a
Family Planning method
Movement Autonomy
Ability to move unaccompanied to market
Ability to move unaccompanied to parental house
Ability to move unaccompanied to friend‘s/relative‘s place
Ability to move unaccompanied to a health care provider

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Ability to move unaccompanied to see a movie
Access to and control over economic resources
Access to husband‘s earnings
Access and control over money earned by self
Can buy small things for self
Can set aside money for self
Can buy gift items for parents, friends, relatives
Total

Women’s Autonomy = [Decision making Autonomy + Movement Autonomy +

Access to and control over economic resources.]

Table: [Link].B. Categorization of Maximum and Minimum Scores

Maximum Minimum
Score: Score:
15 0

Table: [Link].C. Categorization of Women’s Autonomy Score

Categorization Score Range

of Autonomy
Low 0-5
Medium 6 - 10
High 11 - 15

Gender Role Attitudes

Gender is responsible for shaping the lives of men and women in the society. Gender
determines the role we play in the society, it determines the type of education we get,
and also the type of medical care we receive. Unfortunately, in India, the power,
position and authority enjoyed by men and women in the society are not equal. The
society being patriarchal in nature, women are always at a backseat in terms of power,
position and authority compared to men. This is manifested by early marriages of
girls, denial of access to family planning measures, unintended pregnancies, poor

115
maternal and child health. This variable is categorized into 8 statements and a
woman‘s responses to the statements have been recorded in terms of ‗agree‘ or
‗disagree‘. The responses are coded with 1 in case of agree and 0 in case of disagree.
Thus, scores of individual women are formed by adding their response codes for all
the statements. Women are then categorized into -

1. Low conformity to traditional gender role attitudes

2. Medium conformity to traditional gender role attitudes
3. High conformity to traditional gender role attitudes

Construction of Gender Role Attitude Index

Table: [Link].A Gender Role Attitudes of Married Women Respondents

Women who agree / Disagree to the following Gender Role Response of

statements Women
Agree Disagree
=1 =0
A girl should not be allowed to decide when and whom to
marry
Performing household chores is the job of wives only
A husband should alone decide how household money should
be spent
A husband‘s opinion should always prevail even if it is wrong
and differs from that of his wife

A husband has the right to physically and, or, verbally rebuke

a wife if she is unable to discharge household duties assigned
to her
A husband would not be wrong if he keeps illicit relationship
with, or, marry another woman if he is not happy and satisfied
with his wife
It is always lucky to have a son than a daughter
A girl child need not be sent to school since education has
nothing to do with accomplishing household chores which she
actually needs to master
Total

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Table: [Link].B Categorization of Maximum and Minimum Scores

Maximum Minimum
Score: Score:
8 0

Table: [Link].C. Categorization of Gender Role Attitudes According to Scores

Categorization of Gender Role Attitudes Score Range

Low conformity to traditional gender roles 0-2
Medium conformity to traditional gender roles 3-5
High conformity to traditional gender roles 6-8

Standard of Living Index (SLI)

Standard of living refers to the level of wealth, material goods, comfort and
necessities available to certain socioeconomic class in a certain area.

To calculate the Standard of Living Index, the scoring method used in National
Family Health Survey - 2 (1998-99) have been adopted. The entire households
surveyed are classified into three categories i.e., Low, Medium, and High Standard of
Living by the addition of scores based on the available facilities and consumer
durables.
The method of calculation of scores with indicators and category are given below:

Table3.10.1.4.A Standard of Living Index (SLI)

INDICATOR CATEGORY SCORE
Type of House Pucca 4
Semi-pucca 2
Kachha 0
Ownership of house Yes 2
No 0
Source of lighting Electricity 2
Kerosene/Gas/Oil 1
Any other 0

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 INDICATOR CATEGORY SCORE
Separate room for cooking Yes 1
No 0
Main fuel used for cooking Electricity/LPG/Biogas 2
Coal/Charcoal/Kerosene 1
Any other 0
Source of drinking water Pipe water/Well/Hand
pump
in residence 2
Public tap/Hand pump/Well 1
Other water sources 0
Type of toilet facility Own toilet- 4
Public flush toilet 2
Public pit toilet 1
Open space /
Field (no toilet) 0
Ownership of livestock Owns livestock 2
Does not own livestock 0
Ownership of durable goods None 0
Pressure Cooker/Bed/Clock 1
Electric fan/Radio/Sewing 2
machine/Bicycle
Color T.V/ Refrigerator 3
Scooter / Motor cycle 4
Jeep / Car
Index scores range from 0–14 for a low SLI to 15–24 for a medium SLI and 25–67 for
a high SLI.

Table: [Link].B Categorization of Maximum and Minimum Scores

Maximum Minimum
Score: Score:
67 0

Table: [Link].C Categorization of SLI According to Scores

Categorization of Score Range
SLI
Low 0 - 14
Medium 15 - 24
High 25 - 67

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Household Income

The total monthly household income is taken as another independent variable which is
divided into the following 5 categories-

Table3.10.1.5.A. Categorization of Monthly Income

Household Monthly Income
(Rs.)
<3000
3001-5500
5501-8000
8001-10500
>10500

For the calculation of chi-square in order to determine the relationship of Household

Monthly Income with dependent variables, pooled income is divided into two
categories-

Table: [Link].B. Final Categorization of Household Monthly Income

Household Monthly
Income (Rs)
< 5500
>5500

Dependent Variables:

The dependent variable in the present study is Reproductive Health of women.

The study aims at seeing the effect of the above mentioned independent variable on
Reproductive Health.

Reproductive Health (RH)

The International Conference on Population and Development (ICPD), 1994

redefined reproductive health where individual health was placed at the centre and the
social, cultural and economic contexts in which people live were placed at the

119
periphery. RH was defined as ―a state of physical, mental and social well being and
not merely an absence of disease or infirmity, in all matters relating to the
reproductive system and to its functions and processes.‖ In order to enable people
achieve such a state, ICPD stated that ―People are able to have a satisfying safe sex
life and they have the capability to reproduce and the freedom to decide if, when and
how often to do so.‖ It is clear from the above definition that RH involves a number
of aspects. In 2004 WHO outlined 5 components for good sexual and reproductive
health.

1. Ensuring contraceptive choice and safety and infertility services

2. Improving maternal and newborn health
3. Reducing sexually transmitted infections, including HIV, and other
reproductive morbidities
4. Eliminating unsafe abortion and providing post abortion care
5. Promoting healthy sexuality, including adolescent health and reducing harmful
practices.

In determining the dependent variable reproductive health, an attempt has been made
to encompass all its aspects and divided it into the following categories –

A. Knowledge
1. Knowledge of female reproductive cycle
2. Knowledge of contraceptive methods
3. Knowledge of family planning basics
4. Knowledge of ante natal, delivery and post natal services (in case of currently
pregnant women and women who delivered within a year prior to the survey)
5. Knowledge of HIV/AIDS and other STDs and their prevention
6. Knowledge of induced abortion

B. Practice

1. Practice of Family Planning Methods – ever and current use

2. Delivery practices (institutional or home in case of women who delivered
within a year prior to the survey).

120
 3. Interaction with health care providers (during the past six months prior to
survey).
4. Practice of seeking treatment in case of gynaecological ailments. (Those who
self reported gynaecological ailments in the past 6 months).

Table: [Link]. A. DESCRIPTION OF INDEPENDENT VARIABLES

Independent Variables Category Number Percent

Age at Marriage <18 years 39 7.3%
>18 years 492 92.7%
Literate 419 79%
Literacy Illiterate 112 21%

Work Status Working 365 69%

Non Working 166 31%
Autonomy Low 250 47%
Medium 228 43%
High 53 10%
Mass Media Exposure No Exposure 74 14%
Exposure 457 86%
Gender Role Attitude Low conformity to 64 12%
traditional gender roles
Medium conformity to 223 42%
traditional gender roles
High conformity to 224 46%
traditional gender roles
Standard of Living Index Low 218 41%
Medium 225 48%
High 58 11%
Monthly House Hold Income <5500 297 56%
(Rs.) >5500 234 44%
Source: Field Survey Data

Table: [Link].B. DESCRIPTION OF RESPONSE VARIABLES

Response Variables Category Number Percent

Knowledge of Women Regarding Yes 282 53%
Female Reproductive Cycle No 249 47%
Knowledge of HIV/AIDS/STIs Yes 270 51%
No 261 49%

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 Response Variables Category Number Percent
Knowledge of various Contraceptive Yes 444 84%
Methods No 87 16%
Knowledge of Women Regarding Yes 292 55%
Family Planning Basics No 239 45%
Knowledge of Women regarding Yes 303 57%
Induced Abortion
No 228 43%

Knowledge of Women Regarding Yes 380 72%

Pregnancy, ANC, Child-Birth and
No 151 28%
PNC

Family Planning Practice by women: Yes 418 79%

Ever Used No 113 21%
Family Planning Practice by women: Yes 92 57%
Current Use No 70 43%
Place of Delivery Hospital 88 96%
Home 4 4%
Interaction with health care providers Interacted 276 52%
Not Interacted 255 48%
Actions taken by the women who Sought Medical 157 58%
reported symptoms of Gynaecological Treatment
ailments Did not seek 116 42%
Medical
Treatment
Source: Field Survey Data

3.11 FORMULATION OF HYPOTHESIS

Based on the above conceptual framework, the following hypotheses have been
constructed.

H1: Higher the age at marriage of women, higher the knowledge of various aspects of
reproductive health.

H1: Higher age at marriage leads to better practice of reproductive health care –
family planning services, ANC, delivery, PNC, care seeking in gynaecological
illnesses.

122
H1: Knowledge of reproductive health is higher among literate women than their
illiterate counterparts.

H1: Literate women‘s practice, utilization of reproductive health services is more than
illiterate women.

H1: Knowledge of reproductive health aspects is higher in women who enjoy high
autonomy.

H1: Use of family planning methods, ante natal, delivery and post natal care and
seeking care during gynaecological illnesses is more among women enjoying high
autonomy.

H1: Working women have higher knowledge of different aspects of reproductive

health than their non – working counterparts.

H1: Working women‘s practice and use of various reproductive health services is
higher than non-working women.

H1: Women with high mass media exposure have higher knowledge of reproductive
health aspects.

H1: Women with high mass media exposure have higher practice and utilization of
reproductive health services.

H1: Women with lower conformity to traditional gender attitudes have higher
knowledge of reproductive health.

H1: Choice and use of family planning methods, reproductive health care seeking
increase with lower conformity to traditional gender attitudes.

H1: Women with higher SLI have higher knowledge of reproductive health.

H1: Practice, utilization of reproductive health services and care seeking behavior is
higher among women with higher SLI.

H1: Women whose household income is high have higher knowledge of reproductive
health than those with lower household income.

H1: Practice, utilization of reproductive health services and care seeking behavior is
higher among women with higher household incomes.

123
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Anderson, P. J. (2004). “The social context for harvesting Iriartea deltoidea

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 CHAPTER 4

4. AN OVERVIEW OF THE STUDY AREA

This chapter will provide an introduction of the study area with background
characteristics of the study population. The chapter is divided into 3 sections where
Section 1 will deal with the historical background of the Hooghly district along with
demographic and other features, Section 2 will deal with the background of the
Uttarpara and the Uttarpara Kotrung Municipality and its demographic features, social
aspects, economic aspects and health aspects and Section 3 will give an account of the
slums in the municipality and Section 4 will give an overview of the slums surveyed.

4.1 PROFILE OF HOOGHLY DISTRICT

4.1.1 Historical Background & Administrative Set Up

The study is set in Uttarpara, a town in the Hooghly (also spelt as Hugli) district of
West Bengal. Though there is no documentation regarding the naming of the district
but many beliefs are associated with the name. One of such beliefs is the name
originates from the word „Hogla‟ which denotes a tall reed which was found in
abundance in the banks of the river and low marshy lands of the area. Another source
tells that the name owes its origin from the Portugese. During the 16 th Century,
Hooghly which was then called by the Portugese as ‗Port Pequeno‘ became the largest
centre of European trade in Eastern India. The Portugese settled in Hooghly as early
as 1595 with the permission of the Moghul Emperor Akbar. The Portugese ships used
to sell salt and then evacuate the remaining portion in small huts in the area. The
storehouse of any commodity in Bengali is called ‗gola‘. The Portugese called it ‗O-
Golim‘ following their typical nasal accent. This O-golim later changed to Hugli or
Hooghly by the Bengalis.

Hugli was the centre of trade and foreign invaders like the Portugese, the Dutch, the
Danes, the English came to the district for business and built ‗kuthis‘ for themselves.
Chandernagore was under the French from 1696 to 1950. Chinsurah and Serampore
were under the Dutch and the Danes respectively for a long period. After the British

126
won the Battle of Plassey, Mirkashim gave the zamindari of Burdwan, Chitagong and
Midnapore to the British in 1760. These areas were under the British administration.
In 1795, the district of Burdwan was divided into two for administrative purposes.
The northern part was called Burdwan while the southern part was called Hugli. The
Bengal Presidency was at that time divided into 14 districts of which Hugli was one.
The district became a separate Collectorate in the year 1822. The district after being
exposed to a number of foreign invaders became a rich mix of varied cultures which
has an influence on the people living in various parts of the district. Through a
number of administrative changes, the district finally got its present shape in the year
1795.

Situated on the eastern bank of the Hugli River, the district falls under the Burdwan
subdivision of the state of West Bengal. The area of the district is 3149 square
kilometers. The district has four subdivisions- 1. Sadar 2. Arambag, 3.
Chandannagar, 4. Serampore. There are 18 Community Development Blocks, 12
municipalities and 1 Municipal Corporation in the district. The town of Uttarpara falls
within the ambit of Serampore Sub-division of the district. There are 23 Police
stations in the district. As per the Census of 2011, there are 77 urban units in Hugli
and a total of 1866 villages in the 18 Community Development blocks of the district.

Section 7 of the West Bengal Municipal Act, 1993 provides for categorization of
municipalities.

1. Category A – population above 2,15,000

2. Category B – population above 1,70,000 & upto 2,15,000
3. Category C- population above 85,000 & upto 1,70,000
4. Category D – population above 35,000 & upto 85,000
5. Category E – population not exceeding 35,000.

The district of Hooghly , according to the above classification has 1 Municipal

Corporation, 2 category B municipalities, 6 category C municipalities, 3 category D
municipalities and 1 category E municipality.

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4.1.2 Demographic Features of the District

The area of the district is 3149 square kilometers and the density of the
population is 1753 persons per square kilometers. The district has a population of 55,
19,145 out of which 51% are males and 49% are females. About 61% of the
population resides in rural part of the district whereas the urban part of the district is a
home to the remaining 39% of the population. The percentage of urban share of
Population of Hugli District has expanded from 33.5% (Census, 2001) to 38.6%
(Census, 2011) of Total Population of respective Census.
The populations in the district have increased by 9.5% during the period from 2001 to
2011. The sex ratio in the district stands at 961 (number of females per 1000 males),
which is higher than the sex ratio in West Bengal (950) according to the Census of
2011. The sex ratio has gone up by 14 females per 1000 males in the years 2001 to
2011. The Hindus are the major religious community in the district with massive 83%
whereas the Muslims are the second largest religious community standing at 16%.
Some of the worth mentioning facts of the district regarding its population are –

 Hugli District ranks 6th in terms of Total Population in the state and it ranks
8th in terms of 0-6 year‘s Population in the state.

 Hugli District occupies 7th position in terms of Scheduled Caste Population in

the state.

 Hugli District occupies 11th position in terms of Scheduled Tribe Population

in the state.

 Hugli District ranks 17th in decadal Population growth rate among the
Districts with 9.5%.

4.1.3 Socio-Economic Features of the District

The literacy rate in the district as per the Census 2011 is 81.80%. 87% of the
males and 76% of the females in the district are literate. The literacy percentage has
increased by 7%. The male literacy has been up by 4% and the female literacy is up
by 9 % from the last Census of 2001. The district has 39% of its population as

128
working population either engaged in main or marginal work. About 61% males and
16% females comprise of the working population. About 31% of the working
populations are main workers while approximately 8 % of the workers are marginal
workers. The non workers comprise of 60.99% of the population of which 39.12% are
male and 83.76% are females. (Census, 2011)

4.1.4 Health Profile of the District

A. Health Care Infrastructure Available in the District as on 2008 (As per DHDR
Hooghly)

 Total No. of Health Institutions (Hospitals, Health Centers, Clinics,

Dispensaries) - 813
 Total No. of Beds - 5515
 Total No. of Beds per 10,000 Population - 7.47
 No of Doctors - 406
 Doctors per 10,000 Population- 0.8

B. Important Health Indicators in the District as on 2008 (As per DHDR

Hooghly)

 Infant Mortality Rate ( Death of Children per 1000, below 1 - year age)-
17.79

 Maternal Mortality Rate at the time of Birth (MMR) per 1-lakh Mothers-
196 (0.196%)

 Crude Birth Rate (CBR) – 18.16 live births per 1000 population
 CBR (Rural Hooghly) – 19.14 live births per 1000 population
 CBR (Urban Hooghly) – 16.99 live births per 1000 population

 Life Expectancy at Birth(L.E) – 69.88 years

 Life Expectancy (Males) – 68.68 years
 Life Expectancy (Females) – 71.19 Years

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  Routine Immunization of children till 5 years of age (2008-2009) – 73.6%

 Rate of Institutional Delivery – 80.8%

 Rate of Institutional Delivery (Rural Hooghly) – 68.9%
 Rate of Institutional Delivery (Urban Hooghly) – 90.25%

 Antenatal (ANC) and Post natal (PNC) Checkups of Mothers during

2006-2008

Table: [Link] Antenatal (ANC) and Post natal (PNC) Checkups of Mothers
during 2006-2008

Types of Health Care ANC – 3 Check Ups (%) PNC – 3 Check Ups (%)
Units (HCUs)
HCUs in Rural Areas 64.14% 58.02%
District hospitals/Sub- 24.98% 33.19%
District Hospitals/State
general Hospitals
HCUs in Urban Areas 9.76% 8.35%
Others 1.13% 0.44%
District 100% 100%
Source: Statistical Section CMOH Office (PH-Wing) Hooghly

According to DHDR Hooghly (2008)-

 Percentage of total HIV Positive cases out of total cases tested (2007-2008) –
3.3%
 Prevalence rate of HIV positive cases among pregnant women – 0.13% of
total cases

The health indicators of the District of Hooghly reflect that with respect to a number
of health indicators, the performance of the district has remained above the state
average. The IMR of the district stands at 17.79 per 1000 live births which are much
better than the state average. Among the infant mortality cases, 62% of the cases have

130
occurred in economically poor households. In the area of immunization also the rate
of immunization in the district is 73.6%, much above the state average of 54.4% but
still lagging behind the expected rate of 100%. Block wise data is available for the
district but Municipality wise segregated data is not available in the district. The
overall performance of urban Hooghly is found to be poorer than the district average.
One of the reasons being people of urban Hooghly have greater access to private
health centre‘s specially for immunizing their children, which is not adequately
represented in the public health documentation. Two most important indicators of
safe motherhood are extent of institutional delivery and the pre and post natal care of
the mother. The district has done well in the rate of institutional delivery in order to
secure safe motherhood. The extent of institutional delivery in the district is 80.8%
which again is higher than the state average of 54.1% but lower than the desired 100%
level. The rate of ANC and PNC is satisfactory in the district. Though the rate of
ANC is greater than that of PNCs for the obvious reason that once a child is born the
mother is not much bothered about her health any more, again here, performance of
urban Hooghly is found to be low in terms of ANC and PNC visits of the mother
because of greater access of the mothers in urban areas to private health care
providers.

4.1.5 Important Infrastructural facilities in District households

The tables below will show distribution of some basic infrastructural facilities in both
rural and urban households of the district.

Table: [Link] Total Number of households in rural and urban Hooghly

Number of Hooghly Rural Urban

Households
Total 1269438 777386 492052
Source: Census of India, 2011, HH- series Tables on Houses, Household amenities
and assets. Table computed by the Researcher after gathering the data from the above
source.

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Table: [Link] Percentage distribution of various types of households in rural and
urban Hooghly

Nature of Hooghly (%) Rural (%) Urban (%)

Households
Permanent 64.55 49.51 88.3
Semi Permanent 30.18 42.78 10.27
Temporary 4.77 7.21 0.92
Source: Census of India, 2011, HH- series Tables on Houses, Household amenities
and assets. Table computed by the Researcher after gathering the data from the above
source.

The total number of households in the district is 1269438, among which 777386
households belong to rural Hooghly whereas 492052 households belong to urban
Hooghly. The Census 2011 estimates the number of houseless population at 1086.
The households are divided into various categories in the Census – permanent, semi-
permanent and temporary households. The permanent households are made of pucca
materials like burnt brick, concrete and cement whereas the temporary households
have their walls and roofs made of kutcha materials like bamboo, reed, sticks, grass,
straw and the like. The district has a prominence of permanent households both in the
rural and urban areas. Temporary households comprise of 7.21% in the rural and
0.92% of the urban households.

Table: [Link] Percentage distribution of households in rural and urban Hooghly

by their major source of drinking water

Source of drinking Hooghly (%) Rural (%) Urban (%)

water
Tap water (treated) 29.13 10.23 58.97
Tap water 5.73 5.52 6.08
(untreated)
Covered well 0.44 0.46 0.4
Uncovered well 0.23 0.16 0.35

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Source of drinking Hooghly (%) Rural (%) Urban (%)
water
Handpump 43.68 60.72 16.74
Tubewell 19.63 21.91 16.03
Spring 0.06 0.03 0.11
Rivers/canals 0.23 0.23 0.23
Tank/pond/lake 0.19 0.2 0.18
others 0.67 0.53 0.9
Source: Census of India, 2011, HH- series Tables on Houses, Household amenities
and assets. Table computed by the Researcher after gathering the data from the above
source.

Census data, 2011 reveals that 58.97% of the households in urban Hooghly have
access to treated tap water for drinking purposes. The rural areas on the other hand
depend more on hand pumps and tube wells as major source of drinking water which
comprise of 60.72% and 21.91 % of the households respectively.

Table: [Link] Percentage distribution of rural and urban households in Hooghly

by their drainage connectivity for waste water outlet

Type of drainage Hooghly (%) Rural (%) Urban (%)

facility
Closed drainage 9.2 4.92 15.95
Open drainage 33.15 16.22 59.88
No drainage 57.66 78.85 24.16
Source: Census of India, 2011, HH- series Tables on Houses, Household amenities
and assets. Table computed by the Researcher after gathering the data from the above
source.

The drainage connectivity data is dismal showing that 78.85% of the rural households
and 24.16% of the urban households have no drainage facility at all for waste water
outlet. This is particularly of concern since absence of drainage and accumulation of
waste water can lead to a number of vector borne and water borne diseases in the
population.

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Table: [Link] Percentage distribution of rural and urban households in Hooghly
by their available latrine facility

Type of latrine facility Hooghly (%) Rural (%) Urban (%)

Some form of latrine (flush / pour, 71.21 60.09 88.77
pit, night facility serviced by human,
animals etc)
Public latrine 3.33 2.24 5.06
(No latrine)
Open (No latrine) 25.46 37.67 6.17
Source: Census of India, 2011, HH- series Tables on Houses, Household amenities
and assets. Table computed by the Researcher after gathering the data from the above
source.

The data on availability of latrine in the household shows that nearly 40% of the rural
households in the district has no latrine facility. The numbers of public latrines
available in rural areas are too scanty (2.24%). Nearly 38% of the rural populations
are forced to defecate in the open area which increases the vulnerability of the
population to vector borne diseases. The situation is dismal for the female population
also since they become victims of much gynaecological morbidity because of the
unavailability of household latrines. The figure for urban Hooghly is better where
percentages of public latrines are greater (5.06%) than their rural counterparts. Also,
the numbers of households who use open latrines are lesser (6.17%) in urban areas.

Table: [Link] Percentage distribution of rural and urban households in Hooghly

by their main source of lighting

Main source of lighting Hooghly (%) Rural (%) Urban (%)

Electricity 76.04 66.85 90.56
Kerosene 21.91 31.18 7.25
Solar 1.03 0.95 1.17
Other oils 0.2 0.21 0.18
others 0.15 0.15 0.14
No lighting 0.68 0.65 0.71
Source: Census of India, 2011, HH- series Tables on Houses, Household amenities
and assets. Table computed by the Researcher after gathering the data from the above
source.

134
The figures for main source of lighting in the district show that the district has almost
universal lighting in the households. The main source of lighting in both the rural and
urban areas is electricity. Other sources like kerosene and other oils, solar are also
used as main lighting sources in many households. Less than 1 % of the households in
rural and urban Hooghly have no lighting at all.

4.2 PROFILE OF UTTARPARA KOTRUNG

Uttarpara-Kotrung, is the southernmost Class-I town in the Serampore subdivision of

Hooghly district. It lies within: 22039‟20‖ N to 22041‟35‖ N latitudes and 88019‟15‖
E to 88021‟54‖ E longitudes. It is located at a distance of 10 km from the capital of
the state of West Bengal.

4.2.1 Historical background of Uttarpara, Uttarpara Kotrung Municipality

4.2.1.A. Historical background of Uttarpara

“Gangar paschimkul Baranasi samatul

Tar modhye uttam Uttarpara gram”

Nothing other than this narration could give a better introduction to the rich heritage
town of Uttarpara. Poets have considered the western banks of the Ganges as being
equivalent to the holy city of Varanasi and Uttarpara is the best place to live in on the
western banks. In the year 1704, a zamindar of the Sabarnya Chowdhury clan, Shri
Ratneswar Roychowdhury left his ancestral village near Barrackpore to settle in a new
residence on the banks of river Hooghly – Ootarpara or Uttarpara. Gradually, his
family enlarged through marriage and procreation. He also brought other Brahmin
families to settle in this place.

135
Figure: [Link] Location of UKM under KMA

Source: KMDA, BSUP, Sep 2012, Adapted by the Researcher

136
According to [Link], Uttarpara has a rich cultural heritage, having
buildings which speak of architectural splendor of the yesteryears, initiating path
breaking liberal movements in the 19th Century Bengal, pioneering many social
transformations. Sri Aurobindo gave his last political speech here before leaving for
Pondicherry in 1909. The speech is popularly called the ‗Uttarpara speech‘. Sri Joy
Krishna Mukherjee (related to Ratneswar Roy Chowdhury) a philanthropic zamindar
of Bengal, contributed to the establishment of a library, a public hospital and a school.
The library, known as Joy Krishna library has been graced by the august presence of
many prominent personalities of Bengal. Popular Bengali poet Michael Madhusudan
Dutt spent his last days in this library. The history of Uttarpara is incomplete without
its library. It is the first free library in the history of Bengal. Joy Krishna Mukherjee
and his brother Raj Krishna Mukherjee realized the value of education and thus gave
donations and one of their palatial buildings towards the establishment of a school.
The school opened in 1846 and in 1852, famous academician Shri Ramtanu Lahiri
took over as Headmaster and laid the foundation of one of the greatest schools of
West Bengal – Uttarpara Government High School. In the year 1851, Joy Krishna
and Raj Krishna Mukherjee started a hospital in one of their palatial buildings to serve
the population. The hospital, is popularly called the Rajbari Hospital, is a State
General Hospital in the area.

4.2.1.B. Historical background of the Uttarpara Municipality

In the year 1851, post a cholera epidemic, progressive minded Joy Krishna
Mukherjee understood the role of a civic body in place to ensure modern sanitation
and hygienic drinking water. He appealed to the Government to set up a civic body in
Uttarpara. His first appeal was rejected but his second appeal was accepted and this
led to the birth of the Uttarpara Municipality – the second town in then Bengal, to
adopt the Municipal Act of 1850, sec XX16. The first meeting of the nominated
Municipal Board as held on 14th of April, 1853. The board had nominated members
till independence of the country. The nomination system was abolished in the year
1948. Kotrang was merged with Uttarpara Municipality in the year 1964 and the name
of the municipality changed to Uttarpara Kotrang Municipality ([Link]).
Previously the town was confined between the river Ganges in East, and the railway

137
track on the West, but now it has crossed the railway boundary and has included
Makhla within its Municipal Boundary since the 9th of August, 1991.

Figure: [Link] UKM under West Bengal Municipal Bodies

Source: A Hand Book of Municipal Administration, Government of West Bengal,

Institute of Local Government and Urban Studies, Municipal Affairs Department,
March 1993

138
Plate: [Link] Photograph of Uttarpara Kotrung Municipality (UKM)

4.2.2 Administrative Boundaries of the Uttarpara Kotrang Municipality

The municipal area is bounded by the following-

 On the north--Boundary of Konnagar Municipality and kanaipur Gram
panchayat.
 On the east--River Hooghly
 On the south--Boundary of Bally Municipality Bally Jagachha Panchayat
Samity
 On the west—Boundary of Raghunathpur Gram Panchayat.

Area of Uttarpara Kotrung Municipality According to Census

 The current Uttarpara – Kotrang Municipality (according to Census, 2001)

includes 24 numbers of wards.
 The present Uttarpara Kotrung Municipality can be divided into 3parts:-

139
  Makhla (which includes Makhla –N.M.-2.71 sq km & Bhadrakali of 2.62sq
km) included from 1991 census. Total area - 5.33 sqkm
 Area of Uttarpara Kotrung Municipality is (Census, 1991) 12.56 sqkm.
 Kotrung (N.M.) included from 2001 census. 3.760 sq km.
 Area of Uttarpara-Kotrung Municipality in 2001 16.56 sq km. (Uttarpara
Kotrung Municipality DDP Main Book)

4.2.3 Connectivity of Uttarpara by Rail, Road and Air

Railways

Uttarpara is accessible by Eastern Railways from Howrah 10km .Eastern

Railways main line is passing through the city in North-South direction separating the
city in two halves Makhala in the western side and Uttarpara Kotrung and Bhadrakali
in the eastern part. The railway track originating from Howrah is leading towards
Asansol via Burdwan city.

Roadways

The historically famous G.T. road also, known as NH-2 cuts through the town
Uttarpara in a clear North-South direction. By road Uttarpara is 11 km from Kolkata.
Air
Uttarpara is 30 km away from Netaji Subhas Chandra International Airport
and the way to airport is well connected by roads and flyover networks. The travel
time is about 50 minutes to the Airport.

4.2.4 Climatic Conditions

Hooghly has a tropical ―Savanna‖ climate. The annual mean temperature of

Uttarpara Kotrung is 26.8°C, although monthly mean temperatures range from 16°C
to 33°C and maximum temperatures in Hooghly often exceed 38°C. The main
seasonal influence upon the climate is the monsoon. Maximum rainfall occurs during
the monsoon in August and the average annual total is above 1,500mm. Moderate
north westerly to north-easterly winds prevails for most of the year with a high

140
frequency of calms. Summer is dominated by strong south-westerly monsoon winds.
Winters are comfortable with temperatures lying between 11 to 17°C.

4.2.5 Status of Existing Water Supply

The present source of water supply is both from deep tube well and new water
treatment plant at Searampore. The generated water is from 12 deep tube wells and
treatment plant at Searampore in the tune of 14.25 mld. Besides, there are 360 hand
tube wells being operated regularly. At present, water is being supplied at about 100
lpcd and it is expected as 100 lpcd in the year 2016 also.

4.2.6 Status of existing Sewerage facilities

The Town is unsewered. The domestic waste is being discharged through six
no. open surface drains / sewers for ultimate discharged at the River Ganga. The out
fall points are:

1. Baidik para ghat

2. Blttala Ghat
3. Dharmatala Ghat (Near Shaw Wallace)
4. Ram Site Ghat
5. Ram Ghat / Mete Ghat
6. Opposite of Uttar para Kotrung Municipality

Another three no. outfall drains are being discharged to Bally Khal which is situated
at the southern of the Municipality. The out falls are:

1. Shib Narayan Road,

2. Shalimar wire Rope and
3. Verma Nikashi

The industrial waste water is being treated by the respective industries through their
own treatment units. The Waste water characteristic of this town has been monitored

141
by All India Institute of Hygiene & Public Health (Uttarpara Kotrung Municipality
DDP Main Book).

4.2.7 Demographic Profile of Uttarpara Kotrang Municipality

The town has a population of 159147 according to Census 2011 including both
institutional and houseless population. Among them, the male population is 81410
while the female population is 77737. The town is divided into 24 wards (District
Census Handbook, Hugli). The population density of Uttarpara Kotrung is 9202
persons per square kilometers. They form 2.98% of the population of the district.

Table: [Link] Demographic Growth Data of Uttarpara-Ward wise (1991 – 2011)

Ward No. 1991 2001 2011
1 3325 5812 5499
2 4491 6815 7533
3 3529 6167 6936
4 3244 5612 7247
5 4528 4844 4999
6 3031 6075 6112
7 3556 12241 14956
8 3731 4031 4356
9 4010 5762 6106
10 5283 7434 8095
11 4268 5358 5359
12 5780 4267 4602
13 6924 4739 5672
14 10919 4914 4862
15 3304 5503 5686
16 7265 4603 4521
17 3011 5926 6072
18 4750 4396 4086
19 5970 6740 6774

142
 Ward No. 1991 2001 2011
20 9948 8499 8695
21 12522 10574 11313
22 12398 6474 9060
23 5858 8379 8785
24 _ 5078 1821
TOTAL 131645 150243 159147
Source: Table computed by the Researcher after gathering the data from
1. [Link] - for 1991 and 2001
data
2. [Link] for 2011 data

Caste wise male female population of Uttarpara Kotrung (Census – 2011)

Uttarpara has a total population of 159,147 of which 81,410 are males and 77,737 are
females. 147,383 people belong to the general caste whereas the numbers for SCs and
STs stand at 10,537 and 1227 respectively.

Figure: [Link] Caste wise male female population of Uttarpara Kotrung (Census
– 2011)

Source: [Link]

143
Religion wise Distribution of Population of Uttarpara Kotrung (Census -2011)

The Hindus constitute about 97% of the total population while the Muslims constitute
about 2% of the population.

Figure: [Link] Religion wise Distribution of Population of Uttarpara Kotrung

(Census -2011)

Source: [Link]

Growth of Population in Uttarpara Kotrung (Census 2011)

The overall growth rate of the population was found to be 5.8% since the last Census
of 2001. However, the rate of growth was not uniform across all castes.
The rate was highest in case of the general population standing at 6.9%, whereas the
growth rate in case of the SCs, STs, and the child population was seen to decrease
substantially from the last Census of 2001.

144
Figure: [Link] Growth of Population in Uttarpara Kotrung (Census 2011)

Source: [Link]

Sex Ratio (Females per 1000 Males) Uttarpara Kotrung (Census 2011)

The overall sex ratio of the town stands at 955 females per 1000 males as per
the Census 2011. The sex ratio again is not uniform across all the castes in the region.
Among the general castes, it is 957, among the SCs; it is 923 whereas among the STs,
it is 1003. The sex ratio in the town has increased by 47 females per 1000 males since
the last Census.

Literacy Rate of Uttarpara Kotrung (Census 2011)

The literacy rate of Uttarpara Kotrung according to 2011 census is 91%, which
is a 5 % increase from the last Census. 93% of the males and 88% of the females are
literate. Male and female literacy has gone up by 3 % and 5 % respectively from the
2001 Census.

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Figure: [Link] Literacy Rate of Uttarpara Kotrung (Census 2011)

Source: [Link]

Ward wise comparison of specific Demographic Features of Uttarpara Kotrung

(Census 2011)

Table: [Link] Ward wise comparison of specific Demographic Features of

Uttarpara Kotrung (Census 2011)

Wards Sex Ratio (No. of Child Sex Ratio (No. of Literacy

females per 1000 males) females per 1000 males rate (%)
under 6 years of age)
1 927 918 88%
2 932 843 83%
3 962 938 91%
4 995 928 95%
5 928 847 81%
6 958 924 92%
7 948 980 94%
8 896 741 94%

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 Wards Sex Ratio (No. of Child Sex Ratio (No. of Literacy
females per 1000 males) females per 1000 males rate (%)
under 6 years of age)
9 1002 772 92%
10 987 935 93%
11 1022 848 97%
12 1022 1071 95%
13 984 892 97%
14 1019 1008 95%
15 1018 731 97%
16 1036 1000 94%
17 958 859 92%
18 950 936 94%
19 969 822 92%
20 824 848 75%
21 924 873 83%
22 945 1118 92%
23 941 872 91%
24 872 788 87%
Source: Table computed by the Researcher by using data from Census, 2011

The table shown above reflects the ward wise demographics of Uttarpara Kotrung
from 2011 Census data. The sex ratio is found to be the highest in ward no. 16, which
has 1036 females per 1000 males. The sex ratio is lowest in ward no. 20 where there
are 824 females per 1000 males. The child sex ratio was computed to find out the
number of females per 1000 males in case of children less than 6 years of age. Ward
no. 15 has the lowest child sex ratio of 731 females per 1000 males while ward no. 22
has the highest number of females per 1000 males standing at 1118. The literacy rate
was found to be the highest at 97% in 3 wards of Uttarpara Kotrung Municipality-
wards 11, 13 and 15. The literacy rate was lowest at 75% in ward no. 20.

147
4.2.8 Work Profile of Uttarpara Kotrung Municipality (Census 2011)

About 37 % of the populations are engaged either in main or in marginal

work. The working population comprises of 58% of the male and 15% of the female
population.

Figure: [Link] Work Profile of Uttarpara Kotrung Municipality

Source: [Link]

Table: [Link] Ward wise comparison of Work Participation Profile of Uttarpara

Kotrung (Census, 2011)
Ward Total Number of Types of Worker
No. Worker (%) Main Worker (%) Marginal Worker Non Worker (%)
(%)
Male Female Total Male Female Total Male Female Total Male Female Total
1 60.7 15 38.8 57.8 12.8 36.2 2.9 2.3 2.6 39.3 85.0 61.2
2 61.0 15.9 39.2 58.6 13.3 36.8 2.4 2.6 2.5 39.0 84.1 60.8
3 58.4 15.5 37.4 57.5 14.1 36.2 1.0 1.4 1.2 41.6 84.5 62.6
4 56.8 10.5 33.7 55.9 9.7 32.8 0.9 0.8 0.9 43.2 89.5 66.3
5 60.8 23.0 42.6 57.8 19.7 39.5 3.0 3.3 3.1 39.2 77.0 57.4

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Ward Total Number of Types of Worker
No. Worker (%) Main Worker (%) Marginal Worker Non Worker (%)
(%)
Male Female Total Male Female Total Male Female Total Male Female Total
6 60.2 16.6 38.8 57.8 13.4 36.1 2.3 3.1 2.7 39.8 83.4 61.2
7 57.5 11.5 35.1 55.7 8.7 32.8 1.8 2.8 2.3 42.5 88.5 64.9
8 54.4 17.6 37.0 47.2 12.3 30.7 7.2 5.2 6.3 45.6 82.4 63.0
9 56.5 18.0 37.2 54.9 16.3 35.6 1.6 1.7 1.7 43.5 82.0 62.8
10 55.4 16.2 35.9 52.9 14.6 33.9 2.4 1.6 2.0 44.6 83.8 64.1
11 56.2 15.5 35.6 54.9 14.1 34.3 1.3 1.4 1.4 43.8 84.5 64.4
12 58.2 16.1 36.9 56.8 11.9 34.1 1.4 4.3 2.9 41.8 83.9 63.1
13 55.6 13.9 35.0 53.9 12.7 33.5 1.7 1.2 1.5 34.4 86.1 65.0
14 55.8 14.2 34.8 53.8 12.4 32.9 2.0 1.8 1.9 44.2 85.8 65.2
15 53.7 13.5 33.4 53.2 12.7 32.8 0.5 0.8 0.7 46.3 86.5 66.6
16 56.3 15.9 35.7 54.6 13.6 33.7 1.8 2.3 2.0 43.7 84.1 64.3
17 55.6 14.0 35.3 51.4 12.2 32.2 4.3 1.9 3.1 44.4 86.0 64.7
18 58.5 15.8 37.7 57.4 15.2 36.8 1.1 0.7 0.9 41.5 84.2 62.3
19 54.1 17.0 35.9 51.8 14.9 33.6 2.4 2.1 2.3 45.9 83.0 64.1
20 64.8 21.1 45.1 49.7 13.5 33.4 15.1 7.6 11.7 35.2 78.9 54.9
21 61.9 16.8 40.2 57.5 14.4 36.8 4.3 2.3 3.4 38.1 83.2 59.8
22 56.6 11.5 34.7 54.6 9.3 32.6 1.9 2.1 2.0 43.4 88.5 65.3
23 58.0 17.4 38.3 55.4 13.6 35.1 2.6 3.9 3.2 42.0 82.6 61.7
24 54.7 13.0 35.3 52.7 11.8 33.7 2.0 1.2 1.6 45.3 87.0 64.7
Source: Table computed by the Researcher by using data from 1. (Census, 2011) & 2.
[Link]

4.2.9 Public Health under Uttarpara Kotrung Municipality

The Municipality provide services for Health Care include preventive measures for
checking the spread of dangerous disease (vector control), providing immunisation
including public vaccination and inoculation, registering an event of birth and death,
ambulance services etc. There are other Central and State Government Health
Schemes that are implemented like Calcutta Urban Development Programme
(CUDP), Indian Population Project (IPP-VIII), National Anti Malaria Programme,

149
National Leprosy Elimination Programme, National AIDS Control Programme and
Diarrhoeal and Enteric Disease Control etc. The focus of these Central and State
Government programmes have been mostly directed to catering to the preventive
health care needs of the BPL families with particular emphasis on reproductive and
child health care. A recent addition to the list of health programmes undertaken was
vaccination for Japanese Encephalitis.

Uttarpara Kotrung Municipality have 180 field workers (Honorary Health Workers or
HHW) who provide door-to door primary health services to the urban poor. Field
workers (HHWs), along with First Tier Supervisors and Second Tier Supervisors form
a concrete network for catering the jobs at three levels viz. Block level, Sub- Centre
level and Health Administrative Unit level. This set up was created for the
implementation of Calcutta Urban Development Programme (CUDP) and Indian
Population Project (IPP) VIII. The HHW programme has enabled the poor community
to demand services such as institutional delivery, immunization, contraceptive
services, emergency mother and child health care facilities (Uttarpara Kotrung
Municipality, DDP Main Book). The DDP Technical Group identified several areas
of concern in the field of public health and laid down the following objectives with
respect to 3 themes-

Theme 1: Public Health Services

(a) Strengthening and developing Health Management Information System. Heath
information sites should be credible sources of health information.
(b) Exploring opportunities for strengthening decentralization by extending Sub-
center and provision of adequate Health Centre in all wards as per population.
(c) Better co-ordination with State Government Hospitals and dispensaries for
maintaining a better referral system.
(d) Improve the asset and human resource utilization pattern of health services such as
ambulance services, dispensaries etc.
(e) Expanding existing health care facility for providing services to greater section of
low income slum dwellers in the municipal area.
(f) Strengthening the competence of Health Workers for better communication and
services to the citizen of UKM.

150
Theme 2: Reproductive and Child Care Services

(a) To establish quality antenatal care to 100% the slum women.

(b) To establish 100% institutional delivery for all women living in slums.
(c) 100% immunizations of infants against six killer diseases within 12 months of
birth.
(d) Improving the package of health services beyond population stabilization.
(e) Making sterilization services available by way of improving effort related to
family planning.
(f) To provide services within the RCH domain that have not been adequately
addressed, as well as some health priorities outside the RCH domain like imparting
lessons on sanitation, personal hygienic practices and nutrition etc which are major
contributors to the burden of diseases.
(g) Spreading health awareness through various methods of communication not only
to the beneficiaries of the programmes but also to the excluded groups and areas
within the wards.

Theme 3: All other Government Programmes for Preventive Health Care and
other independent initiatives taken by the Urban Local Body.

(a) Promotion of hygienic measures to lead to reduced diarrhoeal disease with prompt
and appropriate care and reducing household expenditure on recurrent diarrhoea.
(b) Increase the coverage of vector control operations by rationalizing the use of
assets and human resource available.
(c) Effective implementation of Government Programmes to achieve the targeted
goals and objectives.

[Link] Health Profile of the Population under Uttarpara Kotrung Municipality

The DDP Main Book clearly states the absence of any secondary data with respect to
the health profile of the population at the municipal level. The Municipality data only
gives information regarding few aspects of health infrastructure in terms of anailable

151
hospitals, nursing homes, maternity homes, health care units, sub-centres, number of
available beds, number of available doctors etc.

However, the District Human Development Report, Hooghly, 2010, gives figures on
Infant Mortality Rate (IMR), Maternal Mortality Rate (MMR) with respect to certain
years as recorded by the Uttarpara State General Hospital (SGH). The Uttarpara SGH
shows the infant mortality rate for the year 2008-2009 to be 7.05 per 1000 live births.
Maternal Mortality rate is found to be 0 per 1 lakh during the years 2006-2009 under
the Uttarpara SGH (DHDR, Hooghly, 2010).

[Link] Hospitals & Nursing Homes of the Area

There are 2 hospitals in the area (available from [Link]). One

is the Uttarpara State General Hospital, popularly called the Rajbari Hospital, whereas
the second one is called the Mahamaya Sishu o Matrimangal Kendra. The first one is
a government operated hospital and the second one is under the administrative control
of the Uttarpara Kotrung Municipality. The location of the State General hospital and
Mahamaya Sishu o Matrimangal Kendra is in Ward Nos 19 and 9 respectively. There
is a third hospital called the Hindmotor Hospital which is meant exclusively for the
workers of Hindustan Motors. The private nursing homes of the area are-

1. Arogya Niketan Private Limited

2. The Care
3. We Care Nursing Home and Diagnostic Centre
4. Nilima Matri sadan
5. Kamala Roy Hospital Private Limited
6. Park Lions Hospital and Research Institute
7. Makhla Seva Sadan
8. Re Life

152
Plate [Link].1 Photograph of Uttarpara State General Hospital

Plate [Link].2 Photograph of Mahamaya Sishu o Matrimangal Kendra

153
The DDP Main Book of UKM states that the utilization rates and feedbacks of all the
health facilities are very poor. It states that the staffs, in most of these health care units
is temporary in nature and are grossly underpaid. Thus infrastructural deficiencies
coupled with, lack of adequate skilled staff contributes to poor utilization and
feedback of the patients. Another factor which contributes to poor utilization is the
nearness of the area to the state capital, Kolkata. People of the area prefer to get
treated at Kolkata than here. The District Human Development Report, however,
throws some light on the utilization of services in Uttarpara State General Hospital.
The Uttarpara State General Hospital has 204 beds with bed occupancy of 70% as
shown by data during 2006-2008. The clinical attendance of the patients in Uttarpara
SGH has also been assessed for the said period. Clinical attendance and use of
medical facilities is an important indicator of public health service utilization.

It was found that the hospital catered to 3.93% of outdoor patients, 7.35% of
emergency patients and 7.82% of indoor patients out of the total number of patients in
the district. 1.92% and 1.44% of the total patients in the district were referred in and
referred out of the hospital respectively during the period of 2006-2008 (District
Human Development Report, Hooghly, 2010).

4.3 Slums of Uttarpara Kotrung Municipality

As per DDP Main book there are 67 Slums under UKM which are located on private,
municipal and service land as per following breakup
1. Private Land – 14 Nos.
2. Municipal Land & Other Slums – 39 Nos.
3. Service Land (Govt. Land, Railway Land & CMC) – 14 Nos.
No. of families residing in these slums is 2997 with an approximate population of
20,979 heads. As per available data, the no. of families under BPL is 726 with an
approx. population of 5082 heads.

Slums in general are devoid of certain basic services like drainage, piped sewerage,
safe tap water supply and latrines. The Report of the Fourth State Finance
Commission, West Bengal has found out that there exists a huge gap in core service

154
delivery in the cities and its slum areas. Adequate attention needs to be paid to these
basic services in order to achieve a clean and sustainable urban development.

Table: 4.3.1 Service Delivery gap in Core Services in City and Slums in West
Bengal (%)

Service category West Bengal India

DRAINAGE
City 33.2 18.2
Slum 31.3 18.8
PIPED SEWERAGE
City 86.4 67.3
Slum 85.4 75.5
LATRINE
City 34.7 21.4
Slum 33.5 27.2
TREATED TAP WATER
City 50.0 38.0
Slum 44.3 34.7
Source: Census Report 2011

The Table shows that the state of West Bengal is far behind the national average as far
as the gaps in services delivery in cities and slums are concerned. There is a gap in
service up to 31.3% with respect to drainage, 85.4% with respect to piped sewerage,
33.5% with respect to latrines and 44.3% with respect to treated tap water.

Under the Uttarpara Kotrung Municipality, the slums show poor level of physical
infrastructure and basic services. The Slum Infrastructure Improvement Plan in
Uttarpara Kotrung Municipality DDP Main Book revealed the following about the
slums-

1. Inadequate water supply

2. Kaccha roads
3. Kaccha drains

155
 4. Insufficient street lights
5. Overflowing of the roads adjacent to waterbodies.

With the help of Quick Slum Survey (QSS) in all the 67 slums of UKM the priority
service areas were identified by site visits and community feedback. Accordingly,
services were prioritized according to the name of the slums under as Slum
Infrastructure Plan of DDP Main Book.

Table: 4.3.2 UKM Prioritized Slum Areas

PRIORITY PRIORITISED ISSUES NAME OF THE SLUM WARD NO.
NO.
1 Repair of staff quarter, Community Harijan Basti Ward No. 5
Latrine, Drainage
2 Water supply, drainage, Street lights Jelepara Basti Ward No. 22
3 Paved Road, Water supply, Street light Jheelpar Basti Ward No. 21
4 Street lights, water supply, drainage Shalbagan Basti Ward No. 21
5 Roads, drainage, street light, Paramanik Para Ward No. 21
Community latrines
6 Street lights Kulipara Basti Ward no. 5
7 Community latrine, Hand Tube well, Oriyapara Ward No. 7
Water supply, Street light
8 Water Supply, Street light, Drainage Dhalipara Ward No. 21
9 Street light, Roads, Water supply, Bidhan Colony Ward No. 2
Drainage, Retaining wall, Community
latrine
10 Water supply, drainage, street light Charaktala Basti Ward No. 22
11 Retaining wall, road paved, Street Harisabha Basti Ward No. 21
light, Water supply
12 Roads (paved), Water supply, Harisabha Basti Ward No. 21
Drainage
13 Road (paved), Water supply, Street Pekera Basti Ward No. 21
lights
14 Water supply, Drainage, Street light, Manasabagan Basti Ward No. 21
Road(bituminous)
15 Road (paved), Road (bituminous), Makaltala Basti(eastern Ward No. 21

156
 Drainage, Street light part)
16 Drainage, Bathing room in Shimultala Shimultala Basti Ward No. 9
ghat, Community latrine, Street light
17 Water supply, Community latrine, Singhpara Basti Ward No. 20
drainage, hand tube well, street light
18 Water supply, Road(paved), Drainage, Mandalpara Basti Ward No. 21
Street light
19 Water supply, Drainage, Road Tentultala Ward No. 23
(bituminous), Street lights,
Community latrine, Retaining wall
20 Water supply, Drainage, Street light, Kalitala Basti Ward No. 21
Road(bituminous)
21 Drainage, water supply, Street lights Roypara Basti Ward No. 21
22 Drainage, street light, water supply Jelepara Basti Ward No. 22
23 Drainage, street light, water supply Haranathpur Basti Ward No. 23
24 Water supply , Street light Jelepara Basti Ward No. 21
25 Road(paved), road(bituminous), Jayanta Nagar Ward No. 2
Drainage, Street light
26 Water supply, Drainage, Street light Jelepara Basti Watrd o. 6
27 Water supply, Street light, Chakpara Ward No. 17
Road(paved)
28 Water supply, street light, Drainage Haranathpur School Basti Ward No. 23
29 Water supply, Drainage, Street light Jelepara basti Ward No. 2
30 Water supply, Drainage, Street light, 22 Plot Basti Ward No. 6
Community latrine
31 Water supply, Drainage, Street lights B.B. Street Basti Ward No. 6
32 Road(paved),drainage, street Colony Basti Ward No. 10
lights,community latrine, hand tube
well

Source: Adapted by the Researcher from Uttarpara Kotrung Municipality DDP Main
Book, 2011

157
 Plate 4.3.1. Photograph of a slum of Uttarpara

4.4. Selection of the slums for study

30 slums which were considered as priority in terms of infrastructure and basic

services in DDP Main Book of UKM were selected for the study. Selection of
households was on the basis of purposive sampling. A total of 420 households were
surveyed which led to 531 respondents. The name of the slums, number of
households surveyed, and number of respondents from each household are given in
the Chapter 3 (Methodology).

Plate 4.4.1. Photograph of a slum of Uttarpara

158
REFERENCES

A Hand Book of Municipal Administration. (1993). Government of West Bengal,

Institute of Local Government and Urban Studies, Municipal Affairs
Department.

Calcutta Metropolitan Development Authority. (1990). “Calcutta 300: Plan for

Metropolitan Development 1990-2015”, CMDA, Calcutta, pp. 5.1.1-5.1.2.

Census of India. ( 2011). HH- series Tables on Houses, Household amenities and
assets.

District Human Development Report, Hooghly, 2010. Retrieved from

[Link] accessed on
20.03.2013

Government of India. (2010). “West Bengal Development Report”, Planning

Commission, Academic Foundation, Government of India, New Delhi, pp.
121-131.

Government of India. (2011). “Provisional Population Totals, Paper 1 of 2011 (India

and States/UT’s)”, Directorate of Census Operations, New Delhi, retrieved
from [Link]
[Link], accessed on 22.03.2013.

http:// [Link]: about Uttarpara and Hooghly, accessed on 20.09.2012

[Link] for 2011 data: accessed on

22.12.2014

[Link] - for 1991 and 2001 data

accessed on 05.03.2012

[Link]
accessed on 14.03.2012: Jawaharlal Nehru National Urban Renewal Mission.

[Link] accessed on 26.12.2014, Official

Website of Kolkata Metropolitan Development Authority, Government of
West Bengal.

[Link] accessed on 26.12.2014, Official

Website of Uttarpara Kotrung Municipality

[Link] accessed
on 21.03.2013

159
Kolkata Metropolitan Development Authority. (2005). ―Vision 2025- Perspective
Plan of Calcutta Metropolitan Area 2025, Draft Final Report”, KMDA,
Kolkata, pp. 2.6.

National Council of Applied Economic Research. (2004). ―East India Human

Development Report”. Oxford University Press, New Delhi, pp. 266.

National Sample Survey Organisation. (1998). ―Morbidity and Treatment of

Ailments”, Round 52nd (July 1995 - June 1996), Report No. 441 (52/25.0/1),
Department of Statistics, Government of India, New Delhi.

National Sample Survey Organisation. (2006). ―Morbidity, Health Care and the
Condition of the Aged”, Round 60th (Jan-June, 2004), Report No. 507
(60/25.0/1), Ministry of Statistics and Programme Implementation,
Government of India, New Delhi.

Uttarpara-Kotrung Municipality. (2008). ―Draft Development Plan, 2007-2012”,

Uttarpara-Kotrung Municipality, Uttarpara-Kotrung.

160
 CHAPTER 5

5. BACKGROUND CHARACTERISTICS AND SOCIAL DETERMINANTS

In this chapter, a brief account of the background characteristics of the women under
study has been provided. This chapter also discusses a total of eight social
determinants - age at marriage, literacy, work status, monthly household income, SLI
, autonomy, gender role attitude, mass media exposure, which are thought to have a
bearing on the reproductive health of women.

5.1. Background Characteristics of the Respondents

531 ever married females from 30 slums under UKM were interviewed using a
structured questionnaire. This section will provide a glimpse of certain background
characteristics of women – age composition, caste, religion, present marital status,
literacy, work status, age at marriage and co habitation, births given, represented by
their numbers and percentage distribution in the sample. Thus, this section will cover
first five social determinants – age at marriage, literacy, work status, monthly
household income, and standard of living index (SLI).

5.1(A) Age at Marriage

Table.5.1.1 Age Composition: Percentage Distribution of Age Composition of

Respondent Women (Surveyed Households)

Age Group in Years No. of Women Percentage Distribution

(Class Wise)
15 - 21 80 15%
22 – 28 138 26%
29 – 35 155 29%
36 – 42 120 23%
43 - 49 38 07%
Total (N = 531) 531 100%
Source: Field Survey Data

161
Table.5.1.2 Pooled Age Group: Percentage Distribution of Pooled Age Group
Composition of Respondent Women (Surveyed Households)

Age Group in Years No. of Women Percentage Distribution

(Pooled)
< 18 years 39 7.3%
> 18 years 492 92.7%
Total (N = 531) 531 100%
Source: Field Survey Data

Table (5.1.1) shows the percentage distribution of the age composition of the
respondent women. The entire reproductive age group 15-49 years is divided into 5
separate classes of age with equal width of 7 in each class. It is found that 15% of
women belong to the age group 15-21 years, 26% to 22-28 years, 29% to 29-35 years,
23% to 36-42 years and 7% to the age group 43-49 years. Maximum number of
respondents belongs to the age group 29-35 years.

Table (5.1.2) shows a pooled age composition of the respondents on the basis of their
age below and above 18 years of age. It is seen that 7.3% of the respondents are
below 18 years of age while the remaining 92.7% are above 18 years of age.

Table.5.1.3 Religion: Religion Wise Distribution of Respondent Women

(Surveyed Households)

Religion No. of Women Percentage Distribution

Hindu 453 85%
Muslim 46 09%
Others 32 06%
Total (N = 531) 531 100%
Source: Field Survey Data

The table (5.1.3) shows that about 85% of the respondents were Hindu, 9% were
Muslims while 6% belonged to other religions. Thus, there is a dominance of
Hinduism among the surveyed women.

162
Table 5.1.4 Caste: Percentage Distribution of Respondent Women Belonging to
Different Castes (Surveyed Households)

Category No. of Women Percentage Distribution

General (GEN) 191 36%
Schedule castes (SCs) 234 44%
Schedule Tribe (STs) 21 04%
Other Backward Caste 85 16%
(OBCs)
Total (N = 531) 531 100%
Source: Field Survey Data

It follows from the above table (5.1.4) that 36% of the respondents were from the
general caste, while 44%, 4% and 16% belonged to SCs, STs and OBCs respectively.
So, it is clear that there is a dominance of the SCs among the respondents.

5.1(B) Literacy

Table 5.1.5 Literacy: Percentage Distribution of Respondent Women by Literacy

(Surveyed Households)

Literacy No. of Women Percentage Distribution

Literate 419 79%
Illiterate 112 21%
Total (N = 531) 531 100%
Source: Field Survey Data

Table 5.1.6 Levels of Educational Exposure Among Literates: Percentage

Distribution of Levels of Educational Exposure of Literate Women (Surveyed
Households)

Levels of Educational Number of Literate Percentage Distribution

Exposure Women
Primary 348 83%
Middle 46 11%
High School 17 04%
Others 8 02%
Total (N = 419) 419 100%
Source: Field Survey Data

The table (5.1.5) shows the percentage distribution of the respondents by their literacy
status. 79% of the respondents are found to be literates while 21% are found to be
illiterates. Table (5.1.6) shows the various levels of educational exposure of the

163
literate population. It is found that 83% have completed their primary school, 11%
have completed their middle school and 4% have completed High school. 2% of the
respondents have gone beyond the High school to their colleges.

5.1(C) Work Status

Table 5.1.7 Work Status: Percentage Distribution of Work Status of Respondent

Women (Surveyed Households)

Work Status No. of Women Percentage Distribution

Working 365 69%
Non working 166 31%
Total (N = 531) 531 (100%) 100%
Source: Field Survey Data

Table 5.1.8 Work Status: Percentage Distribution of Work Status of Literate

Women (Surveyed Households)

Work Status No. of Literate Women Percentage Distribution

Working 285 68%
Non working 134 32%
Total (N = 419) 419 100%
Source: Field Survey Data

Table 5.1.9 Work Status: Percentage Distribution of Work Status of Illiterate

Women (Surveyed Households)

Work Status No. of Illiterate Women Percentage Distribution

Working 80 71%
Non working 32 29%
Total (N = 112) 112 100%
Source: Field Survey Data

The above tables (5.1.7 - 5.1.9) show the work status of the respondents. It is found
that 69% of the population is working while 31% of the population is non- working.
68% of the literates and 71% of the illiterates are found to be working whereas, 32%
of the literates and 29% of the illiterates are found to be non-working.

164
Table 5.1.10 Percentage Distribution of Working Women by Present Employer
Employer No. of working women Percentage Distribution
Government 18 05%
Semi-Government 62 17%
Private including 256 70%
households
Self employed 29 08%
Total (N = 365) 365 100%
Source: Field Survey Data

This table (5.1.10) shows that about 70% of the working women are engaged under
private employer which includes households which employ domestic helps, 5% were
engaged in the Government sector, 17% in semi Government sector and 8% women
were self employed.

Table 5.1.11 Percentage Distribution of Working Women of the Slum Surveyed

by Stages of Life When They Started Working
Stage When Started to Work No. of Working Women Percentage Distribution

Before marriage 87 24%

After marriage 164 45%
After childbirth 80 22%
After Husband‘s death 12 03%
Separation / divorce 22 06%

Total (N = 365) 365 100%

Source: Field Survey Data

The above table (5.1.11) shows the stages when the working women began their
work. It is found that a majority of 45% of the women have begun working after their
marriage, 24% began working before their marriage, 22% after their children were
born, 3% on becoming a widow and 6% on their separation or divorce from husbands.

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Table 5.1.12 Percentage Distribution of Working Women of Surveyed Slum by
Their Reasons of Joining Work
Reasons for Joining Work No. of Working Women Percentage
Distribution
Financial Necessity 175 48%
Family Compulsion 77 21%
Self dependence and 62 17%
fulfillment
Raising living standards 29 08%
Pocket money/ Savings 22 06%
Total (N = 365) 365 100%
Source: Field Survey Data

This table (5.1.12) shows that the chief driving force for women to join work is the
financial necessity of the household. 48% of the working women joined work out of
financial necessity, 21% joined workforce owing to a family compulsion, 17% for
becoming self dependent, 8% for raising their standard of living and 6% for earning
themselves pocket money or for savings.

Table 5.1.13 Percentage Distribution of Working Women by Working Hours Per

Day

Working Hours Per Day No. of Working Women Percentage Distribution

5 11 03%
6 22 06%
7 80 22%
10 252 69%
Total (N = 365) 365 100%
Source: Field Survey Data

The table (5.1.13) shows that a majority of 69% of the women work for about 10
hours a day to earn a living, followed by 22% women working for 7 hours a day, 6%
and 3% women working for 6 hours and 5 hours per day respectively.

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Table 5.1.14 Percentage Distribution of Working Women According to Various
Monthly Incomes
Income Per Month (Rs.) No. of Working Women Percentage Distribution

< 1000 14 04%

1000-2000 22 06%
2000-3000 204 56%
3000-4000 99 27%
>4000 26 07%
Total (N = 365) 365 100%
Source: Field Survey Data

Table (5.1.14) shows that a majority of 56% of the working respondents earn Rs.
2000-3000 per month. A meager 4% of women earn below Rs. 1000 while 7% earn
above Rs. 4000 per month.

Table 5.1.15 Percentage Distribution of Working Women by Their Contribution

to Family Income

Contribution to Family No. of Working Women Percentage Distribution

Income
Full 245 67%
Half 113 31%
Negotiable 7 02%
Total (N = 365) 365 100%
Source: Field Survey Data

The above table (5.1.15) shows that 67% of the working respondents contribute their
full income to the family while 31% contributes half their income. Contribution is
negotiable for about 2% of the working women.

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5.1(D) Household Monthly Income (Rs.)

Table 5.1.16 Household Monthly Income of the Surveyed Women

Household Monthly No. of Working Women Percentage Distribution

Income (Rs.)
<3000 91 25%
3001-5500 102 28%
5501-8000 117 32%
8001-10500 33 09%
>10500 22 06%
Total (N = 365) 365 100%
Source: Field Survey Data

Household Monthly No. of Non Working Percentage Distribution

Income (Rs.) Women
<3000 49 30%
3001-5500 55 33%
5501-8000 37 22%
8001-10500 13 08%
>10500 12 07%
Total (N = 166) 166 100%
Source: Field Survey Data

The table (5.1.16) shows the monthly household income of the respondents – both
working and non-working. It shows that a maximum of 32% of the working women
have a household income ranging between Rs. 5501-8000, while in case of non-
working women, a majority of 33% of women have a household income ranging from
Rs.3001-5500.

Table 5.1.17 Family Type: Percentage Distribution of Family Type of Women

(Surveyed Households)

Family Type No. of Women Percentage Distribution

Nuclear 430 81%
Joint 101 19%
Total (N = 531) 531 100%
Source: Field Survey Data

The above table (5.1.17) shows that about 81% of the women belong to nuclear
families as against 19% belonging to joint families.

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Table 5.1.18 Family Type and Work Status of Women in Surveyed Households

Family Type No. of Working Women Percentage Distribution

Nuclear 296 81%
Joint 69 19%
Total (N = 365) 365 100%
Source: Field Survey Data

Family Type No. of Non Working Percentage Distribution

Women
Nuclear 111 67%
Joint 55 33%
Total (N = 166) 166 (100%) 100%
Source: Field Survey Data

The above table (5.1.18) shows the distribution of working and non working women
according to their family types. It is found that 81% of the working women have
nuclear families and 19% have joint families. 67% of the non working women live in
nuclear families compared to 33% living in joint families.

Table 5.1.19 Marriage and Co-habitation Status

Characteristic No. of Women Percentage

Distribution
Current Marital Status (N=531)
Married 473 89%
Widowed 16 03%
Separated / Divorced / Deserted by husband 42 08%
Age at Marriage (N=531)
Less than 18 years 39 7.3%
Equal or more than 18 years 492 92.7%
Age at First Cohabitation
Less than 18 years (N=39) 32 82%
Equal or more than 18 years (N=492) 492 100%
Source: Field Survey Data

The data (Table.5.1.19) regarding marriage and cohabitation of the respondent women
show that 89% of them are currently married, 3% are widowed and the remaining 8%
are either separated or, divorced or, deserted by husbands. The marriage profile of the
respondents further shows that 7.3% of them were married at less than 18 years of age
while the remaining 92.7% women were married when they were more than 18 years

169
of age. About 82% of the women who were married before their legal age of marriage
started cohabiting with their husbands immediately after marriage while 18% of them
waited for gauna to take place before cohabiting with their husbands. On the other
hand, it is seen that all women who married at or after 18 years of age started
cohabiting with their husbands immediately after marriage.

Table 5.1.20 Birth History of the Respondent Women

Women reporting No. of Women Percentage
Distribution
Ever given birth (N=531)
Yes 363 68%
No 168 32%
Age at first birth (N=363)
Less than 18 years 25 07%
Equal or more than 18 years 338 93%
Number of living children (N=363)
1 17 05%
2 198 54%
3 and more 148 41%
Ever experienced stillbirth (N=363)
Yes 6 02%
No 357 98%
Ever experienced miscarriage
(N=363)
Yes 33 09%
No 330 91%
Source: Field Survey Data

Table (5.1.20) represents the birth history of the respondent women. It was found that
68% of them have ever given birth and 32% of them have not given birth till the time
of this study. Among the women who became mothers, 7% experienced motherhood
when they were less than 18 years of age while 93% of the ever mothers have
experienced motherhood at more than 18 years of age. Of the mothers, 5% reported
having 1 child, 54% reported having 2 children while 41% reported having 3 and
more number of children. About 2% of the mothers reported that they had pregnancies
ending in stillbirth and 9% of the mothers reported that they had a miscarriage in one
of their pregnancies.

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5.1(E) Standard of Living Index

Table 5.1.21 Standard of Living of the Respondent Women

Standard of Living No. of Respondent Percentage
(as per scores of SLI) Women Distribution
Low 218 41%
Medium 255 48%
High 58 11%
Total (N = 531) 531 100%
Source: Field Survey Data

The table (5.1.2) shows that only 11% of the women respondents enjoy high standard
of living, while medium and low standard of living are enjoyed by 48% and 41% of
the women.

5.2 Autonomy
Autonomy of the respondent women has been measured in terms of the scores
obtained by them in the autonomy questionnaire provided in Section 16 of the
questionnaire in the APPENDIX. The questionnaire on autonomy has 3 sections
corresponding to decision making autonomy, movement autonomy and access to and
control over economic resources. The percentage distribution of women according to
the 3 types of autonomy is as follows-

Table 5.2.1 Percentage Distribution of Women According to their Type of

Autonomy (N=531)

Women’s Autonomy No. of women Percentage Distribution

Decision Making 196 37%

Autonomy
Movement Autonomy 223 42%
Access to and control over 154 29%
economic resources
Note: More than one response in each autonomy section was allowed
Source: Field Survey Data

It is evident from the table (5.2.1) that autonomy of movement is enjoyed by the
42%women, followed by 37% women enjoying decision making autonomy and 29%
enjoying the access to and control over economic resources. This indicates that a

171
smaller percentage of women enjoy access to and control over financial resources in
comparison to women enjoying decision making and movement autonomy.

Women‘s total autonomy was arrived at by adding their individual responses to

questions regarding all the three components of autonomy. Accordingly, all
respondents were classified into the following three categories as shown in the table
below –

Table 5.2.2 Percentage Distribution of Women According to their Levels of

Autonomy

Level of Autonomy No. of Women Percentage Distribution

Low Autonomy 250 47%
Medium Autonomy 228 43%
High Autonomy 53 10%
Total (N = 531) 531 100%
Source: Field Survey Data

The table (5.2.2) shows that only 10% of the women respondents enjoy high
autonomy, while medium and low autonomy are enjoyed by 43% and 47% of the
women respectively.

5.3 Mass Media Exposure

Women‘s exposure to mass media was assessed by their responses to questions in

Section 1 of the questionnaire provided in the APPENDIX. Women were asked about
whether or not they are exposed to audio, audio-visual and print media. Considering
the number of illiterates among the respondents, women were also asked whether they
listen to their areas of interest from someone reading out a newspaper to her. The
following table shows the percentage distribution of women according to their
exposures to one, two, all the three and none of the mass media.

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Table 5.3.1 Percentage Distribution of Women According to Their Exposures to
Mass Media

Mass Media Exposure No. of women Percentage Distribution

Exposure to none 74 14%
Exposure to any one 244 46%
Exposure to any two 144 27%
Exposure to all the three 69 13%
Total (N = 531) 531 100%
Source: Field Survey Data

Table (5.3.1) shows that 14% of the women do not have any exposure to mass media
of any type. 46% women are exposed to one, 27% are exposed to two and a meager
13% are exposed to all the three types of media. Study found that most of the women
who reported exposure are exposed to television. Newspaper reading is the least form
of media exposure among the respondent women, though some of them reported
listening to others reading them out the newspaper.

During in-depth interviews, some responses were –

“I watch television for sometime every evening. Though I do not own a television, I
watch it at my neighbours. I like to see the Bengali serials. They show stories of how a
woman fights back amidst all odds in her life. I get inspired by it”.

“I do not have the money to buy newspapers daily though I can read and write. My
husband has bought me a radio. I listen to the FM whenever I get time. It gives much
information on health”. On being probed further to give an example of health
information, she promptly said “that advertisement which says jahan soch, wohan
shauchalay – encouraging every family to build a toilet‖. She reports that she
understood that women who go in the open for defaecation and urination are prone to
many diseases from the advertisement only.

“I work as a domestic help. I am illiterate. A lady in the household I work regularly

reads me the newspaper to let me know what is going around. She says it is important
to know about what goes around in the country and the state. Previously, I did not like
listening to it. But, gradually developed interest. Now, after I complete my work, I ask

173
Boudi to read the newspaper to me”. When further probed to tell about recent news,
she replied, “The court gave the verdict to hang some of the accused in the Kamduni
rape case”. She went on saying “they raped a college girl on her way back home in
Kamduni”. When asked whether she felt the judgement was right, she said “yes, I
wanted all the perpetrators to be hanged. People who are such brutal should not be
allowed to live.

“Influenced by the advertisement of Pradhan mantra Jan Dhan Yojna in the radio, I
have opened an account with zero balance facility in the nearby bank. Without these
advertisements coming regularly in the radio, I would not have known about it at all.
Now, I am proud that I also have my own account and can deposit my little savings
there”.

5.4 Gender Role Attitudes

Women were presented with a number of statements pertaining to gender role

attitudes and asked to show their agreement or disagreement to the statements. The
statement forms a part of Section 17 of the questionnaire and is provided in the
Appendix. The women were then scored according to their replies and categorized
into the following –

Table 5.4.1 Percentage Distribution of Women According to Their Gender Role

Attitudes

Gender Role Attitudes No. of women Percentage Distribution

Low conformity to traditional 64 12%
gender roles
Medium conformity to traditional 223 42%
gender roles
High conformity to traditional 244 46%
gender roles
Total (N = 531) 531 100%
Source: Field Survey Data

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The above table (5.4.1) shows that majority of the women (46%) among the
respondents conformed to traditional gender role attitudes. 12% of the respondents
showed an egalitarian approach to gender roles, i.e. low conformity to traditional
gender roles while 42% of women showed a medium conformity to traditional gender
roles.

During in depth interview, the respondents said the following –

“A husband should work outside and earn money. If he has to do household chores
and look after children, what is the need of marrying? Husbands earn bread and
butter for the family, so, who else is going to decide what will happen to the money
earned? My job is to maintain the house and look after children. If I do not do these
things properly, my husband has the right to rebuke me. You tell me if a husband
comes home hungry and finds that the food is not cooked or the cooking is bad, can he
control his temper? If anything of that sort happens, he slaps me and uses bad words.
I have to accept it since it is my fault that I have not accomplished my duties properly.
He also beats me when he comes home drunk. But, I understand he does it because he
is not in his senses”.

“I have to accept my husband‟s opinion even if I do not agree to it. He is a husband

after all and the principal earner. If I do not agree to what he says, he will create
violence; beat me harsh in front of my children. Such disrespect in front of my
children is embarrassing to me”.

“I need to satisfy my husband sexually and do whatever he asks me to do because I

know he has a relation with another woman. I am always afraid that he might leave
me if he is not satisfied with me”.

“I have stopped the schooling of my daughter after she cleared her fifth standard. In
our native village, girls are married early. So, in order to marry her off, I need to
teach her household chores. After marriage she has to look after her in laws, husband
and take care of children. Where is she going to apply her knowledge acquired from
the school?”

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“I and my husband both are working. I work as an attendant in a private nursing
home and is assigned night duties at least 3 days a week. We have shared the
household chores according to my shifts. He does not mind to try his hand on cooking
and look after children in the nights when I am on duty. My work has taught me the
value of education and I dream of making my daughter a graduate. I have heard that
the State Government is now giving aids like „kanyashri‟ to encourage girls persuing
their studies. I send both my son and daughter to the local school”. When asked about
who decides how household money should be spent, she replies “when we both earn,
why should he alone say how to spend it? Both of us decide what amount we spend
and what we save monthly. I have recently opened a bank account with zero balance
facility at the nearby bank. The bank officials taught me how to operate the account”.

176
 CHAPTER 6

6. REPRODUCTIVE HEALTH

Reproductive health of slum dwelling women has been studied here with respect to
their knowledge and practice of different aspects of the same. The chapter is divided
into two broad divisions – (1) Knowledge of various aspects of reproductive health
and (2) Practice of various aspects of reproductive health. Bivariate analysis is used to
show the relationship between knowledge and practice of reproductive health of
women respectively by their social background characteristics as determinants of
reproductive health. The findings are also supplemented by in-depth- interviews of the
selected women and health workers.

6.1 KNOWLEDGE OF VARIOUS ASPECTS OF REPRODUCTIVE HEALTH

6.1.1 KNOWLEDGE OF FEMALE REPRODUCTIVE CYCLE

Female reproductive cycle, also called the menstrual cycle can be divided into three
phases-pre-ovulatory, ovulation and post-ovulatory phases. Menarche marks the onset
of the reproductive cycle in women while menopause marks the end. The length of
the menstrual cycle is usually 23-35 days but varies widely among women. The first
day of the cycle is the first day of the menstrual flow, often referred to as period, lasts
for 3-7 days. The last day of the cycle is the day before the next period begins. After
menstruation the ovaries are stimulated to produce a mature egg by a hormone called
Follicle Stimulating Hormone (FSH). By this time the uterine wall thickens with
blood and nutrients in order to receive the fertilised ovum. The release of the ovum or
egg from the ovaries into the fallopian tube is called ovulation and usually occurs on
the 14th day of a normal 28 days menstrual cycle. A released ovum can stay alive for
an approximate period of 24 hours. During this period it can get fertilised by a sperm.
So, the days leading to ovulation and the day of ovulation are the days on which a
woman is most likely to become pregnant in case she encounters a sexual intercourse.
If the egg is not fertilised, the entire uterine wall is shed off by the body marking the
onset of the next menstruation. Safe period in a cycle refers to day 1-7 and the last 4-5
days of the cycle. However, this period varies in women depending upon their length

177
of the menstrual cycle. It is necessary for every woman in the reproductive age group
to know about the ‗fertile‘ and ‗safe‘ periods of their reproductive cycle so as to
enable her to lead a satisfying sexual life.

The women respondents were asked about their knowledge of the female reproductive
cycle. Table [Link] shows the results. About 53% of the women respondents had at
least one basic concept of the female reproductive cycle while 11% knew about two
basic concepts and a very meager 4% of the women had knowledge of all the three
concepts. The questions asked to women forms a part of the questionnaire given in the
APPENDIX-I.

Table [Link] Knowledge of Women Regarding Female Reproductive Cycle

Knowledge of Women (N=531) Percentage Distribution
of Women
Women who know about Female Reproductive Cycle 53% (282)

At least one basic concept of Female Reproductive Cycle 53%

Two basic concept of Female Reproductive Cycle 11%
Three basic concept of Female Reproductive Cycle 4%
Source: Field Survey Data

The knowledge of women regarding female reproductive cycle by their background

characteristics acting as social determinants is as follows-

Table [Link] Percentage Distribution of Women who know Female Reproductive

Cycle by Social Determinants (Background Characteristics)

BACKGROUND NUMBER PERCENT

CHARACTERISTICS YES NO YES NO
Age at Marriage
<18 years 6 33 15% 85%
>18 years 276 216 56% 44%
Chi Square: 24.05 (Significant)
Literacy
Literate 271 148 65% 35%
Illiterate 11 101 10% 90%

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 BACKGROUND NUMBER PERCENT
CHARACTERISTICS YES NO YES NO
Chi Square: 106.79 (Significant)
Work Status
Working 231 134 63% 37%
Non working 51 115 30% 70%
Chi Square: 48.59 (Significant)
Autonomy
Low 89 161 37% 63%
Medium 153 75 67% 33%
High 40 13 75% 25%
Chi Square:59.35 (Significant)
Gender Role Attitude
Low conformity to traditional gender 58 06 91% 09%
roles
Medium conformity to traditional gender 138 85 62% 38%
roles
High conformity to traditional gender 86 158 35% 65%
roles
Chi Square:74.33 (Significant)
Mass Media Exposure
Exposure 262 195 57% 43%
No Exposure 20 54 27% 73%
Chi Square:23.48 (Significant)
Standard of Living Index
Low 89 129 41% 59%
Medium 152 103 60% 40%
High 41 17 71% 29%
Chi Square:24.74 (Significant)
Monthly House Hold Income (Rs.)
<5500 103 194 35% 65%
>5500 179 55 75% 25%
Chi Square:91.9 (Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

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Bivariate analysis of knowledge of female reproductive cycle and social determinants
are shown in Table [Link]. It is seen that 15% of the women who are aged below 18
years have knowledge of female reproductive cycle while 56% of women above 18
years of age have the same knowledge. The chi-square value of 24.05 shows that, a
significant relationship exists between age at marriage and female reproductive cycle.
In depth interview a just married 16 years old revealed “I know a woman can become
pregnant if she sleeps with a man even for a night. My mother thus warned me that I
should not do anything like that before marriage. I was thus married off early when
my parents came to know about the boy I loved.” A woman in her twenties with a
three year old child said that “I abstain from sex with my husband during the middle
of my menstrual cycle in order to avoid getting pregnant”. She said that she had been
taught to do so by her doctor after the birth of her first child. There is an expected
significant association found between literacy and knowledge of female reproductive
cycle. 65% of the literates had knowledge of female reproductive cycle as against
10% of the illiterates. This can be explained by the fact that literacy and subsequent
higher levels of education gives rise to knowledge and awareness of various systems
of our body and reproductive system is not an exception. Those attending secondary
school are also exposed to sex education at the schools. This contributes to higher
knowledge of the female reproductive cycle among the literates. The table shows that
women involved in paid work have higher knowledge of female reproductive cycle
than women who are non- working. 63% of women who are working have knowledge
of female reproductive cycle as against 30% of non working women. There is a
significant association between work status and knowledge of female reproductive
cycle as is evident from the chi square value of 48.59. In depth interview of a woman
engaged as a domestic help in several households of the town said ―at first when I
began work I did not have any idea about fertile and safe periods. But, several women
in whose household I work taught me these things after I had my second child. Now I
am cautious to take a note of my last menstrual period (LMP) and refrain from sex
during the middle of the cycle.”This shows that the atmosphere to which working
women are exposed teaches them a lot of things including their reproductive health. It
is expected that women who have high autonomy are more knowledgeable about
female reproductive cycle than those with low autonomy. Women who have high

180
autonomy with respect to decision making about own health and unaccompanied
movement to friends, health care facility, are more prone to gain knowledge about
various matters concerning her health. The study shows that 75% of women with high
autonomy had knowledge of female reproductive cycle compared to 67% and 37%
women with medium and low autonomy. Women having an egalitarian approach to
gender roles i.e., low conformity to traditional gender role attitudes are seen to have
more knowledge about female reproductive cycle than those with medium and high
conformity to traditional gender roles. The chi square value of 74.33 shows a
significant association between the two. Mass media have always played an important
role in dissemination of knowledge and creation of awareness among the people.
Thus, quite expectedly, 57% of women exposed to any type of mass media (print,
audio, or audio-visual) are seen to have a knowledge of female reproductive cycle
compared to only 27% of women who did not have any exposure. Both SLI and
monthly household income of the respondent women were found to be significantly
associated with their knowledge of female reproductive system. 71% of women with
high SLI and 75% of women with monthly household income are found to have the
knowledge of at least one aspect of reproductive health. Low knowledge is exhibited
by women belonging to medium and low SLIs and household income less than 5500
per month. This can be explained by the fact that high income allows the families to
own consumer durables like a television or a radio which enhances the SLI and those
media tools in turn contributes to the knowledge of the women.

6.1.2. KNOWLEDGE OF STIs AND HIV / AIDS

The terms Sexually Transmitted Diseases (STDs) or Venereal Diseases (VDs) have
been replaced by a term called Sexually Transmitted Infections (STIs) in the recent
past. They include all diseases that are transmitted by sexual interaction. STIs differ
from STDs in that they include clinical diseases that do not necessarily involve only
the genitalia but are transmitted by sexual interactions. Examples of STIs include all
STDs including HIV/AIDS and Hepatitis B. STIs like HIV/AIDS can also be spread
from mother to child posing one of the greatest threats to pregnant mothers and their
unborn child and by breastfeeding.

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Table: [Link] Knowledge and Awareness of Women Regarding STIs including
HIV / AIDS

Knowledge of Women (N=531) Percentage Distribution

of Women
Women who know about STIs including HIV / AIDS 51% (270)

Women who know about mode of transmission of 51%

HIV/AIDS/STIs
Knows two symptoms of HIV/AIDS/STIs 35%
Knows two preventive measures of HIV/AIDS/STIs 49%
Knows a pregnant woman should always be screened for 47%
HIV/AIDS
Able to name an STI other than HIV/AIDS 19%
Source: Field Survey Data

The above response table ([Link]) shows that 51% of the respondent women knew
about STIs including HIV/AIDS. 51% women knew about the mode of transmission ,
35% knew two symptoms, 49% knew two preventive measures, 47% knew that a
pregnant woman should be screened for HIV/AIDS and only 19% women were able
to name an STI other than HIV/AIDS. The knowledge of HIV/AIDS have been seen
to be satisfactory in a little more than half of the respondents but STIs other than
HIV/AIDS are still very little known. Barely one fifth of the respondents were able to
name another STI other than HIV/AIDS.

Table: [Link] Percentage Distribution of Women who know STIs including HIV
/ AIDS by Social Determinants (Background Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 5 34 13% 87%
>18 years 265 277 52% 48%
Chi Square: 24.36 (Significant)
Literacy

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Literate 262 157 63% 37%
Illiterate 8 104 07% 93%
Chi Square: 108.48 (Significant)
Work Status
Working 210 155 57% 43%
Non working 60 106 36% 64%
Chi Square: 20.89 (Significant)
Autonomy
Low 80 170 32% 68%
Medium 144 84 63% 37%
High 46 07 86% 14%
Chi Square:76.76 (Significant)
Gender Role Attitude
Low conformity to traditional gender 50 14 78% 22%
roles
Medium conformity to traditional gender 142 81 64% 36%
roles
High conformity to traditional gender 78 166 32% 68%
roles
Chi Square:68.54 (Significant)
Mass Media Exposure
Exposure 258 199 56% 44%
No Exposure 12 62 16% 84%
Chi Square:41.26 (Significant)
Standard of Living Index
Low 71 147 33% 67%
Medium 158 97 62% 38%
High 41 17 71% 29%
Chi Square:50.89 (Significant)
Monthly House Hold Income (Rs.)
<5500 142 155 48% 52%
>5500 128 106 55% 45%
Chi Square:2.49 (Insignificant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

183
The above table ([Link]) shows the percentage distribution of women who know
about HIV/AIDS and STIs by the social determinants. Results of bivariate analysis
show that knowledge of HIV/AIDS and STIs increased with increase in age at
marriage and literacy. Results of chi square showed significant association between
the two variables. Working women are found to have more knowledge about
HIV/AIDS and STIs than non working women. Similarly, autonomy, mass media
exposure, gender roles attitude and SLI are found to have a significant association
with knowledge of HIV/AIDS and STIs in women. Women who had high mass media
exposure exhibited increased knowledge of HIV/AIDS. In –depth interview showed
an overwhelming response of a woman at the mention of the term HIV/AIDS. “You
are talking about Buladi, right? I know what she says on HIV/AIDS. I have seen and
listened to her many times on TV and the radio.” The respondent‘s quick association
of AIDS with Buladi- the official mascot of West Bengal State AIDS Prevention and
Control Society reveals that she has indeed gained knowledge from advertisements in
the T.V and the radio to prevent HIV/AIDS. Another woman during in-depth
interview recalled the contents of one of the advertisements featuring Buladi. “My
husband has a relationship with another woman. Can I have AIDS? Buladi then
advices the woman, to go for a test at the nearest VCTC with her husband”. All these
show that the knowledge and awareness of HIV/AIDS have significantly increased
with the help of the mass media. However, monthly household income is found to be
insignificantly associated with HIV/AIDS and STI knowledge. The result is similar to
a study conducted in Bangladesh to show the influence of socio-demographic factors
on HIV/AIDS awareness among Bangladeshi garment workers which shows that
family income do not have a significant association with HIV/AIDS awareness.

6.1.3 KNOWLEDGE OF VARIOUS CONTRACEPTIVE METHODS

Knowledge of contraceptive methods includes knowledge regarding temporary and

permanent methods of contraception.

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Table: 6.1.3.1Knowledge of Women Regarding Various Contraceptive Methods

Knowledge of Women (N=531) Percentage

Distribution of Women
Women who know Contraceptive Methods 84% (444)

Women who know Permanent Contraceptive Methods 84%

(Male & Female Sterilization)
Women who know at least one Traditional Temporary 32%
Contraceptive Method.
Women who know two Modern Temporary 67%
Contraceptive Methods.
Source: Field Survey Data

The table ([Link]) show that 84% of the respondents know about family planning
methods. Limiting methods (male and female sterilization) are known by greater
number of the respondents than the spacing methods. Women who know at least one
traditional method like rhythm period (32%) are less in number in comparison to
women who know two modern spacing methods (67%). Most of the women had the
knowledge of male condoms and oral contraceptive pills (OCPs) as modern spacing
methods.

The results of bivariate analysis of knowledge of contraceptive methods of women by

their social determinants is as follows –

Table: [Link] Percentage Distribution of Women who know Various

Contraceptive Methods by Social Determinants (Background Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 16 23 41% 59%
>18 years 428 64 87% 13%
Chi Square: 55.73 (Significant)
Literacy
Literate 391 28 93% 7%
Illiterate 53 59 47% 53%
Chi Square: 136.48 (Significant)
Work Status
Working 340 25 93% 7%

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Non working 104 62 63% 37%
Chi Square: 77.48 (Significant)
Autonomy
Low 189 61 76% 24%
Medium 207 21 91% 9%
High 48 5 91% 9%
Chi Square: 22.16 (Significant)
Gender Role Attitude
Low conformity to traditional gender 58 6 91% 9%
roles
Medium conformity to traditional gender 201 22 90% 10%
roles
High conformity to traditional gender 185 59 76% 24%
roles
Chi Square: 20.04 (Significant)
Mass Media Exposure
Exposure 422 35 92% 8%
No Exposure 22 52 30% 70%
Chi Square:182.24(Significant)
Standard of Living Index
Low 161 57 74% 26%
Medium 230 25 90% 10%
High 53 5 91% 9%
Chi Square: 25.78 (Significant)
Monthly House Hold Income (Rs.)
<5500 223 74 75% 25%
>5500 221 13 94% 6%
Chi Square: 35.81 (Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

The knowledge of family planning methods are seen (table [Link]) to be significantly
associated with all the social determinants as is reflected by their chi-square values. It
is found that 87% women who got married at an age of above 18 years knew about
family planning methods while only 41% of the women who had an early marriage
knew about it. A young women of 17 years said during in-depth interview ―It is not
necessary for me to know these things now. I am married for the last 10 months My
mother in law is expecting her grand child from me soon. My husband said that he
will let me know about family planning later.” Knowledge is seen to be higher in

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literates than in their illiterate counterparts. Similarly, knowledge among the working
women is high. Higher Autonomy also led to higher knowledge and women with
higher egalitarian view of gender roles had higher knowledge. Here also the influence
of mass media is huge on both the literate and the illiterate women. India has really
done well in knowledge dissemination regarding family planning methods by utilising
the audio-visual and the audio media. One woman during the in-depth interview
repeated the famous tag line “Hum do, hamare do” when asked about family
planning methods. When asked to give an example of OCP, prompt was the reply
―Mala –D‖. Further probing with how a condom looks like reply was “looks like a
deflated balloon”.

6.1.4. KNOWLEDGE OF FAMILY PLANNING BASICS

It is expected that once a woman knows or have heard about a family planning
method, she knows the details of that particular method. This section dealt with the
assessment of detailed knowledge regarding a method of contraception.

Table: [Link] Knowledge of Women Regarding Family Planning Basics

Knowledge of Women (N=531) Percentage Distribution
of Women
Women who know about Family Planning Basics 55% (292)

At least details of one type of Family Planning Method 55%

Details of two types of Family Planning Method 23%
Details of three & more types of Family Planning Method 5%
Source: Field Survey Data

The above table ([Link]) shows that 55% of the respondents knew about the details of
at least one type of method, followed by 23% and 5% knowing details of two methods
and more than three methods respectively. Women exhibited their highest knowledge
regarding details of female sterilization. “It is to be done after you have two children.
You need to stay for a day in the hospital. The Government pays money if you do it.
There is no fear of having children after this operation” – are the views of a woman
who claimed to have knowledge regarding female sterilization. The percentage of

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knowledge drops when asked about details of two, three or more methods. This shows
that though the knowledge of contraceptive methods among the women is satisfactory
but they lack the knowledge of method details. “I know Mala –D helps in spacing of
children but I don‟t have much idea regarding how many days I have to take it in a
month”. A woman who had read up to the eighth standard exhibited her knowledge of
condoms by imitating the lines from a popular advertisement of National Aids Control
Organization (NACO). She said “Condom ak, suraksha teen”, meaning one condom
gives you three protections. On further probing to know whether she knew about the
protections given by condoms, the reply was prompt “unintended pregnancy,
protection from HIV/AIDS and protection from STIs”. Lesser knowledge about the
method was seen in case of IUDs, emergency contraceptives.

The results of bivariate analysis of knowledge of family planning basics of women

with social determinants are as follows-

Table: [Link] Percentage Distribution of Women who know about Family

Planning Basics by Social Determinants (Background Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 7 32 18% 82%
>18 years 285 207 58% 42%
Chi Square: 23.33 (Significant)
Literacy
Literate 283 136 68% 32%
Illiterate 9 103 8% 92%
Chi Square:126.44 (Significant)
Work Status
Working 239 126 65% 35%
Non working 53 113 32% 68%
Chi Square: 51.90 (Significant)
Autonomy
Low 82 168 33% 67%
Medium 168 60 74% 26%
High 42 11 79% 21%
Chi Square: 94.53 (Significant)

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 SOCIAL DETERMINANTS NUMBER PERCENT
YES NO YES NO
Gender Role Attitude
Low conformity to traditional gender 51 3 80% 20%
roles
Medium conformity to traditional gender 145 78 65% 35%
roles
High conformity to traditional gender 96 148 39% 61%
roles
Chi Square: 48.97 (Significant)
Mass Media Exposure
Exposure 277 180 61% 39%
No Exposure 15 59 20% 80%
Chi Square: 41.88 (Significant)
Standard of Living Index
Low 82 136 38% 62%
Medium 163 92 64% 36%
High 47 11 81% 19%
Chi Square: 50.70 (Significant)
Monthly House Hold Income (Rs.)
<5500 80 217 27% 73%
>5500 212 22 91% 9%
Chi Square: 214.31(Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

All the social determinants are found (Table: [Link]) to have a significant association
with knowledge of family planning basics. Literate women with higher levels of
knowledge and women with higher autonomy are found to have a higher knowledge
of family planning basics.

6.1.5. KNOWLEDGE REGARDING INDUCED ABORTION

Induced abortion or Medical Termination of Pregnancy (MTP) is legal in India since

1972. The table shows the percentage distribution of women according to their
knowledge of induced abortion.

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Table: [Link] Knowledge of Women Regarding Induced Abortion

Knowledge of Women (N=531) Percentage Distribution

of Women
Women who know Induced abortion (MTP) is legal in 57% (303)
India

A woman can ask for abortion when the pregnancy is 57%

unwanted
Abortion can be done up to a specified time after 50%
conception only(up to 12 weeks and in special cases from
12th – 20th week)
Abortion should always be done at Govt. registered 27%
clinics and by registered medical practitioners
Unsafe abortion can lead to serious health hazards 25%
including death
Source: Field Survey Data

It is seen (Table: [Link]) that about 57% of the women know that MTP is legal in
India and women can ask for abortion when her pregnancy is unwanted. But the
percentage of knowledge decreases when asked about the time, place and by whom it
can be performed. One of the respondents during in-depth interview remarked “I
know it is to be done in the initial stages but I am not sure till which month of
conception it can be done‖. Another remarked “I know of a doctor who does induced
abortion in an atmosphere of confidentiality. He gives jaributi in order to terminate
pregnancy. There is no need for any kind of operation. Women in our area prefer that
over hospitals since nobody gets to know what you have done.” Only 25% of the
respondents know that induced abortion in unregistered places and in the hands of
unqualified persons can lead to death.

Results of bivariate analysis of knowledge of induced abortion with social

determinants of women is shown in the following table –

190
Table: [Link] Percentage Distribution of Women who know about Induced
Abortion by Social Determinants (Background Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 8 31 26% 74%
>18 years 295 197 60% 40%
Chi Square: 22.95 (Significant)
Literacy
Literate 263 156 63% 37%
Illiterate 40 72 36% 64%
Chi Square:26.40 (Significant)
Work Status
Working 243 122 67% 33%
Non working 60 106 36% 64%
Chi Square: 43.13 (Significant)
Autonomy
Low 90 160 36% 64%
Medium 166 62 73% 27%
High 47 6 89% 11%
Chi Square:89.96 (Significant)
Gender Role Attitude
Low conformity to traditional gender roles 56 8 88% 12%
Medium conformity to traditional gender roles 160 63 72% 28%
High conformity to traditional gender roles 87 157 36% 64%
Chi Square:89.47 (Significant)
Mass Media Exposure
Exposure 282 175 62% 38%
No Exposure 21 53 28% 72%
Chi Square:28.87 (Significant)
Standard of Living Index
Low 88 130 40% 60%
Medium 167 88 65% 35%
High 48 10 83% 17%
Chi Square:47.82 (Significant)
Monthly House Hold Income (Rs.)
<5500 105 192 35% 65%
>5500 198 36 85% 15%
Chi Square:129.63 (Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

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The table ([Link]) shows that the more the age at marriage, greater is the knowledge
of induced abortion among women. 60% of women who married after 18 years know
about induced abortion as compared to only 26% who married at an early age. The
knowledge about induced abortion is higher in women who are literate and are
engaged in paid work. Autonomy and gender role attitude is also shown to have a
significant association with knowledge of induced abortion with women of higher
autonomy and low conformity to traditional gender role attitudes exhibiting higher
knowledge. Mass media influence knowledge of induced abortion as 62% of those
exposed have knowledge of induced abortion compared to 28% who do not have any
mass media exposure. High SLI and high monthly income are found to be
significantly associated with knowledge of induced abortion.

6.1.6. KNOWLEDGE OF PREGNANCY, ANTE-NATAL, DELIVERY AND

POST NATAL CARE

Motherhood is an important phase in the life of all women. So, it is expected that they
should know about the special care to be taken of themselves, the danger signs that
may ensue, places to go when confronted with problems, importance of institutional
delivery and presence of skilled personnel during delivery and importance of check up
of themselves and their child after birth.

Table: [Link].a Knowledge of Women Regarding Pregnancy, ANC, Child-Birth

and PNC

Knowledge of Women (N=531) Percentage Distribution of

Women
Women who know regarding Pregnancy ,ANC, 72% (380)
Child-Birth and PNC
Source: Field Survey Data

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Table: [Link].b Knowledge of Women Regarding Pregnancy, ANC, Child-Birth
and PNC

Knowledge of Women Regarding Pregnancy, ANC, Child- Percentage

Birth and PNC Distribution of
Women
One should have a nutritious diet during pregnancy and must not 72%
skip meals
One should have at least 3 antenatal checkups during the period 65%
of pregnancy
Know at least 3 danger signs during pregnancy (convulsions not 34%
from fever, swelling of legs, body or face, vaginal bleeding,
excessive white discharge, excessive fatigue, night blindness,
blurred vision, fast or difficult breathing, abdominal pain etc)
Know where to go and report in case any of the danger signs 34%
ensue
Know the importance of institutional delivery and need for 72%
skilled attendant during delivery for safe motherhood and
childbirth
Know that post delivery check up is as important as ante natal 72%
check up
Know the warning signs (at least 3) after delivery that demands 18%
medical attention (excessive bleeding, severe abdominal pain,
severe vaginal pain, pain in the incision area in case of C/S,
fever, swelling of the legs, etc)
Source: Field Survey Data

The above tables ([Link].a & [Link].b) show women‘s knowledge with respect to
pregnancy, ANC, child birth and PNC. It is seen that 72% of the women know that a
pregnant women needs a nutritious diet and should not skip meals. One expectant
woman said “we need to have light nutritious meals. The Anganwadis provide us with
khichdi and soyabean curry which they say is good for my health”. 65% know that
there should be at least 3 ANCs during pregnancy. But, it is seen that less women

193
(34%) knew the danger signs of pregnancy. One currently pregnant respondent said “I
went for ANC twice but the doctors did not tell me about any danger signs”. It is seen
that 72% women know that it is important to have their babies delivered in a health
care facility by a qualified doctor. 72% women recognised the need for a post natal
check up. But, in a similar manner to the danger signs during pregnancy, the post
delivery danger signs are known to less number of women (18%). The findings of this
study is similar to the findings of a study conducted in the states of Gujarat and West
Bengal which showed that women had least knowledge of complications or danger
signs during the post partum period (Ram, Sinha , & Mohanty, 2006).

The table for bivariate analysis of knowledge of ANC, pregnancy, child birth and
PNC of women by their social determinant is as follows-

Table: [Link] Percentage Distribution of Women who know about Pregnancy,

ANC, Child-Birth and PNC by Social Determinants (Background
Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 6 33 15% 85%
>18 years 374 118 76% 24%
Chi Square: 65.28 (Significant)
Literacy
Literate 331 88 79% 21%
Illiterate 49 63 44% 56%
Chi Square: 53.95 (Significant)
Work Status
Working 286 79 78% 22%
Non working 94 72 57% 43%
Chi Square: 26.48 (Significant)
Autonomy
Low 142 108 57% 43%
Medium 192 36 84% 16%
High 46 7 87% 13%
Chi Square: 50.74 (Significant)
Gender Role Attitude

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 SOCIAL DETERMINANTS NUMBER PERCENT
YES NO YES NO
Low conformity to traditional gender 58 6 91% 9%
roles
Medium conformity to traditional gender 179 44 80% 20%
roles
High conformity to traditional gender 143 101 59% 41%
roles
Chi Square: 39.86 (Significant)
Mass Media Exposure
Exposure 354 103 77% 23%
No Exposure 26 48 35% 65%
Chi Square: 50.07 (Significant)
Standard of Living Index
Low 126 92 58% 42%
Medium 204 51 80% 20%
High 50 8 86% 14%
Chi Square: 35.33 (Significant)
Monthly House Hold Income (Rs.)
<5500 176 121 59% 41%
>5500 204 30 87% 13%
Chi Square: 50.14 (Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

The chi square values (Table: [Link]) indicate that all the determinants have a
significant association with knowledge of pregnancy, ANC, child birth and PNC. 76%
of women who married late knew about ANC, child birth and PNC as compared to
15% of the women who married early. Literate women shows an obvious higher
knowledge (79%) compared to illiterate women (44%) as they can read the materials
provided to them during the ANC visits. Women‘s engagement in paid work leads to
a higher knowledge. Similarly, women with medium and high autonomy show higher
knowledge of ANC, pregnancy, child birth and PNC. 91% of the women with low
conformity to traditional gender roles have the said knowledge in contrast to 80% and
59% of women belonging to the medium and high conformity to traditional gender

195
role category. The knowledge is seen to increase with exposure to mass media, high
SLI and high income.

6.1.7. KNOWLEDGE OF REPRODUCTIVE HEALTH RIGHTS

Reproductive and Sexual Health Rights are part of basic Human Rights. They are
universal, indivisible and undeniable. They include access to reproductive and sexual
health care and related information and autonomy in decision making in case of
reproductive and sexual health. These rights are defined in ICPD, Programme of
Action (POA), 1994. The elements of Sexual and Reproductive Health Rights as
outlined in the POA are -

 Voluntary, informed and affordable family planning services

 Pre-natal care, safe motherhood services, assisted childbirth from a trained
attendant and comprehensive infant health care
 Prevention and treatment of STIs, including HIV/AIDS and cervical cancer
 Prevention and treatment of violence against women and girls
 Access to safe abortion services and post abortion care
 Sexual health information, education and counseling, to enhance personal
relationships and quality of life.

Sexual and Reproductive Health Rights assume that all people have the right to
control their bodies, have sufficient and correct information to adopt healthy
behaviours, and have affordable, accessible services not only during pregnancy but,
also both before and after pregnancy, or even if they choose not to become pregnant.
These rights guarantee that every person has the right to a healthy, consensual, safe
and satisfying sex life. (Amnesty International, USA). So, it is desirable for both men
and women to know about the rights they are entitled to so that they can exercise
these rights properly in order to lead an enjoyable sexual life with optimum
reproductive and sexual well-being.

In this section, the respondents were asked about their knowledge of their
reproductive health rights. The percentage distribution of women according to their
knowledge is shown in the following table-

196
Table: 6.1.7.1Percentage Distribution of Women according to their knowledge of
Reproductive Health Rights (RHR)

Knowledge (N=531)* Percent of Women

Right to decide freely the number of children to 29%
bear
Right to decide freely when to bear children 17%
Right to decide spacing between two children 25%
Right to freedom from forced sterilization 7%
Right to access Reproductive HealthCare in need 37%
Right to receive education on Reproductive & 12%
Sexual Health and Illnesses
Right to access safe Abortion 10%
Right to decide not to bear children at all 0%
Source: Field Survey Data

Note: The responses of women are mutually inclusive. A woman was allowed to
respond to more than one right. The percentage of women thus is more than 100%.
The table ([Link]) shows that about 37% women have the knowledge of right to
access reproductive health care in need, 29% know that they have the right to decide
freely the number of children to bear, 25% women know they have the right to decide
spacing between two children, 17% know they have the right to decide when to bear
children. 7% know that they have the right to freedom from forced sterilization, 12%
know that they have the right to education on reproductive and sexual health and
illnesses and 10% know that they have the right to safe abortion. Last but not the
least, none of the women respondents knows that they even have the right to decide
not to bear children at all.

Even though there is knowledge among the women about their reproductive rights,
exercising these rights is often not easy for them. During in depth interview, a woman
spoke her heart out-

“My husband coerces me to have sex with him. Initially, I have refused it once or
twice since I was unwell on those days, but he bet me blue for having refused it. He
says it is my duty to keep him sexually happy as he is my husband and he can demand
it from me whenever he feels like. He even has asked me not to talk to those lady

197
health workers. He considers family planning methods are vices and the HHWs put
these ideas in my head. I have 4 children. Still he did not allow me for ligation. I
cannot protest since I am illiterate and my husband will not allow me to work for a
pay. He thinks wives are there to manage household, give birth to and manage
children. Under these conditions, tell me what I will do even if I know some of the
reproductive rights. If I am asked to leave home for wanting to practice these rights,
who will give me shelter”.

“After marriage, me and my husband decided that we would have two children. I gave
birth to two girls. I wanted to get my sterilization done after the birth of two children.
My husband also agreed. But, my in- laws wanted me to give them a grandson. They
put constant mental pressure on me and my husband. They told my husband that there
will be no one to carry on the „vansh‟. In the face of such pressure, I decided to
become a mother the third time. Thankfully, I gave birth to a son and also underwent
ligation at the same time”.

“I decided to have my second issue when the first will be three years old. I was on
pills which I used to get initially from the HHWs. Then, due to inadequate supply, I
had to buy it from the medical stores. It was not always possible for me to buy pills
due to lack of money. My husband also could not resort to condoms due to financial
constraints. We then abstained from sex during the fertile period of my cycle. Still, I
conceived for the second time when my elder son was 1.5 years”.

This woman‘s report of not getting regular supplies of pills and condoms was also
supported during the in depth interview of a HHW, where she said,

“We have very limited supplies of pills and condoms and it is not possible for us to
cater to all the women and men who want to adopt them with this inadequate supply.
We insist the couples to buy them from medical stores. While the ones with higher
household incomes do it, the ones who are poor are left with an unmet need for
contraception”.

198
(It is to be noted that at the time of writing this report, the supply of all contraceptives,
common medicines like paracetamol, oral rehydration solution (ORS) packets etc.
was completely stopped in the entire sub centres of the area).

On their rights to receive education on Sexual and Reproductive health and illnesses,
one HHW said,

“For the last 5 years there has not been a single Information, Education and
Communication (IEC) Programme on reproductive and sexual health arranged by the
Municipality. In my 20 years of service, I have seen these programmes at least once in
three months before, but, in recent times, they are completely non-existent. Those
programmes used to disseminate knowledge on various family planning methods and
gynaecological and obstetric illnesses by showing pictures and explaining them. We
are not conversant with all the illnesses, so, when these women come to us, we ask
them to visit hospitals. In public hospitals, because of the huge crowd, doctors often
do not have time to educate the women on their illnesses. Doctors sometimes even
forget to alert the pregnant women regarding danger signs of pregnancy in public
hospitals”.

On the right to decide not to bear children at all, a surprised woman during in depth
interview said,

“Motherhood helps a woman to be complete. How can one not want to bear children?
That is the reason a woman is born for”.

Another remarked, “even if I do not want to become a mother, do you think my

husband and in laws will agree to it? They will kick me out of the house if they hear I
can even think that way. If I do not get them a child, my husband will go for a second
marriage”.

6.2. PRACTICE OF VARIOUS ASPECTS OF REPRODUCTIVE HEALTH

This section will deal with practices of women associated with their reproductive
health.

199
6.2.1. FAMILY PLANNING PRACTICES – EVER USE AND CURRENT USE

The table below shows the family planning practices of respondent women by their
ever and current use.

Table: [Link] Family Planning Practice by women: Ever Used and Current Use
of Contraception
Family Planning Practice by Women Percentage Distribution of Women
Methods Ever Used (N=531) 79%
Methods Currently in Use (N=162) 57%
Source: Field Survey Data

Table: [Link] Family Planning Practice by Women: Ever Used and Current Use
of Contraception
Methods of Contraception Percentage Distribution
of Women
Methods Ever Used (N=531) 79% (418)
Female Sterilization 39%
Oral Contraceptive Pills 79%
IUDs 1%
Condoms By husbands 4%
Others 2%
Never used any method 21% (113)
Methods Currently in Use (N=162) 57% (92)
Oral Contraceptive Pills 57%
IUDs 1%
Condoms By husbands 3%
Others 0.5%
Not using any method 43% (70)
Source: Field Survey Data

According to Table ([Link]) 79% women respondents said that they have used family
planning methods sometimes in their lives. Among the ever users, limiting methods
are more popular and have been used by 39% of the women. It is interesting to note

200
that while female sterilization is widely practiced by women, only one case of male
sterilization has been reported among the husbands of the respondents. Among the
spacing methods, the most widely used method is the intake of OCPs. 79% women
respondents reported the use of OCP at some point in their lives but the continuity of
use and thereby the efficacies of the OCPs as a spacing method in these women are
doubtful. Respondents reported,

“I take OCPs to prevent pregnancy. But sometimes I forget to take it regularly”.

Another woman said “I use OCPs whenever I have the money to spend on it. I have to
procure it from the pharmacy. It is not available in the sub centres always.
Sometimes, when the sub centre has a supply, the health workers give it to me free of
cost. But this happens rarely.”

“It is always not possible to spend money on buying Mala-D. Thus, my use is
irregular. It is also difficult for me to count the number of days for which I have to
take the pills and then give a gap” – was the remark of another user.

The ever use of IUD as a spacing method is limited to only 1% of the users. The low
popularity of the method is owed to varied reactions of the users –

“I had an IUD implantation from the Government hospital. But I experienced

bleeding and pain. Doctor said that it does not suit everybody, so, I asked him to get it
removed”.

“After IUD implantation, I suffered from pain during my intercourse. My husband

asked me to get it removed”.

“I have an IUD implanted for the past 2 months. The doctor at the hospital advised
me to get it implanted since it can give me long term protection from pregnancy. My
child is 2 years old now and I and my husband do not want the second child so soon. I
am happy after the implantation since I can have a fearless sexual life without
worrying about unintended pregnancy. I did not have any side effects from the
implantation”.

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Condoms are reported to be used by the husbands of 4% of the respondents only.
There is thus a very low use. Women reported the following about their husband‘s use
of condoms-

“Our entire family resides in one small room. I have 2 children. My husband started
using condoms but there is a dearth of place for keeping these. My sons used to take
them out and blow them thinking that they are balloons. This embarrasses me and my
husband. So, the use has become limited now”.

“My husband says that it interrupts the sexual pleasure. So, he does not want to use
this”.

“My husband comes home drunk almost every day and coerces me to sex. It is not
possible to tell a drunken person to put on condoms. So, I have to remain careful. He
still did not approve my going for sterilization and he is not interested to perform his
own, though we have 3 children”.

“Condoms are distributed for free from the health sub centre only when there is
availability, which is a rare incident. At other times, we need to buy it. My husband
spends most of his money earned on alcohol. Where will the money come from to buy
condoms”?

“After using it for once, it needs to be thrown. So, in terms of expense, it is costly for
us”.

“My husband used to use condoms. But I had an intense itching problem during
intercourse, so, he discontinued the use”.

2% of the ever user women reported that they resort to traditional methods like
rhythm period and withdrawal by the husbands.

On being asked about the permanent method of contraception, a woman who got her
sterilization done said “my husband did not want to get the operation done. I also
thought that because of the operation he might become weak and can no longer be
able to do heavy work. So, we decided that I should go for the operation”.

202
About 21% of the respondents reported that they have not used any methods at any
point in their lives.

Field survey found that there are 92 current users of family planning methods after
eliminating those who have undergone sterilization, those currently pregnant and
intending to be pregnant, those who are widows, deserted by husbands or are
divorced. Among the current users, 57% of the women are using OCPs and 1% IUDs.
About 3% of the husbands are condom users and only 0.5% women are practicing
traditional methods.

The results of bivariate analysis family planning practice by women by their social
determinants is as follows-

Table: [Link] Percentage Distribution of Women according to Family Planning

Practice: Ever Use of Contraception by Social Determinants (Background
Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 10 29 26% 74%
>18 years 408 84 83% 17%
Chi Square: 70.79 (Significant)
Literacy
Literate 372 47 89% 11%
Illiterate 46 66 41% 59%
Chi Square: 117.26 (Significant)
Work Status
Working 317 48 87% 13%
Non working 101 65 61% 39%
Chi Square: 46.07 (Significant)
Autonomy
Low 170 80 68% 32%
Medium 200 28 88% 12%
High 48 5 91% 9%
Chi Square: 32.61(Significant)
Gender Role Attitude
Low conformity to traditional gender 57 7 89% 11%
roles
Medium conformity to traditional gender 191 32 86% 14%

203
 SOCIAL DETERMINANTS NUMBER PERCENT
YES NO YES NO
roles
High conformity to traditional gender 170 74 70% 30%
roles
Chi Square: 22.4 (Significant)
Mass Media Exposure
Exposure 392 65 86% 14%
No Exposure 26 48 35% 65%
Chi Square: 97.5 (Significant)
Standard of Living Index
Low 140 78 64% 36%
Medium 226 29 88% 12%
High 52 6 90% 10%
Chi Square: 46.44(Significant)
Monthly House Hold Income (Rs.)
<5500 199 98 67% 33%
>5500 219 15 94% 6%
Chi Square: 50.14(Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

As expected, age at marriage has a significant association with ever use of family
planning methods. It is seen from Table ([Link]) that 26% of women who got married
below 18 years of age used family planning methods in contrast to 83% women who
married after 18 years of age. 89% of the literate women are found to be ever users in
contrast to 41% illiterate women. Thus, there is a significant association between
literacy and ever use of family planning methods. Similarly, paid work, high
autonomy, low conformity to traditional gender role attitudes, mass media exposure is
seen to be significantly associated with higher use of family planning methods. 87%
women among paid workers, 91% women with high autonomy, 89% of women
having low conformity to traditional gender role attitude and 86% women with mass
media exposure are found to be ever user of a family planning method. High monthly
household income and high SLI is also seen to be associated significantly with family
planning methods. 90% women living in households with high SLI and 94% women
whose monthly household income is more than Rs. 5500 are found to be ever users of
family planning methods. The association of ever use of family planning methods is

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strongest with literacy (chi square value 117.26), followed by mass media exposure
(chi square value 97.5), age at marriage (chi square value 70.79) and monthly
household income (chi square value 50.14).

The table below ([Link]) shows the results of bivariate analysis of current use of
family planning by women with their social determinants.

Table: [Link] Percentage Distribution of Women according to Family Planning

Practice: Current Use of Contraception by Social Determinants (Background
Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 10 29 26% 74%
>18 years 82 41 67% 33%
Chi Square: 20.31 (Significant)
Literacy
Literate 72 36 67% 33%
Illiterate 20 34 37% 63%
Chi Square: 11.70 (Significant)
Work Status
Working 70 23 75% 25%
Non working 22 47 32% 68%
Chi Square: 30.38 (Significant)
Autonomy
Low 34 42 45% 55%
Medium 47 23 67% 33%
High 11 5 69% 31%
Chi Square: 8.49 (Significant)
Gender Role Attitude
Low conformity to traditional gender 14 5 74% 26%
roles
Medium conformity to traditional gender 46 22 68% 32%
roles
High conformity to traditional gender 32 43 43% 57%
roles
Chi Square: 11.57 (Significant)
Mass Media Exposure
Exposure 82 48 63% 37%
No Exposure 10 22 31% 69%
Chi Square: 10.6 (Significant)
Standard of Living Index

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Low 22 44 33% 67%
Medium 54 24 69% 31%
High 16 2 89% 11%
Chi Square: 27.28 (Significant)
Monthly House Hold Income (Rs.)
<5500 34 57 37% 63%
>5500 58 13 82% 18%
Chi Square: 31.94 (Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

Similar to the earlier table, the above table ([Link]) also shows significant association
of all the social determinants with the current practice of family planning methods.

6.2.1.A. RECOMMENDATIONS, DECISIONS FOR THE USE OF

CONTRACEPTIVE METHODS AND THEIR PLACE OF AVAILABILITY

Table: 6.2.1.A.1 Recommendation, Decision for Use of Contraceptives and Place of

Availability (N=418)
Ever users of contraceptives Percent of Women
Recommendation for use
Doctors 15%
Female Honorary Health Workers 47%
Family/Significant others 38%
Decision for ever use
Self 23%
Husband 34%
Mutual decision of both the spouses 43%
Place of Obtaining method
Govt. Hospital/ Municipal Hospital 39%
Private Nursing Home 2%
Local Pharmacy 59%
Source: Field Survey Data

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The above table (6.2.1.A.1) shows the percentage distribution of women (ever users
of any Family Planning methods) with regard to the persons who recommended such
use, persons who decided upon a particular method and the place at which the
methods were available. The table shows that the highest recommendations for use of
any family planning method had come from the female HHWs working in the health
sub centres. 47% of the women ever users were recommended the use by female
HHWS. About 38% of the women users were recommended the use by their family,
mostly, mothers and significant others including friends while in case of 15% of the
users, it was recommended by the doctors. These women come in frequent contacts
with the HHWs regarding their own health and their child‘s health. So, the HHWs are
the persons who recommend family planning method use mostly to women. Their
contacts with the doctors are limited except in cases of pregnancy and childbirth and
in instances of extreme gynaecological illnesses, thus, only 15% of the women are
recommended by the doctors the use of a family planning method.

As regards the decision to use a particular method, 43% of the users reported that it
was a mutual decision of both the spouses, 34% reported that it was the decision of
their husbands while 23% of the women reported that it was exclusively their decision
to use a particular method.

Most of the female sterilizations done were performed either at the Uttarpara State
General Hospital or Municipal hospital. Financial assistance to women after her
adoption of sterilization is an important motivator. Though, at the time of conduction
of the survey the municipal hospital discontinued performing the sterilization
operation. A small number of women had their sterilizations done at local low cost
private clinics. 59% of the ever users reported of obtaining the FP method from the
local pharmacy which accounted for the OCPs and the condoms. 39% of the users
reported obtaining the method from the Govt. Or Municipal hospital while a meager
2% women users reported getting the method from private nursing homes.

6.2.2 PRACTICE OF INSTITUTIONAL DELIVERY

The National Population Policy 2000 envisaged achieving 80% institutional delivery
and 100% delivery by trained personnel. The objective behind this target was to

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reduce the Maternal Mortality Rate and the Infant Mortality Rate in the country.
Though both the rates have decreased substantially from what it was in the year 2000,
still, the country has not been able to achieve a 80% institutional delivery rate and
100% deliveries by skilled attendants. The data from NFHS-3 (2005-2006) for the
urban poor in West Bengal shows the rate of institutional delivery at 58.9% and
63.9% of the births attended by skilled personnel. The total of percentage of
institutional deliveries in the state of West Bengal stand at 42%, and those attended by
skilled personnel at 47.6% respectively, according to NFHS-3. The table below shows
the percentage distribution of the respondents who delivered during the past one year
of the time of survey by their place of delivery.

Table: [Link] Practice of Institutional Delivery and Delivery at Home Attended

by Skilled Birth Attendant (Those who delivered during the past 1 year)
Practice of Institutional Delivery and Delivery at Home Percentage
Attended by Skilled Birth Attendant (one year prior to Distribution of women
survey)
Institutional Delivery (N=92)
Yes 88 (96%)
No 4 (4%)
Delivery at Home Attended by a Trained Birth
Attendant (N=4)
Yes 0 (%)
No 4 (%)
Source: Field Survey Data

According to the table ([Link]), there were 92 women among the respondents who
had delivered during the past one year of the survey. Out of them, 96% had their
babies delivered at a health care institution while 4% had their babies delivered at
home. In none of the 4% cases, the women had trained personnel to aid them in giving
birth. Uttarpara has a State General Hospital situated centrally and a Municipal
Hospital and none of these hospitals are very far from the surveyed slums. So, most of
the women, deliver at these hospitals. Moreover, under the Janani Suraksha Yojna

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(JSY), the women get an incentive for delivering at a health care institution, which act
as a motivator for institutional delivery in most of the cases.

The 4 respondents who had their delivery at home said

“It was my first pregnancy. I had my name registered here and received the first 2
ANCs from Uttarpara State General Hospital. Then, due to some emergency, I had to
move to my in laws place in rural Uttar Pradesh. The hospitals were very far and did
not have anybody at home to accompany me to the far away hospital. Thus, my
delivery took place in the home itself. I was delivered by a local dai (traditional birth
attendant). Dai was very good with good hygiene practices. She patted me gently and
told me there was nothing to fear. She sat beside me continuously till I felt a little
better. She cleaned my baby with warm water and wrapped him in a piece of warm
cloth. She asked me to feed the baby with the first yellow milk. But, 3 days after
delivery, my in laws arranged for going to the hospital for me and my baby‟s check up
and immunization”.

“I live in a joint family. My in –laws are very conservative. They said my husband,
brothers and sisters in law were all delivered at home. I registered myself in the
hospital but could not complete all the 3 ANCs. The attending doctor was male, so,
my mother in law objected. I was delivered at home in the hands of my mother in law,
who has experience in delivering babies”.

“I was in the advanced stages of my pregnancy. My husband had gone to his native
place and I stayed back here with my son. At midnight, I realised that the water has
broken and I was suffering from intense pain. I tried to bear with it for 2-3 hours but
gave away at last. My son called the neighbours who started arranging for my
transport to the State General Hospital, but, I delivered at home. Few of my
neighbours were experienced in child-birth and they helped in the process. In the
morning, I and my new born daughter were sent to the hospital”.

“I had been staying at my mother‟s place in Aarah since I conceived. I had few
complications at the beginning of my third trimester and was advised to see a doctor
at the Calcutta Medical College. My husband lives here and works as an electrician. I

209
was brought to Uttarpara and I showed myself at the Medical College. The Doctor
opined that I have to undergo a premature delivery since there was a threat to both
mine and my baby‟s health. The doctor gave me a date for admission. Two days prior
to my day of admission, I felt extremely ill and my husband called the local dai on the
advice of my neighbours .I was not in a position to be transported to Calcutta then.
The dai delivered me and 3-4 hours later I was taken to Medical College with my
baby. The dai cleaned me and my baby and accompanied us to the Medical College.
My baby had low birth weight, had difficulty in breathing and suffered from jaundice.
These were taken care of at the Medical College where my baby had to stay for a
month”.

So, in 3 cases, the delivery at home was not intentional but had taken place compelled
by a situation.

The results of Bivariate analysis of practice of delivery and social determinants of

respondent women is as follows-

Table: [Link] Percentage Distribution of Women with regard to their Place of

Delivery by Social Determinants (Background Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 12 1 92% 8%
>18 years 76 3 96% 4%
Chi Square: 0.41( Insignificant)
Literacy
Literate 61 0 100% 0%
Illiterate 27 4 87% 13%
Chi Square: 8.23 (Significant)
Work Status
Working 63 0 100% 0%
Non working 25 4 86% 14%
Chi Square: 9.08 (Significant)
Autonomy
Low 39 4 91% 9%
Medium 40 0 100% 0%
High 9 0 100% 0%
Chi Square: 4.77( Insignificant)

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 SOCIAL DETERMINANTS NUMBER PERCENT
YES NO YES NO
Gender Role Attitude
Low conformity to traditional gender 11 0 100% 0%
roles
Medium conformity to traditional gender 38 1 97% 3%
roles
High conformity to traditional gender 39 3 93% 7%
roles
Chi Square: 1.52 (Insignificant)
Mass Media Exposure
Exposure 78 0 100% 0%
No Exposure 10 4 71% 29%
Chi Square: 23.3 (Significant)
Standard of Living Index
Low 34 4 89% 11%
Medium 44 0 100% 0%
High 10 0 100% 0%
Chi Square: 5.94 (Insignificant)
Monthly House Hold Income (Rs.)
<5500 49 3 94% 6%
>5500 39 1 98% 2%
Chi Square: 0.58 (Insignificant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

The above table ([Link]) shows that there is a significant association between
literacy, work status and mass media exposure and the choice of the place of delivery.
Literacy with higher levels of education, women‘s engagement in paid work and their
exposure to mass media of any kind is always associated with higher rates of
institutional delivery attended by skilled personnel. Age at marriage, autonomy,
gender role attitude, SLI and monthly household income are seen to have an
insignificant association with institutional delivery. This is especially true for a place
like Uttarpara, where services are available and the health facilities are accessible by
nearly the entire population.

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6.2.3 PRACTICE OF ANTE-NATAL CARE BY CURRENTLY PREGNANT
WOMEN

ANC helps in preventing, identifying and treating problems encountered by women

during pregnancy. It links pregnant woman and her unborn child to the formal health
care system which in turn increases their chance to deliver at an institution and in the
hands of a skilled birth attendant. WHO recommends a minimum of 4 antenatal visits,
tetanus toxoid injections, screening and treatment of would- be mothers for infectious
diseases and identification of warning signs during pregnancy. NFHS 3 (2005-2006)
show that about 10.2% of the pregnant women among the urban poor have completed
their ANCs meaning they had at least 3 visits for antenatal check ups,90 doses of iron
and folic acid and received tetanus toxoid injection. The percentage of women who
completed the ANCs in the state of West Bengal stands at 12.3%.

The following table shows the practice of ANC by currently pregnant slum dwelling
women.

Table: [Link] Practice of Ante Natal Care (ANC) by Currently Pregnant Women
(N=87)
Of the Number of pregnant women those reporting Percentage Distribution
of Women
Registration of pregnancy with Auxiliary Nurses and
Midwives (ANM)
Yes 78 (90%)
No 9 (10%)
Received a card from the ANM (N=87)
Yes 78 (90%)
No 9 (10%)
Visited a Health Care Facility for ANCs (N=78)

Once 22 (28%)
More than once 51 (66%)
None (till the time of survey) 5 (6%)

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Of the Number of pregnant women those reporting Percentage Distribution
of Women
Received Tetanus Toxoid Injection (N=73)
Yes 58 (79%)
No 15 (21%)
Received Iron and Folic Acid tablets (N=73)
Yes 47 (64%)
No 26 (36%)
Had their weight, pressure measured and blood and
urine tests done (N=73)
Yes 51 (70%)
No 22 (30%)
Advised to deliver at a healthcare facility (N=73)
Yes 69 (95%)
No 4 (5%)
Received Supplementary Nutrition from Anganwadi
Centres (N=73)
Yes 38 (52%)
No 35 (48%)
Source: Field Survey Data

The table ([Link]) shows that there are 87 currently pregnant women, 90% of whom
have registered their pregnancy with the ANMs and received a card from them. Out of
them, 28% visited a hospital for ANC once, 66% visited more than once while 6% did
not visit any health care facility till the time of the survey. Of those who attended the
ANC visits, 79% received Tetanus Toxoid injections and 64% received iron and folic
acid tablet strips from the hospital. 70% had their B.P and weight measured and blood
and urine tests done. 95% of them were told about the importance of institutional
delivery by the attending doctors and 52% reported to have regular supplementary
nutrition from the Anganwadi centres.

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One respondent who visit hospital for ANC said “hospital has given me a strip of 100
iron and folic acid tablets but, after consuming some, I developed problems of
constipation and indigestion, so I stopped taking them any more”. She goes on to
show the researcher the unfinished strip.

One of the HHWs remarked “it is very difficult for us to persuade some women to
abide by the instructions given during ANCs by the doctors. In spite of providing them
with iron and folic acid tablets, many women do not consume it giving excuses like it
does not smell good or, it causes constipation”.

On women‘s regularity to go for the ANC, a HHW said, “previously we had weighing
machines and sphygmomanometer in working conditions in our centre. So, women
used to visit the sub centre and check their weights and blood pressure. But, now,
both the machines do not work. We have to ask pregnant women to go to the hospital
even for getting their weights and B.P checked. Many times they do not want to go to
the hospital and sit for long hours to have their B.P and weight checked”.

6.2.4. INTERACTION WITH HEALTHCARE PROVIDERS

Women‘s interaction with health care providers – doctors, ANMs or HHWs signifies
their concern for their own and their child‘s health. It also signifies their urge to seek
care. Women respondents were asked to report their interaction with the health care
providers during the past six months. They were asked to report one principal area of
discussion.

Table: [Link] Interaction with health care providers during the last 6 months
preceding the survey
Interaction with health care providers Percentage Distribution of Women
(N=531)
Interacted 276 (52%)
Not interacted 255 (48%)
Source: Field Survey Data

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Table: [Link] Women who interacted with a Healthcare Provider to discuss the
following in the last Six Months

Women who Interacted with a Healthcare provider to Percentage

discuss the following in the last Six months Distribution of
N=276 Women
Pregnancy related issues (ANC / PNC / Delivery) 90 (33%)
Using a contraceptive method to delay pregnancy/ stop 47 (17%)
pregnancy
Common Gynaecological Illnesses 133 (48%)
STIs other than HIV 3 (1%)
HIV / AIDS related issues 3 (1%)
Note: Women asked to report only one priority area of discussion.
Source: Field Survey Data

The first table ([Link]) shows that 52% of the women had an interaction with the
health care providers regarding various issues concerning their health. The second
table ([Link]) shows that about 48% women had an interaction with health care
providers regarding common gynaecological illnesses, 33%% on pregnancy related
issues,17% on using a family planning method to limit or space birth and only 1% on
STIs other than HIV and HIV/AIDS related issues.

The results of bivariate analysis of interaction with health care providers with the
social determinants of women is as under-

Table: [Link] Percentage Distribution of Women Who Interacted with

Healthcare Providers by Social Determinants (Background Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 8 31 21% 79%
>18 years 268 224 54% 46%
Chi Square: 16.69 (Significant)
Literacy
Literate 249 170 59% 41%
Illiterate 27 85 24% 76%
Chi Square: 44.17 (Significant)
Work Status
Working 220 145 60% 40%

215
 SOCIAL DETERMINANTS NUMBER PERCENT
YES NO YES NO
Non working 56 110 34% 56%
Chi Square: 32.2 (Significant)
Autonomy
Low 86 164 34% 66%
Medium 148 80 65% 35%
High 42 11 79% 21%
Chi Square: 62.02 (Significant)
Gender Role Attitude
Low conformity to traditional gender 53 11 83% 17%
roles
Medium conformity to traditional gender 141 82 63% 37%
roles
High conformity to traditional gender 82 162 34% 66%
roles
Chi Square: 68.68 (Significant)
Mass Media Exposure
Exposure 257 200 56% 44%
No Exposure 19 55 26% 74%
Chi Square: 23.83 (Significant)
Standard of Living Index
Low 81 137 37% 63%
Medium 152 103 60% 40%
High 43 15 74% 26%
Chi Square: 36.54 (Significant)
Monthly House Hold Income (Rs.)
<5500 101 196 34% 66%
>5500 175 59 75% 25%
Chi Square: 87.2 (Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

Table ([Link]) reveal that all the social determinants are found to have a significant
association with interaction of women with healthcare workers as is inferred from the
chi-square values. Results show that higher interaction with healthcare providers is
associated with higher age at marriage, literacy and higher educational levels,
participation in paid work, higher autonomy in terms of decision making, movement
and control over household resources, egalitarian approach in gender role attitudes,
exposure to mass media, high monthly household income and a high SLI.

216
6.2.5 SELF REPORTED GYNAECOLOGICAL AILMENTS

Gynaecological ailments refer to diseases of the female reproductive system. Women

were asked to report symptoms of certain gynecological ailments during the past 6
months of the survey

Table: [Link] Self Reported Gynaecological (Reproductive) Ailments of Women

During the Past 6 Months

Self Reported Gynaecological Ailments Percentage Distribution of Women

of Women (N=531)
Reported 273 (51%)
Not Reported 258 (49%)
Source: Field Survey Data

The table ([Link]) shows that about 51% of the women gave self reported accounts of
their gynaecological ailments while 49% of the women did not report anything. The
women who reported to have experienced a gynaecological ailment were further
probed for the kind of symptoms they suffered from. The following table shows the
percentage distribution of women by their chief symptoms of gynaecological
ailments.

Table: [Link] Percentage Distribution of Women by their Symptoms of

Gynaecological Ailments

Gynaecological Ailments / Symptoms suffered from Percentage Distribution of

during the last six months (N = 273) Women
Abnormal Vaginal Discharge 52(19%)
Vaginal discharge accompanied by itching, bad odour, 46(17%)
abdominal pain and fever
Irregular Menstruation 33(13%)
Symptoms of Urinary Tract Infection(UTI)- Pain, 115 (42%)
burning sensation while passing urine, abnormal
frequency of urination
Pain during intercourse 23(8%)
Bleeding during intercourse 4(1%)
Note: Women asked to report one chief symptom only.
Source: Field Survey Data

217
The above table ([Link]) shows that the most common symptom exhibited by women
is the symptom of UTI. The reason behind this is obvious. Slum women either use a
common toilet or go out in an open area. The common toilets if any are unhygienic
and reservoirs of germs, the water supply in most slum areas is inadequate; many
areas have to depend on nearest pond water which is filled with water hyacinth.
Women are forced to clean themselves with a mug full of water. All these breeds
infections that affect their genitalia. 19% and 17% of the women reported to
experience abnormal vaginal discharge and discharge accompanied by itching, bad
odour, fever and abdominal pain respectively. 8% and 1% of the women reported
having problems of pain during intercourse and bleeding during intercourse while
13% reported to suffer from irregular menstruation.

On UTI symptoms, a woman reported- “This is common to almost all ladies in our
area. Even the unmarried girls have these problems. Previously, I went to a doctor,
but he gave costly medicines. It was not possible to buy them the second time I had the
same problems. (Perhaps refers to antibiotics prescribed for UTI). If there is
unbearable pain, I go to the medical store and ask them to give a pain reliever. The
HHWs ask me to keep my genitalia clean by washing with water every time I urinate.
Where will we get so much water? Pond water is not very clean but we have to
depend on it mostly”.

On vaginal discharge, a woman said,

“I have abnormal vaginal discharge since my adolescence and it increased after

marriage. My mother said it was nothing and happens with all girls. My husband also
is not bothered about it. A few of my friends also have this problem. I have discussed
the problem with female HHWs and they advised me to go to the hospital. I feel shy to
tell about it to the hospital doctor since he is a male”.

A young girl of 15 years who has pain and occasional bleeding during intercourse
said,

“I have been married for 5 months. I told my husband about the problem. He said that
I am just making excuses for not having sex with him. I do not enjoy my sexual life
because of the pain I suffer from with each encounter. I also bleed sometimes after the

218
intercourse. My husband says it‟s nothing and assures to take me to a doctor once I
conceive. My parents stay in Bihar, so I cannot share this with her. So, whom to tell?
I cannot be so shameless to go to doctors and speak about it. Since nobody is listening
to us here, I can tell you. Once I visit my parents, I will ask my mother to accompany
me to a doctor”.

6.2.6. TREATMENT SEEKING BEHAVIOUR

Women who reported symptoms of gynaecological ailments were asked whether they
sought treatment from a health care provider.

Table: [Link] Actions Taken by the Women who Reported Symptoms of

Gynaecological Ailments
Of those who experienced symptoms, Percentage Distribution of Women
(N=273)
Sought Medical Treatment 157(58%)
Did not seek Medical Treatment 116 (42%)
Source: Field Survey Data

The table ([Link]) above shows that about 58% of the women who reported symptoms
sought medical treatment. Medical treatment here refers to treatment in any system of
medicine – allopathy, homeopathy, ayurveda etc. and from either public or a private
provider.

Bivariate analysis of actions of women who reported gynaecological ailments by their

treatment seeking behaviour against their social determinants is as follows-

Table: [Link] Percentage Distribution of Women with regard to their Treatment

Seeking Behaviour for Gynaecological Ailments by Social Determinants
(Background Characteristics)

SOCIAL DETERMINANTS NUMBER PERCENT

YES NO YES NO
Age at Marriage
<18 years 5 16 24% 76%
>18 years 152 100 60% 40%
Chi Square: 10.57 (Significant)
Literacy
Literate 126 56 69% 31%

219
 SOCIAL DETERMINANTS NUMBER PERCENT
YES NO YES NO
Illiterate 31 60 34% 56%
Chi Square: 30.7 (Significant)
Work Status
Working 124 59 68% 32%
Non working 33 57 37% 63%
Chi Square: 23.87 (Significant)
Autonomy
Low 48 80 38% 62%
Medium 87 31 74% 26%
High 22 5 81% 19%
Chi Square: 40.03 (Significant)
Gender Role Attitude
Low conformity to traditional gender 26 6 81% 19%
roles
Medium conformity to traditional gender 86 29 75% 25%
roles
High conformity to traditional gender 45 81 36% 64%
roles
Chi Square: 45.92 (Significant)
Mass Media Exposure
Exposure 149 93 62% 38%
No Exposure 8 23 26% 74%
Chi Square: 14.38 (Significant)
Standard of Living Index
Low 46 66 41% 59%
Medium 89 42 68% 32%
High 22 8 73% 27%
Chi Square: 21.29 (Significant)
Monthly House Hold Income (Rs.)
<5500 51 105 33% 67%
>5500 106 11 91% 9%
Chi Square: 91.74 (Significant)
Note:
1. Chi Square test has been conducted by using both positive and negative responses.
Significance (p < 0.05)
Source: Field Survey Data

220
All the determinants are seen to have a significant association with the treatment
seeking behaviour of women who suffered from gynaecological ailments. Treatment
seeking behaviour is seen to be higher in case of women who married after they
turned 18, women who were literate and who were engaged in paid work. Expectedly,
women who enjoyed higher autonomy sought treatment more compared to their
counterparts with medium or low autonomy. Women who are exposed to mass media
of any kind sought treatment more than those who were not exposed. Mass media
contributes to awareness and helps in translating it to a healthy practice. Women with
an egalitarian approach to gender role attitudes showed higher treatment seeking.
Higher Monthly household income and high SLI were found to be significantly
associated with treatment seeking behavior. This is obvious since money is the major
determining force behind treatment seeking.

6.2.7 REASONS FOR NOT SEEKING TREATMENT

The women who did not seek treatment in spite of them being affected by
gynaecological ailments were further asked as to why they did not consider seeking
treatment for their ailments.

Table: [Link] Percentage Distribution of Women by Reasons for Not Seeking

Treatment of Gynaecological Ailments
Reasons For Not Seeking Treatment of Percentage Distribution of
Gynaecological Ailments (N=116) Women
Problem Not considered Serious 70 (60%)
Embarrassment 37 (32%)
Unaffordable 34 (29%)
Inaccessible (In terms of Distance) 6 (5%)
Long waiting time 24 (21%)
Do not know where to go 22 (19%)
Note: The responses of women are mutually inclusive. A woman was allowed to
respond to more than one reason. Maximum of two reasons were allowed. The
percentage of women thus is more than 100%.
Source: Field Survey Data

221
The table ([Link]) shows the distribution of women according to their reasons for not
seeking treatment. Women were asked to point out more than one reason if they
thought all were applicable to her. It is found that 60% of the respondents do not
consider the problem to be serious, 32% feel embarrassed to speak about such a
sensitive issue, 29% consider that they will not be able to afford treatment, 5%
considers that the health care facility is far, 21% feel that they cannot afford such long
waiting times and 19% do not know where to go in case of such a problem.

A woman who do not consider problems like UTI or vaginal discharge to be serious
said –

“It is very common for a woman to have these problems. These are not serious
problems as they do not interrupt my daily activities. We have to learn to live with
them. Treatment is costly and meant for the riches and not us‟.

A woman who feels embarrassed by her problems said,

“I feel ashamed to discuss these problems. In the hospital, there are too many people
in the outdoors; privacy of the patients is hardly there. It is not possible for me to talk
about my problems in public”.

Another woman retorted back during in-depth interview when asked the reason of not
seeking treatment -

“The environment in which I live is unhygienic. There are scarcity of water and lack
of toilet facilities. I have to go in the open for urination and defecation. I face many
problems during the days of my menstruation. These cause so many health problems.
Going to the doctor once and getting treated do not end the problems I face since my
living conditions remain unaltered year after year. So, why unnecessarily spend
money on treatment unless it is too serious”? It is astonishing to see a woman analyze
her problems in such a logical manner. She realized that the real problem was not the
one that manifested in clinical symptoms, but the one which is rooted in the
environment she lives.

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A woman‘s reaction to affordability of treatment,

“I can afford consulting a doctor in the State General Hospital outdoors but what
about buying of medicines? Medicines are costly and I cannot afford to buy them. The
problems I have (vaginal discharge accompanied by bad odour, abdominal pain)
require long term treatment with such costly medicines. I have earlier tried remedies
by quack but it did not work”.

Another woman reacted,

“The State General Hospital outdoor is very crowded. One has to sit for 3-4 hours in
order to see a doctor. Sometimes, there is only one doctor to see so many patients.
Most of the times, the test facilities recommended by a doctor are not available there.
I work as a domestic help. The outdoors are in the morning till the noon which
coincides with my working hours. I will not get a leave from my employers in case I
need to go to see the doctors often. Once I lose my job, who is going to feed me?”

6.2.8 QUALITY OF CARE

Quality of care refers to quality of technical care as well as the art of care. Women
who sought treatment for their gynaecological morbidities and to receive pregnancy
related services were asked several questions on the quality of care received by them.

The table below shows the percentage distribution of women according to the
treatment they received from the care providers.

Table : [Link] Quality of Care Received from the Health care Provider
Of those who sought treatment for symptoms of Reproductive Percentage
Ailments, women who reported that- Distribution of
N=157 Women
They were treated with respect 82 (52%)
The need for their privacy was maintained 56(36%)
Provider was responsive enough to their needs 76 (48%)
They were advised to ask their husbands to use condoms during 143(91%)
sexual intercourse

They were asked to bring their husbands for check ups 134(85%)

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 Of those who sought treatment for symptoms of Reproductive Percentage
Ailments, women who reported that- Distribution of
N=157 Women
They were recommended lab tests 78 (50%)
They were counseled on HIV/AIDS and the ways to prevent it 126 (80%)
The care was affordable to them with ease 79 (50%)
Of those who attended health care facility to receive pregnancy
related services, number reporting that - N = 73

They were tested for their weights, B.P, blood and urine, abdominal 51(70%)
check ups

They were advised for need of proper nutrition and importance of 71(97%)
delivery at a health care facility

They were told about various danger signs during pregnancy and 55(75%)
where to go in case of complications

They were advised on breastfeeding, keeping baby warm and clean 43(59%)
and clean home environment

They were advised to adopt a contraceptive measure to delay the 23(31%)

next pregnancy

Their need for privacy was respected 73(100%)

Note: The responses of women are mutually inclusive. A woman was allowed to respond to
more than one statement. The percentage of women thus is more than 100%.

Source: Field Survey Data

The table ([Link]) shows that of the women who sought treatment for gynaecological
ailments, 52% reported that they were treated with respect, 36% stated that their need
for privacy was maintained, 48% reported that the provider was responsive to their
needs and 50% stated that they could afford such treatment with ease. As regards the
treatment and education of the patients, 91% said that they were advised to ask their
husbands to use condoms since condoms provide protection against STIs and
HIV/AIDS. 85% women were asked to bring their husbands for checkups. This is
vital for STIs and both the couples need to be screened for STIs since both run the
risk of contracting the disease through sexual encounter. 50% of the women were
recommended laboratory tests and 80% were counseled on HIV/AIDS and the ways
to prevent it.

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The table shows that of the women who visited health care facilities for causes related
to pregnancy, all (100%) of them reported that their need for privacy was respected.
97% were told about the need for proper diet and importance of institutional delivery,
75% told about the danger signs during pregnancy and where to go in case of
complications, 70% tested for their blood, urine, abdominal check up, weights and
B.P , 59% advised on breastfeeding and 31% women were advised to adopt a
contraceptive measure to delay the next pregnancy.

REFERENCES

Amnesty International, USA. (2016). “Sexual and Reproductive Health Rights”.

Retrieved from
[Link]
accessed on 02.05.2016

Hasan et al. (2013). “Influence of socio-demographic factors on awareness of

HIV/AIDS among Bangladeshi garment workers”. SpringerPlus, Vol. 2: 174
Retrived from [Link]/content/2/1/174 accessed on
04.12.2015

International Institute for Population Sciences (IIPS) and Population Council. 2010.
Youth in India: Situation and Needs 2006–2007. Mumbai: IIPS.

National Family Health Survey - 3. FactSheets- (2005-2006). India. Key Indicators

For Urban Poor In West Bengal.

Thappa, D. M., Kaimal, S. (2007). “Sexually Transmitted Infections in India: Current

Status (except human immunodeficiency virus/acquired immunodeficiency
syndrome).” Indian Journal of Dermatology, Serial online, Retrieved from
[Link] accessed on 04.08.2015

WHO (2015). Global Health Observatory Data, “Maternal and reproductive health”.
Retrieved from
[Link]/gho/maternal_health/reproductive_health/antenatal_care_text/e
n accessed on 03.02.2016

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 CHAPTER 7

7. SELECTED CASE STUDIES

Case studies are conducted in order to gain a greater understanding of a particular

object or person and add strength to already existing knowledge. This qualitative
research method help the researcher undergo a detailed contextual analysis. In the
words of Robert K. Yin, case study ―is an empirical inquiry that investigates a
contemporary phenomenon within its real life context; when the boundaries between
the phenomenon and the context are not clearly evident; and in which multiple
sources of evidence are used‖ (Yin, 1984, p.23). This chapter documents 12 pertinent
cases consisting of slum dwelling women and the Honorary Health Workers (HHWs)
in their own narratives as far as possible. Conduction of in-depth interviews with
women and HHWs led to the gathering of such narratives. Pseudonyms have been
used in order to preserve the anonymity of the subjects.

7.1 Case: 1

‗A‘ is a 16 year old girl who has been married for nearly a year. She had been to
Municipal school for her primary education but did not complete it. She has 4 other
siblings and is the eldest. She had been in the slum since her birth and has been
married in the same slum. Her father is a rickshaw puller while her mother acts as a
domestic help in 8 households in the neighbouring area. She was asked about her
schooling experience when she recalled – ―I was admitted in the school when I was 6
years old. I liked to go to school and study. The teachers were good and friendly. The
main attraction besides study was the mid day meal of the school. I used to bring it
back home and share and eat with my brother and sisters. Two years passed by. My
mother became very busy with her work outside home and often could not do the
household chores to meet the expectation of my father. We grew up seeing that my
father bet my mother blue if he did not have the meals cooked or household works
done according to his expectations. Verbal abuse was also very common. Being the
eldest child, I thought I should help my mother in her household chores. Slowly, I had
to take up majority of the household chores that included cooking, cleaning utensils,
feeding my brother and sisters, washing clothes and the like. I thus became irregular

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at the school and eventually dropped out. My brother began going to the school along
with two of my sisters. The youngest one was taken care of at home by me. I learnt to
read and write simple Bengali sentences at the school. I often helped and learnt new
things from my brother and sisters who were in school then.”

A had been married at the age of 15 years. She was asked about her early marriage
when she said – “I have been in love with a boy of our locality when I was 13. My
parents feared that I might elope or may engage into sexual relationship with the boy.
Those cause defamation in the family name. Initially they opposed a lot but seeing my
determination towards the relationship they got me married with the boy of my choice
when he got a job in a factory. I was happy that they agreed otherwise I had to elope
in order to marry.”

When asked whether she had any pre marital sex with her husband she answered –
“No, though he insisted. I feared what if I become pregnant and he refuses to marry
me then what would happen. So, I did not encourage him at all for this. Also, women
who have pre marital sex are considered as „bad‟ in our society.”

When asked about her sexual life post marriage she said – ―I have never said „NO‟ to
my husband. My mother and mother in law had taught me that being a wife it is my
job to please him and bind him in the relationship. Men get angry if refused and if this
happens often, they have the chance of going to another woman. So, I go by their
words. Though there used to be immense pain and sometimes bleeding during the
initial days of marriage, I was told that those were normal”.

She lacked ideas about use of contraceptive methods. She has heard the names of
Mala-D and condoms. Blushed a lot when asked, whether they use any. “My husband
says that it is for the men to know and take decisions about the use. I need not know
about them right now. To prevent children from coming is to deny God‟s blessings.
So, why do so? I leave all these decisions on him. He being older and the husband
would always take the right decision.”

When probed whether she knows the dangers of pregnancy of an adolescent, she said
– “those are for the big people and the riches. A few of my friends are already

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mothers. I was born when my mother was of my age. My in laws also want their
grandchild from me now. After all it‟s close to a year we got married and everybody
is expecting good news from us”.

7.2 Case: 2

‗X‘, a 26 year old woman was married at the age of 18 years. She was originally a
resident of rural Bihar who had come to Uttarpara slums after marriage. Her husband
is a rickshaw puller. She is the mother of 3 children. She is a homemaker. She looked
anaemic and underweight. Her first child was born after a year of marriage. She has
always faced abuse and violence at home from her husband. According to her, ―verbal
abuse is very common in the slums...we face it daily...physical abuse in the hands of
husband is also common especially when the husband is drunk. My husband comes
back home drunk everyday and rebukes me. In our one room dwelling, it happens in
front of my children. They also learn abusive languages from their father”. When
asked about sexual relationship with the husband she said “can a woman say no to
her husband? Even if I say no, he will not listen to it and force me to have sex with
him. He does not stay away from having sex with me even when I am pregnant. I lost
one of my children in my second trimester when I refused sex one day and he hit me in
my lower abdomen badly with random kicks”. She was asked whether she had lodged
any complaints in the local police station against her husband. She replied that ―if I do
a police complaint my husband will be arrested...who is going to feed me and my 3
children then? He is no doubt bad but it is he who earns bread for the family”.

She was asked why she did not feel the need for earning herself. She replied that “I
am illiterate. I do not know any type of hand work also. The only thing I have learnt
since childhood is to do household chores. The job which I will get will be of a
domestic servant. We being Brahmins cannot wash utensils at someone else‟s home.
Moreover, my husband does not want me to go out and work even if we do not have
two square meals a day. I however can move out to the local market unaccompanied
in order to buy things but have never been out of Uttarpara on my own”.

She is the mother of 3 children. She was asked whether she has heard about family
planning measures. She said that ―The health worker didis have told me about it. But

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what is the use? My husband is drunk every night and spends most of his earnings on
alcohol. A drunken person cannot be asked to put on a condom. Moreover, we do not
have money to spend on condoms. As regards me, I have taken pills provided by the
health centres a couple of times but those are available on an irregular basis. So, I
have been subjected to unplanned pregnancies‖. She was interrogated that whether
she has heard of safe abortion services in case of unintended pregnancies. She replied
that ―my husband will kill me if he hears that I have resorted to those things. I do
know from other women that such things are available but did not dare to ask for such
services even when my pregnancies were unplanned and unintended”. She was
further asked that whether she has heard of a permanent method of contraception. Her
reply was ―yes...ligation. But, my husband is against it also. He thinks that the
operation will interfere with my ability to please him during sex‖. She then asks “Can
it be done without letting my husband know about it? Does the operation leave scars
on the abdomen? If so, my husband will come to know about it and drive me out from
the house”.

7.3 Case: 3

‗Z‘ is a 40 year old woman with 5 daughters. She used to work as a domestic help in
certain households of the locality but currently did not work due to health conditions.
Two of her daughters are married. She was married at the age of 14 years and had her
first child at the age of 16 years. She has history of 2 spontaneous abortions, 1
stillbirth and 1 neonatal death. Her last child was born when she was 38 years old. In
her words “I was humiliated by husband and in laws for giving birth to a daughter the
first time. They did not accept her well and my first child suffered from neglect right
from her birth. Because of their fear I also could not treat her well. Within a year
after the birth of my first daughter I became pregnant again. I was young...did not
recover from weakness resulting from the birth of the first child but I was pressurised
by husband and in laws to conceive again. This time by seeing the pregnancy
symptoms they thought it would be a boy, but to all our misfortune, it was a girl
again. Tortures increased...not only on me but also my two daughters. We left our
village in Uttar Pradesh and came to Uttarpara slums since my husband got a job at
a nearby brick klin. I did not ever adopt any family planning method since my

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husband and in laws were orthodox and they wanted me to give birth to a son. I had
two spontaneous abortions – one in the first trimester and the other in the second
trimester. Both times doctor said that I was too weak to hold the foetus. In order to
help my husband run the family I took up job as domestic help in few households in
the locality. In the meantime, I gave birth to 3 more daughters. The elder daughters
were married off at our native place when they reached adolescence. Younger ones
stay with us here. After I started working I understood the importance of studies. So, I
began sending my daughters to the local municipal school. The households where I
work help me with buying their books and sometimes their studies. But desire for a
boy child had remained with my family. So, without caring about my health I became
pregnant again. On full term, I experienced a pain in my abdomen and also loss of
foetal movement. I was rushed to the Rajbari Hospital where I gave birth to a still
child. This time it was a boy. My sob had no limits. Two years after that I conceived
again. My health conditions deterred during the pregnancy and I was referred to
Kolkata Medical College. There I had a pre term delivery and the baby was grossly
underweight. This time again, it was a son. Two days later, the baby died because of
malnutrition and underweight. This time I had a ligation done. My daughters asked
me to do it for the sake of my life. They confronted their father and said I will die if I
am subjected to pregnancy anymore. The doctors also said that I had a uterine
prolapse and was advised not to do any hard laborious work. Since then, I had left
working as domestic helps. I stay at home now. Household chores are mostly taken
care of by my daughters. One of them has learned knitting on machines. She has
begun earning a little. I want them to stand on their feet and earn for themselves. I
now understand that there is no difference between a son and a daughter. My
daughters will prove it to their father and grandparents also one day”.

7.4 Case: 4

‗R‘ is a woman of 26 years and is the mother of a daughter and a son. Her daughter is
7 years old while the son is 5 years old. Her son is blind from birth. She had migrated
to Uttarpara slums about three years back. She is currently forsaken by her husband
and earns her bread by engaging herself as a domestic help in neighborhood
households. She has been married at the age of 18 years. Her in laws have been

230
inflicting certain tortures on her since her marriage. She was pregnant one year after
marriage. Even during her pregnancy she had to do all household chores which
included bringing drinking water from a far away tube well in her native place. She
recalled ―my mother in law said that the more you work, the more it is easier to
deliver baby. So, I had to procure water in matkas from far away tube well in the
village. I was not given adequate food. My in laws said that if the stomach is too full, I
would not be able to work much. They took me to traditional healers who
recommended tying of amulets so that I deliver a baby boy”. Situations turned worse
for her when she delivered a baby girl. She was forsaken in a shed along with her
child. No attention was given to the cleanliness of the place where she stayed along
with her new born. She was served twice with food but her husband and in laws
refused to see her daughter‘s face. She said ―as I did not have enough food during
pregnancy and after childbirth, I was very weak and so was my child. There was not
enough production of breast milk to feed my baby”. After some days, few villagers
acted as mediators to improve the situation. She again became pregnant after a year.
She was not allowed to register her pregnancy and received treatment from the
traditional healers in case of need. She was asked whether she faced any problem
during her pregnancy. She reported “I suffered from high fever and rashes on my
body when I was in my 20th week of pregnancy. I insisted to take me to a doctor but
my husband and in laws said that one should not take resort of angreji dawai
...instead desi dawai from the traditional healer will help. I could not do anything but
submitted myself to their wishes. The fever subsided after 7 days leaving me very
weak”. She was delivered again at home by traditional birth attendant. The birth was
premature. She delivered a baby boy this time. Everybody at home was happy. After
few months she discovered that her son cannot see. She explained ―when I took him
outside the rooms the bright sun did not cause any reflex of closing the eye lids in
him. After noting this number of times I insisted my husband to take him to an
allopathy doctor. This being a son, my husband did not resist. We took him to the
doctor and after undergoing a couple of tests the doctor concluded that he is blind
right from his birth”. Analysis of her narration led to the assumption that she might
have suffered from Rubella during her pregnancy which might have led to blindness
in her child.

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On asking whether she thought of another issue, she said ―after two bad experiences I
refused to be mother again. Also parenting a blind child is a huge task. So, I opted for
a ligation at the local health centre for which I received money from the
Government”.

7.5 Case: 5

‗Q‘ is a woman of 20 years who is currently pregnant. She is in the second trimester
of her pregnancy. She stays with her husband and in laws. Her mother in law is very
suspicious about the whole interview process and though she exits the room during
the interview, her ears remains open to it. R is married for about one and a half years.
She has studied up to the 11th standard before she got married. Her husband is studied
till the 5th standard. He works in a factory. When she was asked that why she did not
continue with her studies, she replied “I wished to. But, studying in higher classes
needs a lot of money. Besides the classes one needs to have private tuitions also. My
father could not afford it and decided to marry me off”. She was then asked that
whether she has heard about sexual health, sexual abstinence, and use of
contraceptives for family planning before and after her marriage. She replied “my
family is very orthodox and nobody speaks about these kinds of things there. It is
against our religious beliefs. My family thinks that if an unmarried girl knows about
these things before marriage, it will elicit premarital sex. After marriage my mother
in law made it very clear to me that I should not do anything to prevent being
pregnant. So, I am barred to speak to didis of the health centres since it is them who
speak about controlling births”. She added “I will be prevented to speak to you also if
my mother in law gets a hint that you are asking me these things”.

She was further asked that whether she has ever heard about sexually transmitted
diseases and the ways it could be prevented. She responded “in the school I have
heard about HIV/AIDS...also seen it in the T.V...There‟s a woman called Buladi who
advises others to get certain things done. But, I don‟t know anything in details about
it”. She was asked whether she had protected sex with condoms used by the husband.
She said “my husband has never used it‖.

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On getting her registration for pregnancy done at the local government hospital, she
said ―my in laws did not object much since I am given all medicines free of cost and
can get my tests done for free. I have also heard that would be mothers get a financial
incentive for delivering in the hospital. So, seeing these benefits my in laws registered
me with the local hospital. In our poor household if we can save money on medicines
and cost of delivery, it means a lot for us”.

7.6 Case: 6

‗B‘ is a woman in her mid 30s married for 14 years. She is the mother of 3 children.
Her husband is a van puller. She is illiterate and is a home maker. She was asked
about her take on family planning. She explained “I understand the importance of a
small family in households like us who find it difficult to have two square meals a day.
But, where does the money come from to spend on methods of contraception? My
husband did not approve of tubal ligation till a few years from now‖. She is currently
ligated so, she was probed further on what motivated her to get permanently sterilised.
She said “we cannot afford to buy pills or condoms regularly, so, there is always a
chance of unintended pregnancy. After 3 children, I became pregnant again. There
was turmoil then in my family and my husband was very disturbed. So, I did not have
the courage to share this news with him. I confided this to a friend of mine and said
that I did not want to become a mother again and would like to abort the baby without
my husband knowing about it. She took me to a traditional healer and requested him
to do something to get rid of the unborn baby. He gave me some tablets to be
consumed for the next two days and asked me to take them according to his
instructions. He promised to keep the entire incident confidential. I took the tablets
and after the first day of consuming the tablets I began to bleed through my vagina
profusely. I was getting weaker with so much bleeding. It continued on the second day
also. I lost my senses on the third day and turned white due to loss of so much blood. I
was taken to the nearby hospital where doctors said that I had an incomplete
abortion. I was enquired about the place from where I sought the abortion service. I
had to reveal now both to the doctor and also to my husband. I was given 3 units of
blood and underwent an operation. Doctor in the hospital scolded me and told me
about my rights to a safe place of abortion. He then counselled both me and my

233
husband on the need of family planning. 6 months after this incident I opted for
sterilisation operation”.

7.7 Case: 7

‗C‘ is a young girl of 16 years who is married for the last 3 months. When asked the
reason for early marriage, her reply was “I have 2 more sisters. If my parents do not
marry me early my sisters in turn will have late marriage. My father does not have
means to feed his daughters lifelong. Besides, in our locality, most of the girls get
married early, some even elope”. She had suffered from problems in menstruation
when she saw a gynaecologist during her visit at the health subcentre. The doctor told
her that she is malnourished and has an underdeveloped pelvis. She also cautioned her
not to opt for a pregnancy right now since her body is not yet ready to bear a child.
When asked that whether she has discussed these with her husband, she replied ―there
is no use discussing with him now...after marriage every girl has to conceive,
otherwise people look down upon her...women who are unable to bear a child are
socially isolated…even people avoid seeing their faces in the morning…it is said that
they are unlucky..”. She was asked whether she will abide by the doctor‘s advice
concerning her child bearing she said “I wish to… I understand that if I am unhealthy,
my child will be unhealthy too...but making my husband understand this will be a
problem...till he understands I will have to resort to pills to prevent pregnancy...but I
will have to hide it from him in the beginning...He is influenced by my mother in law
who is against this family planning”. She was further probed that whether she will be
able to keep her taking oral contraceptive pills a secret, she replied “I work as a
domestic help in 4 houses...so I will have money to buy them if they are not available
for free at the subcentres. I will keep them in one such house in order to hide them
from my husband. Since I go for work every day consuming the pills over there would
not be a problem...I even plan to take my husband once to meet the doctor at the
health centre...if she can make him understand, I don‟t think there will be any
difficulty...we both can then plan for our baby at the right time…but till then, it is my
responsibility to preserve my health rights”.

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7.8 Case: 8

‗D‘ is a woman in her 40s having 4 children. She is illiterate and is a home maker.
She has been in the slum since her marriage at the age of 18 years. The slum she lives
in is unhygienic. The water source is located in the main road away from the slum.
The houses are mostly katcha houses with thatched roofs. She has undergone ligation
after the birth of her 4th child. She has not used any temporary family planning
method earlier to avoid or space pregnancies. Her husband is also a non-user of
family planning methods. Two of her children were delivered at home while two were
delivered at the State General Hospital. She was asked whether she has heard about
STIs including HIV/AIDS. She said “I do not know to read and write…neither do I
have a radio or a television, how do I know the names of these diseases”? A further
probe was made to know whether the health workers have ever told her about any of
these diseases and how they might be contracted. She replied “health workers have
visited me during my pregnancy…they have advised me to go to the hospital for
delivery..I have complied during my last two pregnancies…but about these diseases
they have never told me anything”. She was cited some of the symptoms of the STIs
and asked whether she has ever encountered these. She said ―I have problems of
vaginal itching and irritation and sometimes abdominal pain…there is bad odour
from the vagina also..I have been to the local health subcentre to see the doctor
once…she wrote down a few medicines but I could not buy them due to their higher
costs… these problems subside after some days but recur”. She was told that keeping
private parts hygienic is one of the ways in which these can be avoided. She replied ―I
know that a woman needs to clean her private parts with water every time after
urination, but tell me where do I get so much water? Sometimes I have to spend my
entire day with only one bucketful of water…in these circumstances spending water
over personal hygiene is a luxury”. She continued ― many women suffer from these
symptoms here…I knew now only that this is a disease, we thought this to be a part of
our normal lives…unless our living condition change I don‟t think I can get rid of the
disease”.

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7.9 Case: 9

‗E‘ is a woman in her early 30s having two children. She is a slum resident since birth
and has been married in the same slum. She has read till Std IV and is able to read and
write simple Bengali sentences. She works at a nearby bindi making factory. She is
currently ligated. She sends her children to school and her husband works as a mason.
Both her children were delivered in the local State General Hospital. When asked
about her views on need for family planning, she said “it is very necessary to limit the
number of children to two…I believe that if you have two children, you can raise them
up properly..More children will have adverse effects on the family economy, mother
and child health and you won‟t be able to provide them a decent upbringing…In
today‟s life it is difficult to run household through single income, thus I have taken up
a job so that I can at least give my children what they require‖. When asked where
she got the knowledge from, she replied “I used to work as a domestic help earlier in
the house of a lady teacher. She made me understand that how it is important for a
girl to stand on her own feet and earn…this gives you a say regarding your rights”.
She was asked whether she has heard about reproductive rights. She replied “every
woman should be able to decide when she wants to have a child…childbearing is
exclusive for women, so, why shouldn‟t she decide”? She explained that “earning
money helped me to buy OCPs to space and prevent further births after my first child.
My husband also did not say anything about the pills since I was buying them with my
money”. She continued “my job has given me exposure..I can discuss my
reproductive health problems with my married female colleagues, get suggestions
from them…sometimes I also advise them on certain issues…I have learnt about
diseases that one can have through sex, I heard about HIV/AIDS from
television…have become cautious. She was asked about safe sex practices when she
said “I have been successful in getting my husband ready to use condoms during
sex…we buy them, we also look for them in the sub centres”. She was probed further
regarding her decision about ligation. She answered ―it was a mutual decision of me
and my husband… the decision was going to affect both of us, so, we discussed
amongst ourselves and nodded for the operation…we can have a tension free sexual

236
life now..I am thankful enough to my husband that he has understood this and given
my health and our children‟s well-being a priority”.

7.10 Case: 10

‗T‘ is a 35 year old female who has been married at the age of 19 years. Her first child
was born after 5 years of marriage. She had her second child 4 years after the first.
She works at a dye factory as a daily wage labour. She has studied up to Std 7. She
was asked about the huge gap between her marriage and first child bearing. She
answered ―when I got married my husband was 21 years old and did not have a fixed
earning. I have seen poverty at my house since my childhood. I studied till class 7 so
that I can get a job for myself. I started my job before my marriage. I understood that
financial independence leads to power. It helped me to take my own decisions. When I
got married I made it clear to my- in- laws family that I would not quit my job. My
husband and I took a conscious decision that till we both have an income to support
all needs of our child; we would not opt for a child. I communicated this to my in laws
also so that they do not pressurize us for their grandchild. Both of us used protective
devices to prevent conceiving. Finally, when we thought that we are financially secure
to support a child we opted for it. For the second child also we followed the same. I
could secure my right to reproduction this way only because I was financially stable.
Financial security ensured protection of my reproductive health rights”. When asked
about their current practice of family planning she replied ―my husband has
undergone a vasectomy operation two years after the birth of our second child”. She
was further probed regarding what motivated her husband to undergo a vasectomy.
She replied that “the health worker didis made us understand the permanent methods
of contraception. They said that vasectomy is far easier than tubal ligation. They
weeded out all the misconceptions that my husband had about the procedure of
vasectomy. Once satisfied he readily agreed for vasectomy”.

7.11 Case: 11

‗G‘ is an Honorary Health Worker (HHW) who is working in the subcentre for 15
years. She has worked with the slum population for a major part of her working
career. She was asked about changes she has been witnessing in the slum population

237
of Uttarpara regarding their reproductive health. She replied that ―there has been a
tremendous change in the slum population with regard to various aspects of
reproductive health. Today‟s slum inhabitants are more informed about family
planning, institutional delivery etc. Credit mostly go to the mass media like television
and radio apart from us disseminating such information”.

She was asked whether they have been able to ensure 100% institutional delivery, she
replied ―thanks to projects like Janani Suraksha Yojna by the Government which
made it easy for us to convince slum women. Since there is a financial incentive given
to mothers for institutional delivery and also medicines are supplied to women free of
cost, we do not face much problems to convince pregnant women for institutional
delivery...However, in some stray cases where the family is conservative we need to
convince them a little harder. But, nowadays, these cases are rare”.

She was asked about the adoption of family planning measures by the slum
population. She replied that ―people now are interested in limiting families. Everyone
understands the benefit of having a small family. It is prominent especially among
those women who are literate and in some kind of job. Problem with this population
is that most of them depend upon contraceptive measures like oral contraceptive pills
and condoms to be supplied to them for free. Most cannot afford to buy them from
medicine shops on a regular basis. The supply we receive from the hospital barely
meets the needs of the people. Supply being scarce or sometimes absent, coupled with
inability to buy them from outside often brings about unintended pregnancies in slum
dwelling women. Therefore, whenever we find that a woman has had 2 children or
more and one of the children is a boy, we insist that she goes for a permanent method
of contraception. Thus, you will see that women who have had a permanent method of
contraception are quite high in these populations”.

She was probed further by saying that why don‘t they tell them about long term
temporary methods of contraception. She said ―it is useless. Even if we tell them, we
would not be able to provide the facility to them for free. Hospitals like Mahamaya
don‟t do IUD insertions. We also don‟t have such facilities in the subcentres. So, it‟s
better to get rid of the recurrent problem of temporary contraception by adopting a

238
permanent method like ligation”. She was asked that whether health workers have
been successful in motivating the married males undergo a sterilization operation
instead of the females. She said ―in my entire career of 15 years I have come across
only two males who have undergone a sterilization operation. Somehow, the males
across all segments of the society feel that the responsibility of family planning rest on
the females. Also I have seen that males have many myths about vasectomy operation
and many relate it to the loss of their sexuality”.

7.12 Case: 12

‗I‘ is an Honorary Health Worker (HHW) who has been in service for 18 years. She is
also a person who has worked with the slum population for a considerable part of her
career as HHW. She was asked about the tools they use in order to disseminate
information regarding various aspects of reproductive health. She replied that ―we go
door to door and tell the people about family planning and importance of ANC and
institutional delivery. We also disseminate information on mother and child care
whenever the women come to the subcentres with their children for immunisation.
Sometimes there are printed pamphlets given to us by the Municipality on these
matters, but, it works best whenever we tell it to them personally by visiting them.
Pamphlets are generally thrown away after sometime, or, it is totally useless for
people who are illiterate or who don‟t know Bengali‖. She was probed further on their
use of audio-visual media or flip charts to disseminate knowledge. She replied “5-6
years back we used to have certain shows with the help of audio-visual media in the
subcentre to disseminate knowledge regarding various aspects of health. The
response was also enormous. But, now we do not have such programmes any more. I
do not know the reason, must be some issues at the higher level but it is undeniable
that seeing is believing and believing is learning”.

She was asked that, what is the level of knowledge of the slum population regarding
common gynaecological illnesses and STDs? She replied that ―honestly speaking, we
ourselves are not very conversant with these illnesses, so we can hardly disseminate
knowledge about these illnesses and how to prevent them. However, in case of
common symptoms like vaginal itching, abnormal discharge etc, we ask them to go to

239
the Government hospital. But, most women are reluctant to do so since the check up is
at a subsidised rate but not the medicines. Hardly can these women afford such costly
medicines. In fact, some of the slums are pathetic in terms of hygiene, so, urinary
infections are very common. They have learnt to live with it now”.

When asked about STDs, she said that ―I have only heard about HIV/AIDS from the
radio and the television. We did not have any training programme in recent times to
keep us updated about various diseases so that we are equipped to teach the
population we cater to. In general, we know about the ANC, importance of
institutional delivery, immunisation and family planning methods. We have a poor
supply of condoms and OCPs in the subcentres, so we are unable to cater to the entire
population‟s need with these limited resources”.

REFERENCE

Yin, Robert K. (1984). “Case Study Research: Design and Methods.” New
Delhi/London: Sage Publications, p.23

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 CHAPTER 8

8.1 MAJOR FINDINGS

Analysis of quantitative data reveals that all social determinants have a major bearing
on the knowledge and practice of different aspects of reproductive health. (Table:
8.1.1 – 8.1.7)

 It is seen that higher age at marriage (equal to or more than 18 years) is

associated with greater levels of knowledge with respect to female
reproductive cycle, family planning basics, knowledge of HIV/AIDS/STIs,
contraceptive knowledge, knowledge of abortion, and that of pregnancy,
ANC, delivery and PNC. The chi-square values of age at marriage against
each of the reproductive health aspects show a significant relationship
between the two. The value of Cramer‘s V/phi shows moderate to strong
associations between the variables. Strongest association is suggested
between higher age at marriage and knowledge of contraceptive methods and
higher age at marriage and knowledge of pregnancy, ANC, childbirth and
PNC. A similar finding is arrived at on analysis of age at marriage with
practice of various aspects of reproductive health. Higher age at marriage is
seen to bear a significant relationship with ever and current use of family
planning practices, interaction with health care providers and treatment
seeking for gynaecological problems. The relationship between age at
marriage and choice of place of delivery however is insignificant. This can be
explained on the basis of the fact that in an urban set up like Uttarpara, the
hospitals are well accessible to all, provide free checkups and delivery, thus,
institutional delivery is preferred by all irrespective of the women‘s age at
marriage. The Cramer‘s V/phi value show particularly strong association
between age at marriage and ever and current use of family planning methods.
It suggests that the higher the age at marriage, greater is the tendency to
practice family planning methods.

 Literacy plays a significant role in contributing to knowledge of reproductive

health aspects and translation of such knowledge to practice. The study results

241
 also echo the same findings. Knowledge of all aspects of reproductive health
is seen to bear a significant relationship with literacy and values of Cramer‘s
V/phi suggest strong to very strong association. The association is notably
very strong between literacy and knowledge of various contraceptive
methods. A significant relationship of literacy is again seen with practice of
various aspects of reproductive health. Strong association is indicated
between literacy and ever and current use of family planning methods as well
as between literacy and treatment seeking in case of gynaecological ailments.

 Women‘s engagement in paid work is seen to affect both knowledge and

practice of reproductive health aspects as indicated by the analysis. All
aspects of knowledge – female reproductive cycle, family planning basics,
knowledge of HIV/AIDS/STIs, contraceptive knowledge, knowledge of
abortion, and that of pregnancy, ANC, delivery and PNC are found to be
significantly associated with paid work status of women. Paid work status is
found to be significantly associated with reproductive health practices with
respect to ever and current use of family planning practices, interaction with
health care providers and treatment seeking for gynaecological problems.

 Autonomy in women is said to affect their knowledge and practice of health

and reproductive health is not an exception. Autonomy shows a significant
association with knowledge of reproductive health aspects as reflected by the
study results. This signifies that women with higher autonomy are likely to
have more knowledge of reproductive health than women with moderate and
low autonomy. The same result is reflected in the practice of reproductive
health also. Only in the case of choice of place of delivery, the association
stands insignificant. This can again be explained on the basis of availability,
affordability and accessibility of childbirth services in the study area.

 Results of bivariate analysis shows that there exists a significant association

of conformity to traditional gender roles and knowledge and practice of
reproductive health aspects. There exists a strong association of gender role
attitude with female reproductive cycle, family planning basics, knowledge of
HIV/AIDS/STIs, contraceptive knowledge and knowledge of abortion. This

242
 signifies that women with low conformity to traditional gender role attitude
show higher levels of knowledge in the above mentioned areas of
reproductive health. Similar significant relationship is shown in case of
reproductive health practices too, with one exception, i.e., the choice of place
of delivery. The rationale behind it has already been explained in the previous
paragraphs.

 Mass media is a powerful tool to disseminate knowledge among the people.

Mass media exposure is found to be significantly associated with all the
aspects of reproductive health knowledge under study. The Cramer‘s V/phi
values suggest moderate to strong to very strong association between the
variables. The strongest association is reflected in the relationship between
mass media exposure and knowledge of contraceptive methods. The
significant association of mass media with knowledge has been transformed
to reproductive health practices also. All aspects of practice are found to have
significant association with mass media exposure. The strongest of the
association is reflected with choice of place of delivery. This is suggestive of
the fact that the Government has been able to successfully deliver the
message of importance of institutional delivery to the masses along with a
number of incentives to be given to women for adopting institutional delivery.

 Both the determinants – monthly income and standard of living index (SLI) is
seen to have a bearing on the knowledge and practice of reproductive health
aspects. The relationship of monthly income with knowledge of
HIV/AIDS/STIs stands insignificant. A previous study in Bangladesh also
supports the same findings. Knowledge of female reproductive cycle, family
planning basics, HIV/AIDS/STIs, contraceptives, abortion, and that of
pregnancy, ANC, delivery and PNC have significant relationship with both
monthly income and SLI. Similar result is obtained for practice also in
relation to monthly income and SLI. Monthly income is seen to have a
particularly strong association with treatment seeking behavior. This is self
explanatory since medical treatment is a costly affair and very few can afford
it in the slums.

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The above findings have been arrived at from the following tables (8.1.1 – 8.1.7)
computed by the Researcher for quantitative data analysis.

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TABLE. 8.1.1. RELATIONSHIP BETWEEN SOCIAL DETERMINANT VARIABLES AND KNOWLEDGE OF REPRODUCTIVE HEALTH ASPECTS

SOCIAL KNOWLEDGE OF PEARSON’S YATE’S D.F. p- RESULT* CRAMER’S MEASURES

DETERMINANTS REPRODUCTIVE CHI-SQUARE CORRECTION (d.f.) VALUE PHI / V OF
HEALTH ASPECTS FOR ASSOCIATION
CONTINUITY
AGE AT FRC 24.05 22.44 1 <0.0001 Significant 0.2128 Moderate
MARRIAGE HIV / AIDS & STIs 24.36 22.74 1 <0.0001 Significant 0.2141 Moderate
CONTRACEPTIVE 55.73 52.43 1 <0.0001 Significant 0.3240 Strong
<18 Years METHODS
>18 Years FPB 23.33 21.75 1 <0.0001 Significant 0.2096 Moderate
INDUCED ABORTION 22.95 21.37 1 <0.0001 Significant 0.2079 Moderate
PREGNANCY, ANC, 65.28 62.33 1 <0.0001 Significant 0.3506 Strong
CHILDBIRTH, & PNC
LITERACY FRC 106.79 104.6 1 <0.0001 Significant 0.4485 Strong
HIV / AIDS & STIs 108.48 106.27 1 <0.0001 Significant 0.4520 Strong
Literate CONTRACEPTIVE 136.48 133.14 1 <0.0001 Significant 0.5070 Very Strong
Illiterate METHODS
FPB 126.44 124.04 1 <0.0001 Significant 0.4880 Strong
INDUCED ABORTION 26.40 25.31 1 <0.0001 Significant 0.2230 Moderate
PREGNANCY, ANC, 53.95 52.24 1 <0.0001 Significant 0.3187 Strong
CHILDBIRTH, & PNC
WORK STATUS FRC 48.59 47.29 1 <0.0001 Significant 0.3025 Strong
HIV / AIDS & STIs 20.89 20.04 1 <0.0001 Significant 0.1983 Weak
Working CONTRACEPTIVE 77.48 75.27 1 <0.0001 Significant 0.3820 Strong
Non Working METHODS
FPB 51.9 50.55 1 <0.0001 Significant 0.3126 Strong
INDUCED ABORTION 43.13 41.89 1 <0.0001 Significant 0.2850 Moderate
PREGNANCY, ANC, 26.48 25.42 1 <0.0001 Significant 0.2233 Moderate
CHILDBIRTH, & PNC
*Significance Level (0.05) Source: Computed by the Researcher

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TABLE. 8.1.2. RELATIONSHIP BETWEEN SOCIAL DETERMINANT VARIABLES AND KNOWLEDGE OF REPRODUCTIVE HEALTH
ASPECTS
SOCIAL KNOWLEDGE OF PEARSON’S YATE’S D.F. p- RESULT* CRAMER’S MEASURES
DETERMINANTS REPRODUCTIVE CHI- CORRECTION (d.f.) VALUE PHI / V OF
HEALTH ASPECTS SQUARE FOR ASSOCIATION
CONTINUITY
AUTONOMY FRC 59.35 N.A. 2 <0.0001 Significant 0.3343 Strong
HIV / AIDS & STIs 76.76 N.A. 2 <0.0001 Significant 0.3802 Strong
Low CONTRACEPTIVE 22.16 N.A. 2 <0.0001 Significant 0.2043 Moderate
Medium METHODS
High FPB 94.53 N.A. 2 <0.0001 Significant 0.4219 Strong
INDUCED ABORTION 89.96 N.A. 2 <0.0001 Significant 0.4116 Strong
PREGNANCY, ANC, 50.74 N.A. 2 <0.0001 Significant 0.3091 Strong
CHILDBIRTH, & PNC
GENDER ROLE FRC 74.33 N.A. 2 <0.0001 Significant 0.3741 Strong
ATTITUDE HIV / AIDS & STIs 68.54 N.A. 2 <0.0001 Significant 0.3593 Strong
CONTRACEPTIVE 20.04 N.A. 2 <0.0001 Significant .04913 Strong
High METHODS
Medium FPB 48.97 N.A. 2 <0.0001 Significant 0.3037 Strong
Low INDUCED ABORTION 89.47 N.A. 2 <0.0001 Significant 0.4105 Strong
PREGNANCY, ANC, 39.86 N.A. 2 <0.0001 Significant 0.2740 Moderate
CHILDBIRTH, & PNC
MASS MEDIA FRC 23.48 22.28 1 <0.0001 Significant 0.2103 Moderate
EXPOSURE HIV / AIDS & STIs 41.26 39.67 1 <0.0001 Significant 0.2788 Moderate
CONTRACEPTIVE 182.24 177.7 1 <0.0001 Significant 0.5858 Very Strong
Exposure METHODS
No Exposure FPB 41.88 40.26 1 <0.0001 Significant 0.2808 Moderate
INDUCED ABORTION 28.87 27.53 1 <0.0001 Significant 0.2332 Moderate
PREGNANCY, ANC, 56.07 54.01 1 <0.0001 Significant 0.3250 Strong
CHILDBIRTH, & PNC
*Significance Level (0.05) Source: Computed by the Researcher

246
 TABLE. 8.1.3. RELATIONSHIP BETWEEN SOCIAL DETERMINANT VARIABLES AND KNOWLEDGE OF REPRODUCTIVE HEALTH
ASPECTS

SOCIAL KNOWLEDGE OF PEARSON’S YATE’S D.F. p- RESULT* CRAMER’S MEASURES

DETERMINANTS REPRODUCTIVE CHI- CORRECTION (d.f.) VALUE PHI / V OF
HEALTH ASPECTS SQUARE FOR ASSOCIATION
CONTINUITY
STANDARD OF FRC 24.74 N.A. 2 <0.0001 Significant 0.2158 Moderate
LIVING HIV / AIDS & STIs 50.89 N.A. 2 <0.0001 Significant 0.3092 Strong
CONTRACEPTIVE 25.78 N.A. 2 <0.0001 Significant 0.2203 Moderate
Low METHODS
Medium FPB 50.7 N.A. 2 <0.0001 Significant 0.3090 Strong
High INDUCED ABORTION 47.82 N.A. 2 <0.0001 Significant 0.3001 Strong
PREGNANCY, ANC, 35.33 N.A. 2 <0.0001 Significant 0.2579 Moderate
CHILDBIRTH, & PNC
MONTHLY FRC 91.9 90.22 1 <0.0001 Significant 0.4160 Strong
HOUSEHOLD HIV / AIDS & STIs 2.49 2.22 1 =0.1362 Insignificant - -
INCOME (Rs.) CONTRACEPTIVE 35.81 34.41 1 <0.0001 Significant 0.2597 Moderate
METHODS
<5500 FPB 214.31 211.75 1 <0.0001 Significant 0.6353 Very Strong
>5500 INDUCED ABORTION 129.63 127.63 1 <0.0001 Significant 0.4941 Strong
PREGNANCY, ANC, 50.14 48.77 1 <0.0001 Significant 0.3073 Strong
CHILDBIRTH, & PNC
*Significance Level (0.05) Source: Computed by the Researcher

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TABLE. 8.1.4. RELATIONSHIP BETWEEN SOCIAL DETERMINANT VARIABLES AND PRACTICE OF REPRODUCTIVE HEALTH
ASPECTS

SOCIAL PRACTICE OF PEARSON’S YATE’S D.F. p- RESULT* CRAMER’S MEASURES

DETERMINANTS REPRODUCTIVE CHI- CORRECTION (d.f.) VALUE PHI / V OF
HEALTH ASPECTS SQUARE FOR ASSOCIATION
CONTINUITY
AGE AT FPP- EVER USE 70.79 67.41 1 <0.0001 Significant 0.3651 Strong
MARRIAGE FPP- CURRENT USE 20.31 18.67 1 <0.0001 Significant 0.3541 Strong
PLACE OF DELIVERY 0.41 0.01 1 <0.9203 Insignificant - -
<18 Years INTERACTION WITH 16.69 15.36 1 <0.0001 Significant 0.1773 Weak
>18 Years HEALTHCARE
PROVIDERS
SEEKING 10.57 9.13 1 =0.0025 Significant 0.1968 Weak
TREATMENT FOR
GYNAECOLOGICAL
AILMENTS
LITERACY FPP- EVER USE 120.09 117.26 1 <0.0001 Significant 0.4756 Strong
FPP- CURRENT USE 12.88 11.70 1 =0.0006 Significant 0.2820 Moderate
Literate PLACE OF DELIVERY 8.23 5.42 1 =0.0199 Significant 0.2991 Moderate
Illiterate INTERACTION WITH 44.17 42.77 1 <0.0001 Significant 0.2884 Moderate
HEALTHCARE
PROVIDERS
SEEKING 30.70 29.28 1 <0.0001 Significant 0.3353 Strong
TREATMENT FOR
GYNAECOLOGICAL
AILMENTS
*Significance Level (0.05) Source: Computed by the Researcher

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TABLE. 8.1.5. RELATIONSHIP BETWEEN SOCIAL DETERMINANT VARIABLES AND PRACTICE OF REPRODUCTIVE HEALTH
ASPECTS

SOCIAL PRACTICE OF PEARSON’S YATE’S D.F. p- RESULT* CRAMER’S MEASURES

DETERMINANTS REPRODUCTIVE CHI- CORRECTION (d.f.) VALUE PHI / V OF
HEALTH ASPECTS SQUARE FOR ASSOCIATION
CONTINUITY
WORK STATUS FPP- EVER USE 46.07 44.53 1 <0.0001 Significant 0.2946 Moderate
FPP- CURRENT USE 30.38 28.64 1 <0.0001 Significant 0.4330 Strong
Working PLACE OF DELIVERY 9.08 6.07 1 =0.0137 Significant 0.3142 Strong
Non Working INTERACTION WITH 32.2 31.14 1 <0.0001 Significant 0.2463 Moderate
HEALTHCARE
PROVIDERS
SEEKING 23.87 22.61 1 <0.0001 Significant 0.2957 Moderate
TREATMENT FOR
GYNAECOLOGICAL
AILMENTS
AUTONOMY FPP- EVER USE 32.61 N.A. 2 <0.0001 Significant 0.2478 Moderate
FPP- CURRENT USE 8.49 N.A. 2 =0.0143 Significant 0.2289 Moderate
Low PLACE OF DELIVERY 4.77 N.A. 2 =0.0921 Insignificant - -
Medium INTERACTION WITH 62.02 N.A. 2 <0.0001 Significant 0.3418 Strong
High HEALTHCARE
PROVIDERS
SEEKING 40.03 N.A. 2 <0.0001 Significant 0.3829 Strong
TREATMENT FOR
GYNAECOLOGICAL
AILMENTS
*Significance Level (0.05) Source: Computed by the Researcher

249
 TABLE. 8.1.6. RELATIONSHIP BETWEEN SOCIAL DETERMINANT VARIABLES AND PRACTICE OF REPRODUCTIVE HEALTH
ASPECTS

SOCIAL PRACTICE OF PEARSON’S YATE’S D.F. p– RESULT* CRAMER’S MEASURES

DETERMINANTS REPRODUCTIVE CHI-SQUARE CORRECTION (d.f.) VALUE PHI / V OF
HEALTH ASPECTS FOR ASSOCIATION
CONTINUITY
GENDER ROLE FPP- EVER USE 22.40 N.A. 2 <0.0001 Significant 0.2054 Moderate
ATTITUDE FPP- CURRENT USE 11.57 N.A. 2 =0.0031 Significant 0.2672 Moderate
PLACE OF DELIVERY 1.59 N.A. 2 =0.4516 Insignificant - -
High INTERACTION WITH 68.68 N.A. 2 <0.0001 Significant 0.3596 Strong
Medium HEALTHCARE
Low PROVIDERS
SEEKING 45.92 N.A. 2 <0.0001 Significant 0.4101 Strong
TREATMENT FOR
GYNAECOLOGICAL
AILMENTS
MASS MEDIA FPP- EVER USE 97.50 94.50 1 <0.0001 Significant 0.4285 Strong
EXPOSURE FPP- CURRENT USE 10.60 9.34 1 =0.0022 Significant 0.2558 Moderate
PLACE OF DELIVERY 23.30 16.94 1 <0.0001 Significant 0.5033 Very Strong
Exposure INTERACTION WITH 23.83 22.62 1 <0.0001 Significant 0.2118 Moderate
No Exposure HEALTHCARE
PROVIDERS
SEEKING TREATMENT 14.38 12.96 1 =0.0003 Significant 0.2295 Moderate
FOR GYNAECOLOGICAL
AILMENTS
*Significance Level (0.05) Source: Computed by the Researcher

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 TABLE. 8.1.7. RELATIONSHIP BETWEEN SOCIAL DETERMINANT VARIABLES AND PRACTICE OF REPRODUCTIVE HEALTH
ASPECTS

SOCIAL PRACTICE OF PEARSON’S YATE’S D.F. p– RESULT* CRAMER’S MEASURES

DETERMINANTS REPRODUCTIVE CHI-SQUARE CORRECTION (d.f.) VALUE PHI / V OF
HEALTH ASPECTS FOR ASSOCIATION
CONTINUITY
STANDARD OF FPP- EVER USE 46.44 N.A. 2 <0.0001 Significant 0.2957 Moderate
LIVING FPP- CURRENT USE 27.28 N.A. 2 <0.0001 Significant 0.4104 Strong
PLACE OF DELIVERY 5.94 N.A. 2 =0.0513 Insignificant - -
Low INTERACTION WITH 36.54 N.A. 2 <0.0001 Significant 0.2623 Moderate
Medium HEALTHCARE
High PROVIDERS
SEEKING TREATMENT 21.29 N.A. 2 <0.0001 Significant 0.2793 Moderate
FOR
GYNAECOLOGICAL
AILMENTS
MONTHLY FPP- EVER USE 59.22 53.65 1 <0.0001 Significant 0.3225 Strong
HOUSEHOLD FPP- CURRENT USE 31.94 30.15 1 <0.0001 Significant 0.4440 Strong
INCOME (Rs.) PLACE OF DELIVERY 0.58 0.06 1 =0.8065 Insignificant - -
INTERACTION WITH 87.20 85.57 1 <0.0001 Significant 0.4052 Strong
<5500 HEALTHCARE
>5500 PROVIDERS
SEEKING TREATMENT 91.74 89.39 1 <0.0001 Significant 0.5797 Very Strong
FOR
GYNAECOLOGICAL
AILMENTS
*Significance Level (0.05) Source: Computed by the Researcher

251
The qualitative part of the study dealt with detailed description of reproductive health
knowledge and practice in the context of social determinants, from the participant‘s
viewpoint, in which they have told their own stories. The qualitative findings have set
the quantitative results into a human context.

Findings from In-Depth interviews of slum dwelling women and HHWs reveal
the following-

 Early marriage is common in slums. One of the most important factors for
getting girls married early is to prevent pre-marital sex which can cause
defamation to the family. Early motherhood is often demanded by the husband
and in-laws without any consideration for the implications of young
motherhood to the mother and the child. Young brides are also reluctant to
know about the health hazards of early pregnancy in most of the cases since it
is a routine affair among the family and friends.
 Speaking openly about reproductive and sexual health with elders before as
well as after marriage is considered to be bad. In some cases the women are
even restricted to speak to health care workers about these issues. This
prevents women from knowing about their reproductive health issues and
rights.
 There are several myths in the minds of women regarding the process by
which women can get pregnant among both literate as well as illiterate
women.
 Knowledge of female anatomy and female reproductive cycle is limited even
among women who have been to school, in addition to women who have
never been to school. School education does not incorporate sex education in
most of the cases contributing to ignorance in this area.
 Paid work status and the atmosphere in which a woman is exposed at the
workplace are instrumental in contributing to knowledge of her reproductive
health and are instrumental in translating such knowledge to practice.
 Women‘s knowledge and practice of various dimensions of reproductive
health increases with increase in her educational level.

252
 Women are to most extent ignorant about their reproductive and sexual rights.
The husband and the in laws control how much information should a woman
have about family planning methods and when. Even in cases where
knowledge about reproductive health rights exists, women fear to put them
into practice for fear of being rebuked.
 Husbands being the principal earner and the head of the household, their
approval or disapproval of a particular contraceptive method influence their
wives‘ use of the methods. Women being in a dependent relationship with the
husband neither can opt out of the abusive marital tie nor can have better
control in matters concerning their reproductive health. Women with paid
work status and having control over the money earned can negotiate better in
matters of their reproductive health.
 Incidences of coerced marital sex are common in the slums. Women generally
have to comply with wishes of their husbands for fear of being rebuked or
from the fear that their husbands would go for extra marital relationships if
refused sex. This often puts them at higher risk of unplanned pregnancies,
contracting STIs.
 Domestic violence is the rule of the day in the slums. Apart from
psychological ill effect, it puts women in greater risk of unsafe sex,
miscarriage, and still birth. Sexual violence leads to certain gynaecological
ailments like vaginal bleeding, vaginal trauma etc.
 Incidences of unplanned pregnancies are more due to lack of continuous
family planning practice.
 There is much discontinuation in the use of family planning methods by
women because of two reasons – unavailability or interrupted supply of
contraceptives in the subcentres and lack of affordability to buy them from the
market. There is a huge unmet need for contraception.
 Use of condoms by men is very limited. This puts women vulnerable to
unplanned pregnancies and risk of contracting sexually transmitted infections.

253
 Women opt for a terminal method of contraception (sterilization) in absence of
other choices of contraception. Choice of both long and short term
contraception measures are limited for these women.
 The responsibility for family planning lies on the shoulder of the women in
most cases. Use of condoms is limited among men and only a single case of
vasectomy is found in the survey.
 Low male involvement in all matters related to reproductive health of women
– family planning, ANC, delivery, PNC, prevention of STIs including
HIV/AIDS. These are viewed as areas which concern only a woman.
However, in cases where males are educated beyond the primary level, their
involvement is found to be high in matters related to the reproductive health of
their wives.
 Husband‘s educational level determines inter-spousal communication
regarding contraceptive methods, decisions involving child birth and their
future etc. Husbands who are educated beyond primary level discuss with their
wives on issues concerning the reproductive health of both.
 Institutional delivery is motivated mainly by the fact that the ANC, tests and
delivery are all free of cost and mothers get a financial incentive on delivery at
the hospital. Besides, the centralized location of the State General Hospital
and Municipal Hospital in Uttarpara make them well accessible to all.
 Danger signs during pregnancy are known to very few women in spite of their
regular ANC checkups. Accordingly, danger signs of post delivery are also
known to still fewer women.
 Abortion is still considered a matter of shame and guilt to a number of women.
Thus, they are very reluctant to speak about it. It is mostly sought from quacks
in the vicinity where women suppose that their confidentiality is maintained.
 There is a general lack of awareness about sexually transmitted infections with
the exception of the partial or complete knowledge of HIV/AIDS in some
women. The fact that the use of male condoms during intercourse can prevent
the spread of HIV/AIDS is also known to only a handful of women.

254
  Women exposed to audio-visual media can relate ―Buladi‖ with HIV/AIDS
prevention. This point out the success of the mass media in creating awareness
about HIV/AIDS and its prevention.
 Feelings of shame, embarrassment, perceiving a gynaecological disease as
normal and not worth talking about, lack of control over financial resources
prevent utilization of health care among slum dwelling women.
 Women often fail to recognize symptoms of gynecological problems like
Urinary Tract Infections. Since most of the women in unhygienic slums suffer
from the problem, they consider it to be normal. In cases where they report
and seek treatment, very few are seen to complete the entire course of
treatment since medicines are costly. For those who complete treatment,
instances of recurrence are not uncommon since the unhygienic environment
in which they live remain unaltered.
 There is an understanding among few women that the social conditions in
which they live breed poor sexual and reproductive health.
 There is lack of knowledge among the HHWs about gynecological illness
symptoms and STIs. So, the dissemination of knowledge by the HHWs with
respect to these illnesses is limited.

8.2 SCOPE OF FURTHER RESEARCH

I. The findings of this study provide some interesting insights into the social
determinants that relate to reproductive health of slum dwelling women and at
the same time suggest avenues for future research.

II. The slums of UKM house a number of persons from other states chiefly
because of the nearness of the place from Kolkata, the capital of West Bengal.
Therefore it is assumed that the findings of the study is not limited to only
Uttarpara slum residents but also to other slum residents living under similar
situations.

255
III. There is a dearth of empirical research on social determinants and their impact
on reproductive health especially on slum dwelling women in West Bengal.
The findings of this study can be used as a reference for the future researchers.

IV. The present study can be extended to cover all the 67 slums under UKM.

V. The study can provide valuable inputs to the Jawaharlal Nehru National Urban
Renewal Mission – Basic Services to Urban Poor and Integrated Housing and
Slum Development Programme.

VI. The study could not take into account the abortion practices of slum dwelling
women. Future research may probe into that dimension of reproductive health.

VII. The study has not assessed the reproductive health of married men. Future
research can take into account the reproductive health of both the couples in
marriage.

8.3 CONCLUSION

Women‘s health deals with the study of physical, mental and social well-being of
women and not merely an absence of disease or infirmity. The National Academy on
Women‘s Health Medical Education‘s definition of women‘s health covers
preservation of her wellness, prevention of illness by screening, diagnosis and
management of conditions those are unique in her, more common and more serious in
her. This definition also takes due recognition of the importance of the study of
gender difference in women‘s health. It recognizes the fact that a woman‘s health
needs are diverse throughout her life cycle and these needs are affected by the race,
culture, ethnicity, educational level, empowerment and access to medical care.

The health of a man and a woman are different and the difference arises from the
biological and gender related issues. Women‘s health assumes greater significance
because in almost all societies of the world, they are disadvantaged by discrimination
rooted in the socio-cultural milieu. These socio-cultural factors often stand as a
stumbling block and prevent women from accessing, utilizing and benefiting from
available health services. According to WHO, some of such factors include –

256
  Difference in power relations between men and women
 Societal norms that prevent women from accessing education and employment
opportunities
 Exclusive focus on women as a machinery for reproduction
 Experience (potential and actual) of physical, mental and emotional violence

Among various aspects of women‘s health, reproductive health has gained a greater
importance post the ICPD, Cairo.

The present study examined how social determinants like age at marriage, literacy,
work status, mass media exposure, autonomy, gender role attitudes, SLI and monthly
family income is related to various aspects of reproductive health knowledge and
practice. It is seen that all determinants have a significant bearing on the reproductive
health knowledge and practice of slum dwelling women. The study finds that women
in the slums lack knowledge and awareness of reproductive health in general. This
calls for a programme intervention which can disseminate such awareness and
knowledge among these women. There has been no such programme in the
municipality for years.

The current use of contraceptives reveals that there is a huge unmet need for
contraception. A sizeable portion of slum dwelling couples depend upon the health
centres to meet their need for contraception since they cannot afford to buy them from
the market. The health sub-centres report dearth of supply or complete lack of supply
of condoms and OCPs. Women thus are forced to discontinue use and become victim
of unintended pregnancies or, resort to an irreversible method forcefully. They also
become victims of unsafe sex and thus vulnerable to STIs including HIV/AIDS. The
Government should arrange for an uninterrupted and sufficient supply of
contraceptives to enable people to attain better reproductive and sexual health.
However, the first and foremost task of the Government should be to improve the
living conditions of all the slums. Unhygienic environment together with poor living
conditions are mainly detrimental to the health of the slum inhabitants, including their
reproductive health.

257
8.3.1 Policy Implications

The findings of the study have led to the following recommendations having a bearing
on the policy implications.

1. Women should have the right to employment with social security since work
has been seen to bring positive health effects in slum dwelling women.
2. Women should have the right to education and vocational training. Education
affects health positively while vocational training is surely going to increase
the employability of women in various sectors.
3. The number of Honorary Health Workers and number of health centres should
be increased in order to match the population growth.
4. The supply of FP measures should be in an uninterrupted manner in all the
health centres and subcentres. The study has shown that there is a huge unmet
need for contraception among eligible couples. These couples lack financial
resources to avail contraception measures. Thus, in order to meet the needs of
these couples the Government should arrange for an uninterrupted and
sufficient quantity of family planning tools.
5. There should be a provision for visit of a lady doctor at least once a week in
all the subcentres. The study revealed that a fair number of women in the
slums are hesitant to go to the hospital because there are male doctors only.
Provision of a lady doctor in the subcentres once a week will help these
women talk about their problems to her openly and undergo treatment
procedure as required. This will certainly go a long way in reducing the
burden of gynaecological and obstetric ill health in slum dwelling women. The
study also revealed that many women do not access care at the hospital due to
long waiting time. Provision of a lady doctor weekly in the nearest sub centre
will reduce the waiting time for seeing a doctor and motivate women to
consult doctor in the hours of need.
6. There should be initiatives on the part of the Government and NGOs to
conduct IEC programmes on reproductive health. This programme should
target both the couples. Husbands should be made an integral part of such
programme.

258
7. The study revealed that a considerable number of women suffer from
gynaecological ailments and could not continue with long term costly
treatment to get rid of it. Thus, there needs to be a regular supply of medicines
comprising of antibiotics and others in the health centres to be supplied for
free to women suffering from poor gynaecological health.
8. It is seen that the environment in which people are born, grow, live, have a
significant effect on their health. So, the living condition in the slums of the
town is to be improved by strong political will. Such improvement will surely
trigger positive improvements in health of the slum population.
9. Women‘s right to informed choice about various contraceptive methods
should be acknowledged by health care providers. Women should have the
freedom to choose according to their own needs and choice of a contraceptive
method should not be imposed on them by health care workers because of a
financial incentive.
10. The Honorary Health Workers should be informed, counseled and trained
about various STIs including HIV/AIDS so that they can be instrumental in
delivering the knowledge to the slum dwelling women.
11. The Government should ensure that there are adequate numbers of doctors and
hospital staff to attend to pregnant women who come for ANCs so that they do
not have to sit unnecessarily for long hours.
12. Given the increased incidence of non HIV/AIDS STIs among men and women
and ignorance about them, calls for a National Programme in place to spread
awareness about those infections among the masses.
13. There should be dissemination of information regarding Medical Termination
of Pregnancy (MTP) among the slum women. They should be informed about
the conditions under which they can seek abortion, where this service is
available and importance of a Govt. registered place and Registered Medical
Practitioners (RMPs) in the procedure. Ill effects of unsafe abortion should be
articulated to them. It is also necessary to weed out the stigma attached to
abortion from their minds. They should recognize it as one of their
reproductive health right.

259
 APPENDIX-I

SOCIAL DETERMINANTS OF REPRODUCTIVE HEALTH AMONG

MARRIED SLUM DWELLING WOMEN: A CASE STUDY OF UTTARPARA
SLUMS

WOMEN’S QUESTIONNAIRE
(15-49 Years)
District: Ward No.:

Town: Interview No.:

Name of the Municipality: Date of Interview:

Name of the Slum: House No:

Section: 1 - Socio Economic Background

Sl. Questions Coding Categories Skip To Coding

No.
1 Respondent‘s Name

2 Age ______ in Completed Years

M M Knows Month

Don‘t know Month - 98

Y Y Y Y Knows

Year

Don‘t know Year - 9998

3 What is your Religion? Hindu – 1

Muslim – 2
Others – 3
4 What is your Caste? General – 1
SC – 2
ST – 3
OBC – 4

260
 5 Type of Family Nuclear – 1
Joint – 2
6 For how long you have ___________ Years
been living here? Always – 95 Q-8
If less than one year – 96 Q-7
7 Just before you came here City – 1
Town – 2
where did you live?
Village – 3
8 Have you ever attended Yes – 1
school? No – 2 Q - 10
9 If yes, what is the highest Primary – 1
standard you completed? Middle – 2
High School – 3
Others – 4
10 Can you read out a Cannot read at all – 1 Q – 15
sentence to me? Able to read only part of the
sentence – 2 Q - 12
Able to read whole sentence
–3 Q – 12
No card with required
language – 4 Q – 12
Blind / Visually impaired –
5 Q – 15
11 Have you ever Yes – 1
participated in a literacy No – 2
program or any other
program that involves
learning to read or write
(not including primary
school)?
12 Do you read news paper Yes – 1
once a week? No – 0
13 Do you listen to radio? Yes – 1
No – 0
14 Do you watch television? Yes – 1
No – 0
15 You ask someone to read Yes – 1
the newspaper to listen No – 0
the details of your interest
16 Are you currently Yes – 1
working? No – 0 Q - 23
16A Presently you are working Government – 1
with (employer) Semi- Government – 2
Private – 3
Self Employed – 4

261
17 What are the reasons for Financial Necessity - 1
joining work? Family Compulsion - 2
Self dependence and
Fulfillment - 3
Raising living standards - 4
Pocket money/ Savings - 5
18 When did you start Before marriage - 1
working? After marriage - 2
After childbirth - 3
After Husband‘s death - 4
Separation / divorce - 5
19 How many hours you _________ Hours
work in a day?
20 What is your present
monthly income?
Rs. ____________
22 What is your monetary Full – 1
contribution to the family Half – 2
income? Negotiable – 3
23 What is your Household
monthly income
Rs. ___________
(including husband and or
others)
24 Type of house Kutcha -0
Pucca - 2
Semi-pucca - 4
24A Ownership of house Yes – 2
No – 0
24B Separate room for Yes – 1
cooking No – 0
24C Source of lighting Electricity – 2
Kerosene/Gas/Oil – 1
Any other - 0
25 What type of fuel do you Electricity/LPG/
use for cooking? Biogas – 2
Coal/Charcoal/
Kerosene – 1
Any other -0
26 What is the main source Pipe water/Well
of drinking water? /Hand pump
in residence – 2
Public tap/
Hand pump/
Well – 1
Other water sources - 0

262
 27 What kind of toilet Own toilet -4
facility do you use? Public flush toilet - 2
Public pit toilet - 1
Open space /
Field (no toilet) - 0
28 Does the Household own Yes - 2 Q – 29
any livestock? No - 0 Q – 30
29 If yes, number _______ Number
30 What durable goods do None -0
you own? Pressure Cooker/Bed/Clock
-1
Electric fan/Radio/Sewing
machine/Bicycle - 2
Color T.V/ Refrigerator/
Scooter / Motor cycle - 3
Jeep / Car - 4
Section: 2 - Marriage and Co-habitation

Sl. Questions Coding Categories Skip To Coding

No.
1 What is your current Married – 1
marital status? Widowed – 2 Q–4
Separated /
Divorced /
Deserted by husband – 3 Q-4
2 Are you living with your Living with Husband – 1 Q-4
husband now, or is he
Staying elsewhere – 2
staying elsewhere? Q-3
3 For how long have you
and your husband not M M Knows Month
been living together?
Don‘t Know Month – 98
Y Y Knows Year
Don‘t Know Year – 9998
4 In what month and year
did you get married? M M Knows Month

Don‘t Know Month – 98

Y Y Y Y Knows
Year

Don‘t Know Year - 9998

263
 5 What was your age at __________ Years
marriage?
6 How old were you when
you started living with __________ Years
your husband?
7 How old were you when
you had the first sexual __________ Years
intercourse?
Section: - 3 Birth History of the Respondent Women

Sl. Questions Coding Categories Skip To Coding

No.
1 Have you ever given Yes – 1
birth? No – 2 Q-5

2 What was your age when ____________ Years

you gave first birth?
3 Do you have any sons or Yes – 1
daughters to whom you
No – 2
have given birth who are
now living with you?
4 How many sons and ____________ Nos.
daughters live with you?
5 Did any of your Yes – 1
pregnancy ever end in
No – 2
stillbirth?
6 Did any of your Yes – 1
pregnancy ever end in
No – 2
miscarriage
Section: 4 Practice of Institutional Delivery and Delivery at Home attended by
Skilled Birth Attendant (those who delivered during the past 1 year)

Sl. Questions Coding Categories Skip To Coding

No.
1 Where did you get your Institutional Delivery:
baby delivered? Yes – 1
No – 0 Q–6

Delivery at Home Attended

by a trained birth attendant
Yes – 1
No – 0

2 How was the child Normal – 1

delivered? Cesarean section - 2

264
 3 What was your length of __________ No. of Days
stay?
4 Before discharge was Yes – 1
your and your baby‘s No – 0
health checkup done and
advice given?
5 In two months after Yes – 1
discharge did you and No – 0
your baby go for any
health checkups?
6 Why didn‘t you deliver at High cost – 1
a healthcare facility? Poor service quality – 2
HCF far from home – 3
Husband/In-laws did not
allow – 4
7 After delivery at home
when did the first ____________ No. of Days
checkup take place?
8 In two months after Yes – 1
delivery did you and your No – 0
baby go for any health
checkups?
Section: - 5 Practice of Ante Natal Care (ANC) by Currently Pregnant Women

Sl. Questions Coding Categories Skip To Coding

No.
1 How many months _________ Months
Pregnant are you?
2 Did you register your Yes – 1
pregnancy with ANM? No – 0
3 Did you get a card from Yes – 1
ANM? No – 0

4 Are you seeing somebody Yes – 1

for antenatal care during No – 0
this pregnancy?
6 How many times did you Once - 1
receive ANC during this More than once - 2
pregnancy? None - 0
7 As a part of your ANC, Your weight measured - 1
were any of the following Your B.P checked- 2
done at least once? Blood sample taken - 3
urine sample taken - 4
Abdomen checked - 5

265
 Your EDD told - 6
Advice given to deliver at a
health centre - 6
Advised for proper nutrition
-7
8 During the ANC visits, Vaginal bleeding -1
were you told about any Convulsions - 2
of the pregnancy Prolonged labor - 3
complications?

9 Were you told where to Yes – 1

go in case you faced any Specify __________
of the complications? No – 0

10 Were you given Tetanus Yes – 1

Toxoid injection during No – 0
this pregnancy?

11 During this pregnancy Yes – 1

were you given or bought Specify __________no. of
any iron and folic acid months
tablets or syrup? No – 0

12 Did you receive any Yes – 1

supplementary nutrition Specify __________no. of
from the Anganwadis months
during pregnancy? No – 0

Section: - 6 Interaction with health care providers during the last 6 months
preceding the survey

Sl. Questions Coding Categories Skip To Coding

No.
1 Did you ever interact with Yes – 1
Health Care Providers? No – 0 Q-7
2 Did she/he talk to you Yes – 1
regarding Pregnancy No – 0
related issues (ANC /
PNC / Delivery)
3 Did she/he explain to you Yes – 1
about contraceptive No – 0
methods to delay or stop

266
 pregnancy?
4 Did she/he explain to you Yes – 1
about Common No – 0
Gynaecological Illnesses
5 Did she/he talk to you Yes – 1
No – 0
regarding STIs other than
HIV?
6 Did she/he explain to you Yes – 1
about HIV / AIDS issues No – 0
and their prevention?
7 Reasons for not Not nice to talk – 1
interacting with Health
In laws/family/husband
Care Providers
against talk – 2
Any other (Specify) – 99
Section: 7 Gynaecological Ailments of Women during the past 6 months and
their Care seeking behavior

Sl. Questions Coding Categories Skip To Coding

No.
1 Are you presently Yes – 1
suffering from any No – 0
gynaecological ailment?
2 Did you ever discuss/seek Yes – 1
treatment for your No – 0 Q–7
gynaecological ailment
from Health Care
Providers?
3 Did you ever (in the last 6 abnormal vaginal discharge
months) suffer/or –1
currently suffering from
any of the following Vaginal discharge
reproductive ailments? accompanied by itching,
bad odour, abdominal pain
and fever – 2

Irregular Menstruation – 3

4 Do you currently have Yes – 1

symptoms of Urinary No – 0
Tract Infection (UTI) -

267
 Pain, burning sensation
while passing urine,
abnormal frequency of
urination?
5 Do you suffer from Pain Yes – 1
during intercourse? No – 0
6 Do you suffer from Yes – 1
bleeding during No – 0
intercourse?
7 Reasons for not Problem Not considered
interacting/seeking Serious – 1
treatment with Health Embarrassment – 2
Care Providers Unaffordable – 3
Inaccessible (In terms of
Distance) – 4
Long waiting time – 5
Do not know where to go–6
Section: 8 Quality of Care Received from the Health care Provider

Sl. Questions Coding Categories Skip To Coding

No.
A Of those who sought
treatment for symptoms
of Reproductive
Ailments
A1 HCP treated you with Yes – 1
respect No – 0
A2 Your privacy was Yes – 1
maintained No – 0
A3 Provider was responsive Yes – 1
enough to your needs No – 0
A4 HCP advised you to ask Yes – 1
your husband to use No – 0
condoms during sexual
intercourse
A5 HCP asked you to bring Yes – 1
your husband for your No – 0
check ups
A6 HCP recommended lab Yes – 1
tests for you No – 0
A7 HCP counseled you on Yes – 1
HIV/AIDS and the ways No – 0
to prevent it

268
 B Of those who attended
health care facility to
receive pregnancy
related services
B1 You are tested for your Yes – 1
weight, B.P, blood and No – 0
urine, abdominal check
ups
B2 You are advised for need Yes – 1
of proper nutrition and No – 0
importance of delivery at
a health care facility
B3 HCP told about various Yes – 1
danger signs during No – 0
pregnancy and where to
go in case of
complications
B4 HCP advised you on Yes – 1
breastfeeding, keeping No – 0
baby warm and clean and
clean home environment
B5 You are advised to adopt Yes – 1
a contraceptive measure No – 0
to delay the next
pregnancy
B6 Your need for privacy Yes – 1
was respected No – 0
Section: 9 Knowledge of Respondents (Women) Regarding Female Reproductive
Cycle and Family Planning Basics

Sl. Questions Coding Categories Skip To Coding

No.
1 It is not possible to get Yes – 1
pregnant on every day of No – 0
a woman‘s cycle if she
has sexual relations
2 From one menstrual Yes – 1
period to the next there No – 0
are certain days when a
woman is more likely to
become pregnant if she
has sexual relations

269
 3 There is a Safe period Yes – 1
during menstrual cycle No – 0
when a woman is least
likely to become pregnant
even if she has sexual
relations
4 Oral Contraceptive Pills Yes – 1
should be taken for 21 No – 0
days continuously, then
stop for 7 days during
menstruation and again
continue
5 Emergency pills can Yes – 1
prevent unwanted No – 0
pregnancy when taken
within 5 days of sexual
intercourse
6 Condoms serve the dual Yes – 1
purpose of preventing No – 0
pregnancy and STIs
including HIV / AIDS
7 IUDs are long term safe Yes – 1
method of temporary No – 0
contraception
8 Male sterilization is far Yes – 1
easier and hassle free than No – 0
female sterilization
Section: 10 Knowledge of Respondents (Women) Regarding Sexually
Transmitted Infections including HIV / AIDS

Sl. Questions Coding Categories Skip To Coding

No.
1 Can you name an STI Yes – 1
other than HIV/AIDS? No – 0
2 Do you know the mode of Yes – 1
transmission of STIs No – 0

including HIV/AIDS?
3 Can you tell me at least 2 Yes – 1
symptoms of STIs No – 0

including HIV/AIDS

270
4 Do you know some STIs Yes – 1
can even be asymptomatic No – 0
5 Do you know that risk of Yes – 1
transmission increases if No – 0

one has multiple sexual

partners
6 Do you know a condom Yes – 1
serves the purpose of No – 0

preventing STIs including

HIV / AIDS?
7 Do you know that it is Yes – 1
necessary to go for No – 0

medical treatment as soon

as symptoms appear?
8 Do you know that it is Yes – 1
necessary for the women No – 0

to go for regular checkups

if their husbands have
STIs and vice-versa?
9 Do you know if a STI is Yes – 1
kept untreated for long it No – 0

increases the risk of

HIV/AIDS?
10 Do you know untreated Yes – 1
STI can lead to No – 0

miscarriage or sterility in
women?
11 Does HIV spread by Yes – 1
hugging, sharing food No – 0

with the affected person?

271
 12 Do you know a simple Yes – 1
test at the nearest VCTC No – 0

can reveal whether a

person is HIV positive?
13 Do you know that a Yes – 1
pregnant woman should No – 0

always be screened for

HIV/AIDS?
Section: 11 Knowledge of various Contraceptive Methods
(Which ways or methods have you heard about?)
Sl. Questions Coding Categories Skip To Coding
No.
1 MALE Yes – 1
STERILIZATION: Men No – 0

can have an operation to

avoid having any more
children.
2 FEMALE Yes – 1
STERILIZATION: No – 0

Women can have an

operation to avoid having
any more children.
3 WITHDRAWAL Men Yes – 1
can be careful and pull No – 0

out before climax.

4 RHYTHM METHOD Yes – 1
Every month that a No – 0

woman is sexually active

she can avoid pregnancy
by not having sexual
intercourse on the days of
the month she is most

272
 likely to get pregnant.
5 PILL Women can take a Yes – 1
pill every day or every No – 0

week to avoid becoming

pregnant.
6 IUD OR LOOP Women Yes – 1
can have a loop or coil No – 0

placed inside them by a

doctor or a nurse.
7 CONDOM OR NIRODH Yes – 1
Men can put a rubber No – 0

sheath on their penis

before sexual intercourse.
8 INJECTABLES Women Yes – 1
can have an injection by a No – 0

health provider that stops

them from becoming
pregnant for one or more
months.
9 EMERGENCY Yes – 1
CONTRACEPTION No – 0

Women can take pills up

to three days after sexual
intercourse to avoid
becoming pregnant.
Section: 12 Knowledge of Respondents (Women) Regarding Induced Abortion

Sl. Questions Coding Categories Skip To Coding

No.
1 Do you know a woman Yes – 1
can ask for abortion when No – 0
the pregnancy is
unwanted?

273
 2 Do you know abortion Yes – 1
can be done up to a No – 0
specified time after
conception only (up to 12
weeks) and in special
cases from (12th – 20th
week)?
3 Do you know Abortion Yes – 1
should always be done at No – 0
Govt. registered clinics
and by registered medical
practitioners?
4 Do you know Unsafe Yes – 1
abortion can lead to No – 0
serious health hazards
including death?
Section: 13 Family Planning Practice by Respondents (women): Ever Used and
Current Use of Contraception

Sl. Questions Coding Categories Skip To Coding

No.
A Did you ever use any of Yes Q – A1
the methods? No Q–B
A1 Female Sterilization Yes – 1
No – 0
A2 Oral Contraceptive Pills Yes – 1
No – 0
A3 IUDs Yes – 1
No – 0
A4 Condoms By husbands Yes – 1
No – 0
A5 Others _______ (Specify)
B Never used any method _______ (Specify) Q-D
C What are the
method/methods you are
currently using?
C1 Oral Contraceptive Pills Yes – 1
No – 0
C2 IUDs Yes – 1
No – 0
C3 Condoms By husbands Yes – 1
No – 0
C4 Others _________ (Specify)
D Not using any method _________ (Specify)

274
Section:14 Recommendation, Decision for Use of Contraceptives and Place of
Availability

Sl. Questions Coding Categories Skip To Coding

No.
1 Who recommended use of Doctors – 1
contraceptives to you? Female Health Workers – 2
Family/Significant others –
3
2 Who took the decision for Self – 1
use of contraceptives? Husband – 2
Mutual decision of both the
spouses – 3
3 From where you Govt. Hospital/ Municipal
get/obtain it? Hospital – 1
Private Nursing Home – 2
Local Pharmacy – 3
Others – 4 (Specify___)
Section: 15 Knowledge of Respondent (Women) Regarding Pregnancy, ANC,
Child-Birth and PNC

Sl. Questions Coding Categories Skip To Coding

No
1 Do you know one should Yes – 1
have a nutritious diet No – 0
during pregnancy and
must not skip meals?
2 Do you know one should Yes – 1
have at least 3 antenatal No – 0
checkups during the
period of pregnancy?
3 Do you know at least 3 Yes – 1
danger signs during No – 0
pregnancy (convulsions
not from fever, swelling
of legs, body or face,
vaginal bleeding,
excessive white
discharge, excessive
fatigue, night blindness,
blurred vision, fast or
difficult breathing,
abdominal pain etc)?

275
 4 Do you know where to go Yes – 1
and report in case any of No – 0
the danger signs ensue?
5 Do you know the Yes – 1
importance of No – 0
institutional delivery and
need for skilled attendant
during delivery for safe
motherhood and
childbirth?
6 Do you know that post Yes – 1
delivery check up is as No – 0
important as ante natal
check up?
7 Do you know the warning Yes – 1
signs (at least 3) after No – 0
delivery that demands
medical attention
(excessive bleeding,
severe abdominal pain,
severe vaginal pain, pain
in the incision area in case
of C/S, fever, swelling of
the legs, etc)?
Section: 16 Women’s Autonomy Questions
(Women Reporting that they have the ability to do the following)

Sl. Questions Coding Categories Skip To Coding

No.
1 Do you have the ability to Yes – 1
decide when to buy daily No – 0
household items?
2 Do you have the ability to Yes – 1
decide about child‘s No – 0
schooling?
3 Do you have the ability to Yes – 1
decide about own and No – 0
child‘s health?
4 Do you have the ability to Yes – 1
decide when to visit a No – 0
healthcare facility?
5 Do you have the ability to Yes – 1
decide when to have a No – 0
child and adoption of
family planning method?

276
 6 Do you have the ability to Yes – 1
move unaccompanied to No – 0
market?
7 Do you have the ability to Yes – 1
move unaccompanied to No – 0
parental house?
8 Do you have the ability to Yes – 1
move unaccompanied to No – 0
friend‘s/relative‘s place?
9 Do you have the ability to Yes – 1
move unaccompanied to a No – 0
health care provider?
10 Do you have the ability to Yes – 1
move unaccompanied to No – 0
see a movie?
11 Do you have access to Yes – 1
husband‘s earnings? No – 0
12 Do you have access and Yes – 1
control over money No – 0
earned by self?
13 Can you buy small things Yes – 1
for self? No – 0
14 Can you set aside money Yes – 1
for self? No – 0
15 Can you buy gift items for Yes – 1
parents, friends, and No – 0
relatives?
Section: 17 Gender Role Attitudes of Married Women Respondents

(Women who agree / Disagree to the following Gender Role statements)

Sl. Questions Coding Categories Skip To Coding

No.
1 A girl should not be Agree – 1
allowed to decide when Disagree – 0
and whom to marry
2 Performing household Agree – 1
chores is the job of wives Disagree – 0
only
3 A husband should alone Agree – 1
decide how household Disagree – 0
money should be spent
4 A husband‘s opinion Agree – 1
should always prevail Disagree – 0
even if it is wrong and
differs from that of his
wife

277
 5 A husband has the right Agree – 1
to physically and, or, Disagree – 0
verbally rebuke a wife if
she is unable to discharge
household duties assigned
to her
6 A husband would not be Agree – 1
wrong if he keeps illicit Disagree – 0
relationship with, or,
marry another woman if
he is not happy and
satisfied with his wife
7 It is always lucky to have Agree – 1
a son than a daughter Disagree – 0

8 A girl child need not be Agree – 1

sent to school since Disagree – 0
education has nothing to
do with accomplishing
household chores which
she actually needs to
master
Section:18 Knowledge of Reproductive Health Rights (RHR)

Sl. Questions Coding Categories Skip To Coding

No.
1 Right to decide freely the Yes – 1
number of children to No – 0
bear
2 Right to decide freely Yes – 1
when to bear children No – 0
3 Right to decide spacing Yes – 1
between two children No – 0
4 Right to freedom from Yes – 1
forced sterilization No – 0
5 Right to access Yes – 1
Reproductive HealthCare No – 0
in need
6 Right to receive education Yes – 1
on Reproductive & No – 0
Sexual Health and
Illnesses
7 Right to access safe Yes – 1
Abortion No – 0
8 Right to decide not to Yes – 1
bear children at all No – 0

278
 APPENDIX-II
CODE BOOK (LIST- WOMEN’S QUESTIONNAIRE)

1. Age 11. Mass Media Exposure

Don‘t know Month - 98 Yes – 1
Don‘t know Year – 9998 No – 0
2. Religion 12. Work Status
Hindu – 1 Yes – 1
Muslim – 2 No – 0
Others – 3
3. Caste 13. Type of Employer
General – 1 Government – 1
SC – 2 Semi- Government – 2
ST – 3 Private – 3
OBC – 4 Self Employed – 4
4. Family Type 14. Reasons for Joining Work
Nuclear – 1 Financial Necessity - 1
Joint – 2 Family Compulsion - 2
5. Resident Self dependence and
Always – 95 Fulfillment - 3
If less than one year – 96 Raising living standards - 4
Pocket money/ Savings – 5
6. Migrated From 15. Work History
City – 1 Before marriage - 1
Town – 2 After marriage - 2
Village – 3 After childbirth - 3
7. Literacy After Husband‘s death - 4
Yes – 1 Separation / divorce – 5
No – 2
8. Educational Standard 16. Monetary Contribution
Primary – 1 Full – 1
Middle – 2 Half – 2
High School – 3 Negotiable – 3
Others – 4
9. Reading Ability 17. Marital Status
Cannot read at all – 1 Married – 1
Able to read only part of the sentence – Widowed – 2
2 Separated /
Able to read whole sentence – 3
Divorced /
No card with required language – 4
Blind / Visually impaired – 5 Deserted by husband – 3
10. Participated in a Literacy 18. Living With Husband
Program
Yes – 1 Living with Husband – 1
No – 2
Staying elsewhere – 2

279
 CODE BOOK (LIST- WOMEN’S QUESTIONNAIRE)

19. Ever Given Birth 30. ANC Checkups

Yes – 1 Weight measured - 1
No – 2 B.P checked- 2
20. Sons or Daughters living with Blood sample taken – 3
respondent Urine sample taken - 4
Yes – 1
Abdomen checked - 5
No – 2
EDD told - 6
21. Pregnancy ever end in Stillbirth
Advice given to deliver at a health centre
Yes – 1
-6
No – 2
Advised for proper nutrition - 7
22. Miscarriage 31. Pregnancy Complications
Yes – 1 Vaginal bleeding -1
No – 2 Convulsions - 2
Prolonged labor - 3
23. Institutional Delivery 32. TT Injections/ Iron & Folic Acid
tablets/ Supplementary Nutrition
Yes – 1 Yes – 1
No – 0 No – 0
24. Delivery at Home attended by a 33. Interaction with Health Care
Trained Birth Attendant Providers
Yes – 1 Yes – 1
No – 0 No – 0
25. Child Delivery 34. Reasons for not interacting with
Health Care Providers
Normal – 1 Not nice to talk – 1
Cesarean section – 2 In laws/family/husband against talk – 2
Forceps – 3 Any other (Specify) – 99
26. Health Checkups 35. Gynaecological Ailments
Yes – 1 Yes – 1
No – 0 No – 0
27. Reason for not delivery at HCF 36. Reproductive Ailments
High cost – 1
Poor service quality – 2 Abnormal vaginal discharge – 1
HCF far from home – 3
Husband/In-laws did not allow – 4 Vaginal discharge accompanied
28. ANM Registration & Card by itching, bad odour, abdominal
Yes – 1 pain and fever – 2
No – 0
29. ANC during pregnancy Irregular Menstruation – 3
Once - 1
More than once - 2
None – 0

280
 CODE BOOK (LIST- WOMEN’S QUESTIONNAIRE)

37. Quality of Care Received from the 43. Recommended use of

Health care Provider Contraceptives
Yes – 1 Doctors – 1
No – 0 Female Health Workers – 2
Family/Significant others – 3
38. Knowledge of Women Regarding 44. Decision for use of Contraceptives
Female Reproductive Cycle and
Family Planning Basics
Yes – 1 Self – 1
No – 0 Husband – 2
Mutual decision of both the spouses – 3
39. Knowledge of Women Regarding 45. Place to obtain contraceptives
Sexually Transmitted Infections
including HIV / AIDS
Yes – 1 Govt. Hospital/ Municipal Hospital – 1
No – 0 Private Nursing Home – 2
Local Pharmacy – 3
40. Knowledge of various 46. Knowledge of Women Regarding
Contraceptive Methods Pregnancy, ANC, Child-Birth and
PNC

Yes – 1 Yes – 1
No – 0 No – 0
41. Knowledge of Women Regarding 47. Women’s Autonomy
Induced Abortion
Yes – 1 Yes – 1
No – 0 No – 0
42. Family Planning Practice by 48. Gender Role Attitudes
women Ever Used and Current Use of
Contraception Yes – 1
No – 0
Yes – 1 49. Knowledge of Reproductive
No – 0 Health Rights (RHR)

Yes – 1
No – 0

STANDARD OF LIVING INDEX CODING

INDICATOR CATEGORY
49. Type of House Pucca - 4
Semi-pucca - 2

281
 Kachha - 0
50. Ownership of house Yes - 2
No - 0
51. Source of lighting Electricity - 2
Kerosene/Gas/Oil - 1
Any other - 0

52. Separate room for cooking Yes - 1

No - 0

53. Main fuel used for cooking Electricity/LPG/Biogas - 2

Coal/Charcoal/Kerosene - 1
Any other - 0

54. Source of drinking water Pipe water/Well/Hand pump in residence

-2
Public tap/Hand pump/Well - 1
Other water sources 0
55. Type of toilet facility Own toilet- 4
Public flush toilet - 2
Public pit toilet - 1
Open space /
Field (no toilet) - 0

56. Ownership of livestock Owns livestock - 2

Does not own livestock - 0

57. Ownership of durable goods None - 0

Pressure Cooker/Bed/Clock - 1
Electric fan/Radio/Sewing
machine/Bicycle - 2
Color T.V/ Refrigerator/
Scooter / Motor cycle - 3
Jeep / Car - 4

282
APPENDIX-III

283
 LIST OF ABBREVIATIONS

AAPOR : The American Association for Public Opinion Research

AIDS : Acquired Immuno Deficency Syndrome

ANC : Ante Natal Check up

BCC : Behaviour Change Communication

BDHS : Bangladesh Demographic & Health Survey

BMI : Body Mass Index

C/S : Caesarean Section

CBR : Crude Birth Rate

CMA : Calcutta Metropolitan Area

CMC : Calcutta Metropolitan Corporation

CMOH : Chief Medical Officer of Health

CSDH : Commission on Social Determinants of Health

CSIP : Calcutta Slum Improvement Project

CUDP : Calcutta Urban Development Programme

DDP : District Development Programme

DFID : Department For International Development (UK)

DHDR : District Human Development Report

DLHFS : District Level Health and Family Survey

EIS : Environment Improvement Scheme

EIUS : Environmental Improvements in Urban Sector

284
FGM : Female Genital Mutilation

FP : Family Planning

FPB : Family Planning Basics

FPP : Family Planning Practices

FSH : Follicle Stimulating Hormone

FWCW : Fourth World Conference on Women (Beijing 1995)

GEMS : Generators of Economic Momentum

HCU : Health Care Unit

HHW : Honorary Health Worker

HIV : Human Immuno Deficiency Virus

HPV : Human Papilloma Virus

ICPD : International Conference on Population and Development

IEC : Information Education and Communication

IIPS : International Institute of Population Sciences

IMR : Infant Mortality Rate

INCLEN : International Clinical Epidemiology Network

IPV : Intimate Partner Violence

IUD : Intra Uterine Device

JSY : Janani Suraksha Yojna

KMDA : Kolkata Metropolitan Development Authority

LE : Life Expectancy

LMP : Last Menstrual Period

285
MDG : Millennium Development Goal

MMR : Maternal Mortality Rate

MNP : Minimum Needs Programme

MTP : Medical Termination of Pregnancy

NACO : National Aids Control Organisation

NFHS : National Family Health Survey

NMBG : National Maternity Benefits Scheme

NMR : Neonatal Mortality Rate

NOPS : National Old Age Pensioners‘ Scheme

NRY : Neheru Rojgar Yojana Scheme

NSDP : National Slum Development Programme

NSSO : National Sample Survey Organization

OBC : Other Backward Classes

OCP : Oral Contraceptive Pill

PNC : Post Natal Care

PRB : Population Reference Bureau

QSS : Quick Slum Survey

RCH : Reproductive and Child Health

RH : Reproductive Health

RR : Response Rate

RTIs : Reproductive Tract Infections

SC : Scheduled Caste

286
SDH : Social Determinants of Health

SGH : State General Hospital

SIP : Slum Improvement Programme

SLI : Standard of Living Index

ST : Scheduled Tribe

STDs : Sexually Transmitted Diseases

STIs : Sexually Transmitted Infections

UBS : Urban Basic Services Scheme

UBSP : Urban Basic Services for the Poor

UKM : Uttarpara Kotrung Municipality

UN : United Nations

UNESCO : United Nations Educational Scientific and Cultural

Organization

UNFPA : United Nations Population Fund (formerly, The United

Nations Fund For Population Activities)

UNHabitat : United Nations Human Settlement Programme

UTI : Urinary Tract Infection

VD : Venereal Diseases

WHO : World Health Organisation

287
 GLOSSARY

Age Specific Fertility Rate: Number of live births per 1000 women in a specific age
group for a specified geographical area over a specific period.

Amenities: Facilities available within the home (refers to toilets, water etc.) or
outside (refer shops, public transport etc.)

Basin without Flush: Indian Latrine.

Child Mortality Rate: The probability of dying between the first and fifth birth days.

Crude Birth Rate: Annual number of live births per 1000 population.

Crude Death Rate: Annual number of deaths per 1000 population.

Couple Protection Rate: Percentage of women in the age group of 15-49 years
protected from pregnancy in a year over a specific area.

Dakhin: South.

Infant Mortality Rate: Number of infants dying under one year of age per 1000 live
births in a year.

Kachcha Drain: Open drain (temporary).

Maternal Mortality Rate: Number of women who die of pregnancy and childbirth
related causes per 1, 00,000 registered live births.

Paschim: West

Pucca Drain: Drains made of concrete structure.

Purbo: East

Sex Ratio: Number of females per 1000 males.

Site: Actual place where a settlement is located.

Total Fertility Rate: Number of children who would be born per woman if current
age specific fertility rates prevail.

Uttar: North

288
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